Libro Medicina Reproductiva 2022

Clinical Reproductive
Medicine and
Surgery
A Practical Guide
Tommaso Falcone
William W. Hurd
Editors
Fourth Edition
123
Clinical Reproductive Medicine and Surgery
Tommaso Falcone • William W. Hurd
Editors
Clinical
Reproductive
Medicine
and Surgery
A Practical Guide
Fourth Edition
Editors
Tommaso Falcone William W. Hurd
Cleveland Clinic London Division of Reproductive
Cleveland Clinic Lerner College of Endocrinology and Infertility
Medicine University of Alabama
Cleveland, OH, USA School of Medicine
Birmingham, AL, USA
ISBN 978-3-030-99595-9 ISBN 978-3-030-99596-6 (eBook)

https://doi.org/10.1007/978-3-030-99596-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2007, 2013, 2017, 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Pub-
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V
The editors would like to dedicate the fourth edition of this textbook to
all enthusiastic students of reproductive medicine, particularly the
fellows, residents, and new clinicians for whom this book was created.
Preface to the Fourth Edition
Fifteen years have elapsed since we first asked a group of clinical experts
from throughout the world to help create a comprehensive textbook of
clinical reproductive medicine and surgery that was straight forward, up
to date, and worth reading. We have been gratified to hear that the sub-
sequent editions of this book have continued to be useful to fellows and
residents in training, and specialists and subspecialists in practice.
The fourth edition includes a number of changes, including two new
chapters and several new authors. All chapter from the previous edition
have been updated and edited for clarity. Questions have been added to
the end of each chapter to help readers self-test their knowledge. We
have also added two chapters to address topics made prominent by tech-
nological advances. The third-party reproduction chapter addresses the
unique clinical and regulatory challenges accompanying the use of
donor gametes and gestational carriers. The uterine transplant chapter
describes the medical and surgical challenges involved in this cutting-
edge approach.
We hope readers find the information about the latest developments
in our fast-evolving field interesting. More importantly, we hope this
book continues to provide easy access to the essential information about
the clinical practice of reproductive medicine and surgery.
Tommaso Falcone
London, England

William W. Hurd
Birmingham, AL, USA
VII
Contents
1 ypothalamic-Pituitary-Ovarian Axis and Control of the

H
Menstrual Cycle..................................................................................................1
Julian A. Gingold, Meaghan Jain, and Cyrus Jalai
2 Female and Male Gametogenesis..........................................................23

Nina Desai, Jenna M. Rehmer, Jennifer Ludgin, Rakesh Sharma,
Raj Kumar Anirudh, and Ashok Agarwal
3 Normal Puberty and Pubertal Disorders...........................................55

Siddhi Mathur, Joseph S. Sanfilippo, and M. Jonathon Solnik
4 Fertilization and Implantation.................................................................79

Christopher K. Arkfeld and Hugh S. Taylor
5 Reproductive Imaging...................................................................................109
Laura Detti
6 Amenorrhea..........................................................................................................139
Alexander M. Kotlyar and Eric Han
7 Polycystic Ovary Syndrome.......................................................................157

Tommaso Falcone and William W. Hurd
8 Abnormal Uterine Bleeding.......................................................................171

Sonia Elguero, Bansari Patel, Anna V. Jones, and William W. Hurd
9 Menopause............................................................................................................201
Tara K. Iyer and Holly L. Thacker
10 Osteoporosis........................................................................................................235
Tiffany M. Cochran and Holly L. Thacker
11 Male Infertility....................................................................................................265
Scott Lundy and Sarah C. Vij
12 Female Infertility...............................................................................................281
Elizabeth J. Klein, Roxanne Vrees, and Gary N. Frishman
13 Fertility Preservation.....................................................................................303
Pasquale Patrizio, Emanuela Molinari, Tommaso Falcone, and
Lynn M. Westphal
14 Ovarian Reserve Testing...............................................................................323

Paula Amato
15 Recurrent Early Pregnancy Loss..............................................................335

Krystle Y. Chong and Ben W. Mol
VIII Contents
16 Ovulation Induction........................................................................................353
Ginevra Mills and Togas Tulandi
17 Assisted Reproductive Technology: Clinical Aspects................367

Pardis Hosseinzadeh, M. Blake Evans, and Karl R. Hansen
18 ART: Laboratory Aspects..............................................................................393

Charles L. Bormann
19 Preimplantation Genetic Testing............................................................409

Jason M. Franasiak, Katherine L. Scott, and Richard T. Scott Jr.
20 ysteroscopic Management of Intrauterine Disorders:

H
Polypectomy, Myomectomy, Endometrial Ablation,
Adhesiolysis, and Removal of Uterine Septum.............................429
Michelle G. Park and Keith B. Isaacson
21 Gynecologic Laparoscopy...........................................................................459
Mohamed A. Bedaiwy, Howard T. Sharp, Tommaso Falcone, and
William W. Hurd
22 Uterine Leiomyomas.......................................................................................491
Gregory M. Christman
23 Tubal Disease and Ectopic Pregnancy.................................................515

Mabel Lee, Rebecca Flyckt, and Jeffrey M. Goldberg
24 Endometriosis.....................................................................................................535
Dan I. Lebovic and Tommaso Falcone
25 Contraception: Evidence-Based Practice Guidelines

and Recommendations.................................................................................553
Ashley Brant, Rachel Shin, and Pelin Batur
26 urgical Techniques for Management of Anomalies of the

S
Müllerian Ducts..................................................................................................573
Marjan Attaran
27 Third-Party Reproduction...........................................................................601
Alexander Quaas
28 Uterus Transplantation.................................................................................613
Elliott G. Richards and Jenna M. Rehmer
Supplementary Information
Glossary......................................................................................................................630
Index............................................................................................................................ 635
IX
Contributors
Ashok Agarwal, PhD American Center for Reproductive Medicine, Depart-

ment of Urology, Cleveland Clinic, Cleveland, OH, USA
AGARWAA@ccf.org
Paula Amato, MD, MCR Division of Reproductive Endocrinology and Infertil-

ity, Department of Obstetrics and Gynecology, Oregon Health and Science
University, Portland, OR, USA
amatop@ohsu.edu
Raj Kumar Anirudh, BA University of Miami, College of Arts and Sciences,

Coral Gables, FL, USA
Christopher K. Arkfeld, MD Department of Obstetrics and Gynecology, Yale

School of Medicine, New Haven, CT, USA
christopher.arkfeld@yale.edu
Marjan Attaran, MD Department of Obstetrics and Gynecology, Section of

Pediatric and Adolescent Gynecology, Cleveland Clinic, Cleveland, OH, USA
attaram@ccf.org
Pelin Batur, MD Department of Obstetrics & Gynecology, Women’s Health

Institute, Cleveland Clinic, Cleveland, OH, USA
baturp@ccf.org
Mohamed A. Bedaiwy, MD, PhD Department of Obstetrics and Gynecology,

University of British Columbia, Vancouver, BC, Canada
Mohamed.Bedaiwy@cw.bc.ca
Charles L. Bormann, PhD, HCLD Department of Obstetrics, Gynecology, and

Reproductive Biology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
cbormann@partners.org
Ashley Brant, DO, MPH Department of Obstetrics & Gynecology, Women’s

Health Institute, Cleveland Clinic, Cleveland, OH, USA
branta2@ccf.org
Krystle Y. Chong, MBBS (Hons) Department of Obstetrics and Gynaecology,

Monash University, Clayton, VIC, Australia
krystle.chong@monashhealth.org
Gregory M. Christman, MD Division of Reproductive Endocrinology and

Infertility, Department of Obstetrics and Gynecology, University of Florida,
Gainesville, FL, USA
X Contributors
gchristman@ufl.edu
Tiffany M. Cochran, MD, MHA OB/GYN & Women’s Health Institute, Center
for Specialized Women’s Health, Cleveland Clinic Foundation, Cleveland, OH,
USA
cochrat3@ccf.org
Nina Desai, PhD, HCLD IVF Laboratory, Department of Obstetrics and

Gynecology, Cleveland Clinic Fertility Center, Beachwood, OH, USA
desain@ccf.org
Laura Detti, MD Department of Obstetrics and Gynecology, Division of

Reproductive Endocrinology and Infertility, Baylor College of Medicine,
Houston, TX, USA
Laura.Detti@bcm.edu
Sonia Elguero, MD Boston IVF-The Albany Center, Albany, NY, USA

selguero@bivfnewyork.com
M. Blake Evans, DO Section of Reproductive Endocrinology and Infertility,

Department of Ob/Gyn, University of Oklahoma Health Sciences Center,
Oklahoma City, OK, USA
michael-b-evans@ouhsc.edu
Tommaso Falcone, MD Cleveland Clinic London, London, UK

Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleve-
land, OH, USA
falcont@ccf.org
Rebecca Flyckt, MD Department of Obstetrics and Gynecology, Reproductive

Endocrinology and Infertility, University Hospitals Cleveland Medical Center,
Cleveland, OH, USA
rebecca.flyckt2@uhhospitals.org
Jason M. Franasiak, MD, HCLD/ALD (ABB) Reproductive Medicine Associates

of New Jersey, Marlton, NJ, USA
jfranasiak@ivirma.com
Gary N. Frishman, MD Department of Obstetrics and Gynecology, Warren

Alpert Medical School of Brown University, Women and Infants Hospital,
Providence, RI, USA
gfrishman@wihri.org
Julian A. Gingold, MD, PhD Albert Einstein College of Medicine, The Bronx,
NY, USA
jgingold@montefiore.org
Jeffrey M. Goldberg, MD Department of Obstetrics and Gynecology,

Reproductive Endocrinology and Infertility, Cleveland Clinic, Cleveland, OH,
USA
Contributors
goldbej@ccf.org
Eric Han, MD Section of Reproductive Endocrinology and Infertility,

Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale
School of Medicine, New Haven, CT, USA
eric.han@yale.edu
Karl R. Hansen, MD, PhD Section of Reproductive Endocrinology and

Infertility, Department of Ob/Gyn, University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
karl-hansen@ouhsc.edu
Pardis Hosseinzadeh, MD Section of Reproductive Endocrinology and

Infertility, Department of Ob/Gyn, University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
pardis-hosseinzadeh@ouhsc.edu
William W. Hurd, MD, MSc, MPH Division of Reproductive Endocrinology

and Infertility, University of Alabama School of Medicine,
Birmingham, AL, USA
whurd@uabmc.edu
Keith B. Isaacson, MD Newton Wellesley Hospital, Harvard Medical School,

Newton, MA, USA
Isaacson.Keith@mgh.harvard.edu
Tara K. Iyer, MD Center for Specialized Women’s Health, Department of

Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic,
Cleveland, OH, USA
iyert@ccf.org
Meaghan Jain, MD Albert Einstein College of Medicine, The Bronx, NY, USA
mejain@montefiore.org
Cyrus Jalai, MD Albert Einstein College of Medicine, The Bronx, NY, USA
cjalai@montefiore.org
Anna V. Jones, BS University of Alabama School of Medicine, Birmingham,

AL, USA
Avj97@uab.edu
Elizabeth J. Klein, MD Department of Obstetrics and Gynecology, Warren

Alpert Medical School of Brown University, Women and Infants Hospital,
Providence, RI, USA
elizabeth_klein@brown.edu
Alexander M. Kotlyar, MD Section of Reproductive Endocrinology and Infertility,

Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of
Medicine, New Haven, CT, USA
akotlyar@genesisfertility.com
XII Contributors
Dan I. Lebovic, MD Department of Obstetrics and Gynecology, Division of

Reproductive Endocrinology and Infertility, Washington University School of
Medicine, St. Louis, MO, USA
ldan@wustl.edu
Mabel Lee, MD Department of Obstetrics and Gynecology, Reproductive

Endocrinology and Infertility, University Hospitals Cleveland Medical Center,
Cleveland, OH, USA
mabel.lee@uhhospitals.org
Jennifer Ludgin, BA OB/GYN/IVF Research Intern, Department of Obstetrics

and Gynecology, Cleveland Clinic Fertility Center, Beachwood, OH, USA
Scott Lundy, MD, PhD Department of Urology, Glickman Urological and

Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
LUNDYS@ccf.org
Siddhi Mathur, MSc, MD Department of Obstetrics and Gynaecology, Mount

Sinai Hospital, Toronto, ON, Canada
Siddhi.Mathur@sinaihealth.ca
Ginevra Mills, MD Department of Obstetrics and Gynecology, McGill

University, Montréal, QC, Canada
ginevra.mills@mail.mcgill.ca
Ben W. Mol, MD, PhD Department of Obstetrics and Gynaecology, Monash

University, Clayton, VIC, Australia
Ben.mol@monash.edu
Emanuela Molinari, PhD Center for Human Reproduction, New York, NY,
USA
Michelle G. Park, MD Southern California MIGS Collaborative, AAGL,

ACOG, Los Angeles, CA, USA
mgpark6@yahoo.com
Bansari Patel, MD Atlanta Center for Reproductive Medicine, Atlanta, GA,

USA
Pasquale Patrizio, MD Department of Obstetrics, Gynecology and Reproduc-

tive Sciences, Division of Reproductive Endocrinology and Infertility, Univer-
sity of Miami, Miller School of Medicine, Miami, FL, USA
pxp612@med.miami.edu
Alexander Quaas, MD, PhD Division of Reproductive Endocrinology and

Infertility, University of California, San Diego, CA, USA
Reproductive Partners San Diego, San Diego, CA, USA
University Hospital Basel, Basel, Switzerland
Alexander.Quaas@usb.ch
Contributors
Jenna M. Rehmer, MD Reproductive Endocrinology and Infertility Division,

Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA
rehmerj@ccf.org
Elliott G. Richards, MD Reproductive Endocrinology and Infertility Division,

Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA
richare@ccf.org
Joseph S. Sanfilippo, MD, MBA Department of Obstetrics, Gynecology and

Reproductive Sciences, Division of Reproductive Endocrinology and Infertility,
Magee-Womens Hospital, Pittsburgh, PA, USA
Department of Obstetrics and Gynecology, University of Pittsburgh,
Pittsburgh, PA, USA
jsanfilippo@mail.magee.edu
Katherine L. Scott, MS, TS (ABB) Division of Reproductive Clinical Science,

Department of Obstetrics and Gynecology, Eastern Virginia Medical School,
Norfolk, VA, USA
Richard T. Scott Jr., MD, HCLD/ALD (ABB) Reproductive Medicine Associates

of New Jersey, Basking Ridge, NJ, USA
rscott@ivirma.com
Rakesh Sharma, PhD American Center for Reproductive Medicine, Depart-

ment of Urology, Cleveland Clinic, Cleveland, OH, USA
SHARMAR@ccf.org
Howard T. Sharp, MD Department of Obstetrics and Gynecology, University

of Utah Hospitals and Clinics, Salt Lake City, UT, USA
howard.sharp@hsc.utah.edu
Rachel Shin, MD, MPH Department of Obstetrics & Gynecology, Women’s

Health Institute, Cleveland Clinic, Cleveland, OH, USA
shinr@ccf.org
M. Jonathon Solnik, MD Department of Obstetrics and Gynaecology, Mount

Sinai Hospital, Toronto, ON, Canada
Head of Gynaecology and Minimally Invasive Surgery, Sinai Health System
and Women’s College Hospital, Toronto, ON, Canada
jonathon.solnik@sinaihealth.ca
Hugh S. Taylor, MD Department of Obstetrics and Gynecology, Yale School

of Medicine, New Haven, CT, USA
hugh.taylor@yale.edu
Holly L. Thacker, MD Center for Specialized Women’s Health, Department of

Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic,
Cleveland, OH, USA
thackeh@ccf.org
XIV Contributors
Togas Tulandi, MD, MHCM Department of Obstetrics and Gynecology,

McGill University, Montréal, QC, Canada
togas.tulandi@mcgill.ca
Sarah C. Vij, MD Department of Urology, Glickman Urological and Kidney

Institute, Cleveland Clinic, Cleveland, OH, USA
VIJS@ccf.org
Roxanne Vrees, MD Department of Obstetrics and Gynecology, Warren Alp-

ert Medical School of Brown University, Women and Infants Hospital, Provi-
dence, RI, USA
roxanne_vrees@brown.edu
Lynn M. Westphal, MD Department of Obstetrics and Gynecology, Stanford

University, Stanford, CA, USA
lynnw@stanford.edu
1 1
Hypothalamic-Pituitary-
Ovarian Axis and Control
of the Menstrual Cycle
Julian A. Gingold , Meaghan Jain, and Cyrus Jalai
Contents
1.1 Introduction – 2
1.2 The Menstrual Cycle – 2

1.2.1 T he Follicular Phase – 3
1.2.2 Early Luteal Phase – 3
1.2.3 Mid- to Late Luteal Phase – 4
1.3 Anatomy of the Menstrual Cycle – 5

1.3.1 ypothalamus – 5
H
1.3.2 Pituitary – 5
1.3.3 Ovaries – 8
1.3.4 Uterus – 9
1.4 Endocrinology of the Menstrual Cycle – 10

1.4.1 nRH Agonists and Antagonists – 11
G
1.4.2 Control of GnRH Pulsatility – 12
1.4.3 Structure of Gonadotropins – 12
1.4.4 Biological Sources of Sex Steroids – 12
1.4.5 Follicular Phase Endocrinology – 13
1.4.6 Luteal-Phase Endocrinology – 14
1.4.7 Additional Mediators – 16
1.5 Review Questions – 17
1.6 Answers – 18
References – 18
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022

T. Falcone, W. W. Hurd (eds.), Clinical Reproductive Medicine and Surgery,
https://doi.org/10.1007/978-3-030-99596-6_1
2 J. A. Gingold et al.
This chapter will cover how the time-,

1 Key Points location-, and dose-dependent interactions
55 The menstrual cycle is divided into fol- between the central nervous system, endo-
licular and luteal phases, with the fol- crine, and pelvic organs coordinate to reliably
licular phase starting with onset of grow and release one egg each month while
menses and ending with onset of the simultaneously preparing the endometrium
LH surge, and the luteal phase starting for a pregnancy. The first section details the
with onset of the LH surge and ending stages of the menstrual cycle. The second
with onset of menses. section covers the functional anatomy of the
5 5 The hypothalamic-pituitary-ovarian hypothalamus, anterior pituitary, ovaries, and
(HPO) axis is a tightly regulated sys- uterus. The third section discusses neuroendo-
tem controlling the menstrual cycle crine regulation of the menstrual cycle. The
and female reproduction through mul- last section also reviews the key hormones
tiple positive and negative feedback driving the menstrual cycle, with a particular
loops. focus on gonadotropin-releasing hormone
55 Pulsatile GnRH release into hypophy- (GnRH), follicle-stimulating hormone (FSH),
seal portal circulation stimulates pitu- luteinizing hormone (LH), estradiol, and pro-
itary LH and FSH production. LH and gesterone (. Table 1.1).
FSH are gonadotropins that stimulate
ovarian follicular development and
hormone production, leading to a slow 1.2 The Menstrual Cycle
rise in estradiol production during the
follicular phase and the onset of high The menstrual cycle is conventionally divided
progesterone production in the luteal into two different stages of ovarian activity as
phase. well as two phases of uterine response. The
55 The LH surge brings about resumption ovarian cycle includes the follicular phase and
of meiosis in the oocyte, production the luteal phase, separated by ovulation. The
of prostaglandins to facilitate follicu- uterine cycle includes the proliferative phase
lar rupture, and the formation of the and the secretory phase. Each menstrual cycle
corpus luteum, which produces the spans from the first full day of menstrual
hormones required to prepare the endo- bleeding to the first full day in the follow-
metrium for implantation. ing menstrual period. On average this cycle
lasts 28 days, though a cycle length between
24 and 38 days is considered within normal
range [1, 2]. This range is based on variation
1.1 Introduction on the length of the follicular/proliferative
phase, with the luteal/secretory phase remain-
The menstrual cycle is the product of a cas- ing relatively constant at 14 days. Normal
cade of hormones from many interacting menses last 3–8 days [1]. Bleeding quantity on
endocrine glands coordinating a cyclic ovar- average during menses is 30 mL, and blood
ian and uterine response. Ovarian produc- loss greater than 80 mL is considered heavy
tion of estrogens and progestins is largely menstrual bleeding [3]. While a wide variety
regulated by the hypothalamus and anterior of conditions may lead to abnormal uterine
pituitary gland, both of which are also regu- bleeding, deviations from these parameters
lated by serum hormone levels. The interplay in the menstrual cycle may suggest a break-
between these endocrine systems forms the down in regulation of the hypothalamic-pitu-
basis of the hypothalamic-pituitary-ovarian itary-ovarian axis or a structural abnormality
(HPO) axis. involving the pelvic organs [1, 4].
Hypothalamic-Pituitary-O varian Axis and Control of the Menstrual Cycle
3 1
.. Table 1.1 Major hormones of the hypothalamic-pituitary-ovarian axisa
Hormone Structure Gene Major site(s) of Half-life Serum

location production concentration
GnRH Decapeptide 8p21–8p11.2 Arcuate nucleus of 2–4 min N/A

hypothalamus
FSH Glycoprotein with α: 6q12.21 Gonadotrophs of 1.5–4 h 5–25 mIU/mL
α- and β-subunits β: 11p13 anterior pituitary
LH Glycoprotein with α: 6q12.21 Gonadotrophs of 20– 5–25 mIU/mL

α- and β-subunits β: 19q12.32 anterior pituitary 30 min
Estradiol 18 carbon steroid NA Granulosa cells 2–3 h 20–400 pg/mL

Proges- 21 carbon steroid NA Theca-lutein cells 5 min 0.1–30 ng/mL
terone
Inhibin Peptide with α- and α: 2q33 Granulosa cells 30– A: 10–60
β-subunits βA: 2q13 60 min B: 10–150 pg/
Inhibin A = α + βA βB: 7p15 mL
Inhibin B = α + βB
aReproduced with permission from Falcone and Hurd [110]
1.2.1 The Follicular Phase diol biosynthesis. Increased estradiol produc-

tion influences uterine response in the follicular
During the follicular (proliferative) phase of phase by stimulating proliferation of the endo-
the menstrual cycle, the dominant hormone, metrial glands. Rising estradiol also provides
FSH, stimulates folliculogenesis. Folliculogen- negative feedback to reduce GnRH production
esis involves recruitment of a cohort of imma- from the hypothalamus and decrease FSH pro-
ture antral follicles in the ovary, one of which duction from the pituitary in the early follicular
becomes the dominant follicle for the menstrual phase, thereby leading to apoptosis of the other
cycle. Antral follicles are visible on transvaginal more FSH-sensitive follicles recruited in that
ultrasound around menses as homogeneous cycle and limiting multifollicular ovulation.
hypoechoic cysts measuring 2–10 mm in mean
diameter across two dimensions. After receiv-
ing appropriate signals, one or more follicles 1.2.2 Early Luteal Phase
from the cohort of antral follicles grow to
maturation. The follicle that goes on to ovulate The luteinizing hormone surge marks the
is often recognizable several days prior to ovu- beginning of the luteal phase and triggers ovu-
lation as the so-called dominant follicle and is lation. The LH surge is mediated by a switch
typically the largest diameter follicle, growing to from negative pituitary feedback to estra-
17–25 mm prior to ovulation [5]. The dominant diol levels during the early follicular phase to
follicle is the most responsive to FSH, owing to positive feedback in response to rising estra-
its expression of the highest concentration of diol levels in the late follicular phase, with a
FSH receptors on its surface among the growing level > 200 pg/mL for over 50 hours being suf-
antral follicles [6]. Surrounding the dominant ficient to promote the LH surge [4]. It is also
follicle is a bed of granulosa cells expressing accompanied by a shift from inactive, glyco-
aromatase, the final enzyme involved in estra- sylated to biologically active, non-glycosylated
LH isoforms as estradiol levels rise [7]. For a Follicular Ovulation Secretory

1 granulosa cells to achieve this level of estra-
FSH and LH
diol, the dominant follicle typically has grown 50
to >15 mm [5, 8]. Animal studies on the nature
of the switch from negative to positive feed- 40 FSH
back of estradiol on LH production point to LH
increased estradiol inducing increased trans- 30
IU/L
mission of glutamate and gamma-aminobu-
tyric acid (GABA) in GnRH neurons [9, 10]. 20
The LH surge promotes the first meiotic divi-
sion of the oocyte in the dominant follicle, 10
previously arrested at the diplotene phase,
and the ultimate rupture of the follicle lead- 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
ing to oocyte release. Meiosis is not completed Cycle Day
until fertilization. Rupture occurs secondary b Estradiol and Inhibin
300
to LH-influenced production of prostaglan-
dins and eicosanoid signaling molecules that 250 Estradiol
Inhibin B
culminate in an ordered release of proteolytic 200 Inhibin A
enzymes [11]. Ovulation occurs about 36 hours
150
PG/ML
after the start of the LH surge and 12 hours

after the peak of the LH surge, leading to fol- 100
licular rupture and oocyte release [12]. The 50
fallopian tube, the typical site of fertilization,
will then sweep up the oocyte. 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Cycle Day
1.2.3 Mid- to Late Luteal Phase
c 16 Progesterone
Estrogen levels fall and progesterone levels dra- 14

matically rise during the luteal phase. While pro- 12
gesterone production from the follicle begins to 10
NG/ML
rise late in the follicular phase, it is predominantly 8

produced following the LH surge, which trans- 6
forms the granulosa cells in the basement mem- 4
brane into progesterone-producing luteal cells. 2
The combined cystic structure following 0
follicular rupture is called the corpus luteum,
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
literally “yellow body” in Latin. These luteal Cycle Day
cells are vacuolated and filled with lutein, a
straw-colored fluid. By day 7 or 8 of the luteal .. Fig. 1.1 Hormone fluctuations during the menstrual
phase, peak progesterone levels and vascu- cycle. a Mean values of FSH and LH throughout the
cycle. b Mean values of estradiol and inhibin. c Mean val-
larization of the corpus luteum are reached ues of progesterone during the menstrual cycle. (Repro-
(. Fig. 1.1) [13]. duced with permission from Falcone and Hurd [110])
Progesterone induces dramatic changes
on the endometrium, including cessation of
proliferation of endometrial glands, leading implantation. If embryo implantation occurs,
to increased glandular tortuosity, and appear- human chorionic gonadotropin (hCG), pro-
ance of vacuoles in the endometrial glands duced by the early embryo as early as 8–9 days
that soon secrete a range of proteins and pep- after fertilization, will cause the corpus luteum
tides into the endometrial cavity. These pro- to continue its production of progesterone via
cesses prepare the endometrium for embryo its action on the LH/hCG receptor [14].
5 1
If implantation does not occur, decreas- point they become hormonally active [15, 16].
ing LH levels late in the luteal phase, induced The GnRH neurons synthesize GnRH from a
by negative pituitary feedback, will cause a larger 92 amino-acid precursor [17]. GnRH,
drop in progesterone levels. Declining estro- which is released into the hypophyseal portal
gen and progesterone levels lead to enzymatic vessels, reaches the hypothalamus, thus allow-
degradation of the functionalis layer of the ing the arcuate nucleus of the hypothalamus to
endometrium, inflammatory infiltration, and control the pituitary gland [18].
vasoconstriction, thus beginning the process The hypothalamus also transmits several
of menses. During the late luteal phase, the other hormones via the hypophyseal portal
declining levels of estrogen and progesterone system to communicate with the anterior pitu-
reduce their negative feedback on FSH pro- itary. These hypothalamic hormones include
duction, enabling FSH levels to rise and begin growth hormone-releasing hormone (GHRH),
the menstrual cycle again. which prompts the anterior pituitary to release
growth hormone (GH); prolactin- releasing
hormone (PRH), which prompts the anterior
1.3 Anatomy of the Menstrual pituitary to stimulate milk production through
Cycle release of prolactin; thyrotropin-releasing hor-
mone (TRH), which modulates thyroid func-
This section will cover the anatomy of the tion by stimulating the anterior pituitary to
hypothalamus, pituitary, ovary, and uterus and release thyroid-stimulating hormone (TSH);
highlight the endocrinological connections and corticotropin-releasing hormone (CRH),
between them that underpin the HPO axis. which regulates adrenal function via anterior
pituitary production of adrenocorticotropic
hormone (ACTH).
1.3.1 Hypothalamus
The central nervous system is the primary 1.3.2 Pituitary

regulator of the menstrual cycle. Menstrual
cycle control originates from the hypothala- The pituitary gland is a small ovular structure
mus and pituitary gland. The hypothalamus suspended in the underside of the brain by the
is located at the base of the brain, below the pituitary stalk (infundibulum). It sits in a bony
third ventricle and above the pituitary gland cradle in the sphenoid bone called the sella
(. Fig. 1.2) [15]. It is bordered anteriorly by turcica (. Figs. 1.2 and 1.3) [16]. Due to the
the optic chiasm and inferiorly by the mam- location of the pituitary in the anatomically
millary bodies. The hypothalamus is a master confined sella turcica, significant enlargement
regulator of the menstrual cycle via its signals of the pituitary, as may occur with pituitary
to the anterior pituitary gland, but it also con- tumors such as prolactinomas, may cause
trols many other essential functions, including headache and compression of adjacent cranial
homeostasis, management of emotion and nerves involved in vision, leading to bilateral
behavior in connection with the limbic sys- hemianopsia, though most patients with pitu-
tem, circadian rhythms, the sleep-wake cycle, itary tumors are initially asymptomatic.
electrolyte balance, and food intake. There are two parts of the pituitary gland
The hypothalamus consists of three zones – (anterior and posterior) which have separate
lateral, medial, and periventricular. Each of embryonic origins and functions. The anterior
these zones contains several nuclei. The arcu- lobe, the relevant pituitary component of the
ate nucleus, located in the periventricular zone, hypothalamic-pituitary-ovarian axis, derives
produces GnRH and is the hypothalamic from an outpouching of the pharynx known
regulator of the HPO axis and reproduction. as Rathke’s pouch. The anterior lobe of the
During development, GnRH neurons originat- pituitary can be further divided into three
ing at the olfactory area migrate to the arcuate smaller parts – the pars anterior, pars inter-
nucleus along olfactory axon fibers, at which media, and pars tuberalis [18]. The pars ante-
.. Fig. 1.2 Illustration of the hypothalamus, pituitary, paraventricular nucleus, DM dorsal-medial nucleus, VM
sella turcica, and portal system. The arcuate nucleus is ventromedial nucleus, PH posterior hypothalamic
the primary site of GnRH-producing neurons. GnRH is nucleus, PM premammillary nucleus, LM lateral mam-
released from the median eminence into the portal sys- millary nucleus, MM medial mammillary nucleus. The
tem. The blood supply of the pituitary gland derives three hypothalamic areas are PA preoptic area, AH
from the internal carotid arteries. In addition to the anterior hypothalamic area, and DH dorsal hypotha-
arcuate nucleus, the other hypothalamic nuclei are SO lamic area. (Reproduced with permission from Falcone
supraoptic nucleus, SC suprachiasmatic nucleus, PV and Hurd [110])
rior lobe consists of glandular epithelium and neurotransmitters, such as GnRH, and trans-
secretes six major hormones: prolactin, GH, ports them to the next capillary plexus that
ACTH, FSH, LH, and TSH. surrounds the anterior pituitary [18].
The secretion of these hormones is con- In the case of the HPO axis, GnRH pro-
trolled by the hypothalamus via hormones duced by the hypothalamus reaches pituitary
that travel through the hypophyseal portal gonadotropes to stimulate FSH and LH release.
vessels to act on the specialized cells responsi- The other hypothalamic hormones transmit-
ble for secretion of each of the six hormones. ted through the hypophyseal portal system act
The hypophyseal portal vessels originate with on their own specific cell types in the anterior
a branch of the internal carotid artery, known pituitary, including thyrotropes, which produce
as the superior hypophyseal artery. The TSH; somatotrophs, which produce GH; lac-
hypophyseal artery forms a capillary plexus totrophs, which secrete prolactin; and cortico-
around the hypothalamus, where it picks up trophs, which secrete ACTH (. Table 1.2).
7 1
a b
c d
.. Fig. 1.3 X-ray and T1-weighted MRI images of the cica is not well seen on MRI. c Coronal section demon-
pituitary gland. a Lateral skull film with the sphenoidal strating the relationship of the pituitary to the optic
sinus and sella turcica. b Sagittal section demonstrating chiasm and the pituitary stalk. d Coronal section after
the relationship between the sphenoidal sinus and the gadolinium contrast, demonstrating the close proximity
pituitary gland. The normal posterior pituitary is brighter of the pituitary to the internal carotid arteries. (Repro-
on MRI compared to the anterior pituitary. The sella tur- duced with permission from Falcone and Hurd [110])
.. Table 1.2 Major cell types of the anterior pituitary glanda
Cell type Appearance on light Cellular Hormone products

microscopy frequency (%)
Somatotrophs Acidophilic 50 Growth hormone

Lactotrophs Acidophilic 20 Prolactin
Corticotrophs Basophilic 20 Adrenocorticotrophic hormone (ACTH)
Thyrotrophs Basophilic 5 Thyroid-stimulating hormone (TSH) and free
α-subunit
Gonadotrophs Basophilic 5 Follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and free α-subunit

The posterior lobe of the pituitary is

1 embryonically derived from the forebrain as
an extension of the hypothalamus. The poste-
rior lobe secretes two hormones – antidiuretic
hormone (responsible for regulation of blood
osmolarity) and oxytocin (secreted during
labor and with breastfeeding and involved
in milk release into lactiferous ducts, uterine
contractions, and social bonding).
1.3.3 Ovaries
The female gonads, the ovaries, are paired
ovular structures which embryologically orig-
inate in the mesonephric ridge and descend
into the pelvis [19]. The ovaries are the site of
development and maturation of oocytes, the
female gametes, and production of estradiol
(E2) and progesterone in response to LH and
FSH. The ovary can be divided histologically
into three components:
1. Surface – comprised of a single layer of
cuboidal epithelium
2. Cortex – comprised of connective tissue .. Fig. 1.4 Stages of follicular development. Each pri-
stroma and ovarian follicles containing mordial follicle contains an oogonium arrested in the
oocytes first meiotic division in prophase. The primordial follicle
is surrounded by a single layer of squamous granulosa
3. Medulla – comprised of connective tissue
cells. With each menstrual cycle, a small number of pri-
and a neurovascular network mordial follicles are recruited to become primary folli-
cles. Granulosa cells develop a second layer and become
In the ovarian cortex, granulosa and theca cuboidal. The zona pellucida, a layer of glycoproteins
cells surround each follicle. Prior to birth, separating the oocyte and granulosa cells, develops.
Upon completion of the first meiotic division, the pri-
these follicles are initially referred to as pri-
mary follicle becomes a secondary follicle. During this
mordial follicles, each containing an oogo- transition, a pool of follicular fluid known as the antrum
nium, which is derived from a primary germ coalesces and is surrounded by androgen- producing
cell. All primary oocytes in these primordial theca cells
follicles remain arrested in the prophase stage
of meiosis I until puberty. Immature follicles, The androgens, androstenedione, and tes-
not yet recruited, are surrounded by a thin tosterone, produced by the theca cells, diffuse
layer of granulosa cells [20]. With the onset of to the nearby granulosa cells, which express
puberty and a rise in FSH and LH during each the aromatase enzyme under the influence
menstrual cycle, a cohort of about 20 primor- of FSH signals and convert the androgens to
dial follicles are recruited to undergo the first estrogens (. Table 1.3). Theca cells express
stage of meiosis and become primary follicles. LH receptors but not FSH receptors, while
Once the first meiotic division is com- granulosa cells express FSH receptors but not
pleted, the follicle is termed a secondary follicle LH receptors [21]. For this reason, although
(. Fig. 1.4) [20]. During this stage of early fol- FSH is the only signal required for early follic-
licular maturation, stromal cells surrounding the ulogenesis, LH is essential for producing the
follicle differentiate into theca cells to produce androgens that form the substrate of estrogen
androgens under the influence of LH signals. biosynthesis to promote follicle maturation.
9 1
The ovarian arteries, which directly branch
.. Table 1.3 Site of synthesis of major
steroidogenic products of the ovary
from the abdominal aorta, provide the primary
vascular supply to the ovaries. Anastomotic
Cell type Major steroid hormone products contribution from the uterine arteries, which
branch from the anterior division of the inter-
Theca cells Androgens (androstenedione, nal iliac artery, provides collateral ovarian
DHEA, testosterone)
blood supply. Venous return occurs directly to
Granulosa Estrogens (estradiol, estrone, the inferior vena cava from the right ovarian
cells inhibin, AMH) vein and via the left renal vein from the left
Theca-lutein Progestogens (progesterone, ovarian artery [26].
cells 17-hydroxyprogesterone) Identification of the hilum at the antero-
Granulosa- Estrogens (estradiol, estrone) lateral aspect of the ovary is particularly
lutein cells important in surgical planning, for example,
during excision of ovarian cysts or endo-
metriomas adjacent to the hilum. Surgical
Granulosa cells within each follicle are injury to the hilum or thermal injury from
responsible for the final stages of estrogen use of electrosurgery can disrupt ovar-
production, primarily estradiol and, to a lesser ian blood supply and jeopardize remaining
extent, estrone. Granulosa cells are also the healthy ovarian tissue [27]. Ovarian vascular
source of anti-Mullerian hormone (AMH) anatomy is also particularly important dur-
and inhibin. AMH levels in reproductive-aged ing ovarian transposition surgery, in which
women reflect granulosa cell quantity, which the ovary is relocated with its suspensory
is itself correlated with the primordial follicle ligament blood supply in order to move the
pool. [22, 23] Thus, AMH is used clinically in ovaries out of the pelvis and protect them
the prediction of ovarian reserve for women from damage during therapeutic pelvic radi-
undergoing infertility evaluation [24]. ation.
Once ovulation has occurred, the cor-
pus luteum secretes estradiol and progester-
one initially under support of luteal-phase 1.3.4 Uterus
LH. If implantation occurs, embryonic hCG
allows the corpus luteum to continue produc- While it does not directly regulate the HPO
ing these hormones. Progesterone is primarily axis, the uterus cyclically responds to the fluc-
produced by the corpus luteum during early tuating hormones produced by it. The hor-
pregnancy until around 10 weeks gestational monal response of the endometrium is critical
age and is essential for maintaining the preg- for normal menstrual function and to prepare
nancy through around 7 weeks gestational age, the endometrium for embryonic implanta-
after which placental production is sufficient to tion. The uterus lies in the pelvis, between the
maintain the pregnancy [25]. If there is no preg- rectum and bladder. It consists of two parts,
nancy or hCG to rescue the corpus luteum, it the corpus (body) and the cervix. The uterine
will develop into a white fibrous streak in the wall contains three distinct layers:
ovary known as the corpus albicans [19]. 1. The perimetrium – the outermost layer
Each ovary has two peritoneal attachments. consisting of connective tissue.
The ovarian ligament attaches the ovary to the 2. The myometrium – the middle smooth
uterus and supplies secondary blood supply muscular layer. The myometrium distends
to the ovary. The suspensory ligament of the during pregnancy and contracts secondary
ovary (infundibulopelvic ligament) contains to hormonal stimuli.
the primary neurovascular structures and con- 3. Endometrium – the inner mucosal layer con-
nects the hilum of the ovary to the pelvic side- stituting the primary hormonally responsive
wall. Additionally, the ovary is attached to the tissue affected by the menstrual cycle (see
broad ligament via the mesovarium [26]. 7 Sect. 1.2).
The endometrium consists of two anatomic

1 layers – the functionalis and basalis. The
pyro-Glu1-His2-Trp3-Ser4-Tyr5-Gly6-Leu7-Arg8-Pro9-Gly10-NH2
functionalis layer constitutes the cellular

interface with the endometrial cavity and .. Fig. 1.5 Structure of GnRH-1. (Reproduced with
permission from Falcone and Hurd [110])
undergoes cyclic change with the menstrual
cycle. The basalis layer is primarily respon-
sible for regenerating the functionalis layer in First sequenced and characterized in 1971,
GnRH is a decapeptide (pGlu-His-Trp-Ser-
each cycle [28]. Increasing estrogen levels lead
Tyr-
to glandular proliferation, increase in stromal Gly-Leu-Arg-Pro-Gly-NH2) and is the
matrix, and elongation of terminal arterioles key regulator in the pituitary-gonadal axis
within the functionalis of the endometrium. (. Fig. 1.5) [30]. It is located as a single
Progesterone, which rises most dramati- gene copy on the short arm of chromosome
cally following the LH surge, causes the 8 and is secreted into the hypophyseal por-
endometrium to undergo secretory changes tal circulation to act chiefly on the anterior
characterized by terminal artery lengthening, pituitary gland. GnRH synthesis occurs in a
superficial stromal edema, and glandular tor- small subset of hypothalamic neurons which
secrete it in pulsatile fashion into the hypoph-
tuosity. If implantation does not occur, falling
estrogen/progesterone levels lead to cessationyseal portal blood system, through which it is
of glandular activity and stromal development,transported to the anterior pituitary gland.
ultimately ending with enzymatic degradation Binding and activation of GnRH receptors
and vasoconstriction within the functionalis triggers LH and FSH synthesis and release,
[29]. The functionalis layer becomes unstable ultimately leading to gametogenesis and
and sloughs off with menses. gonadal steroidogenesis for sexual maturation
Inappropriately coordinated hormonal and reproductive function [31].
influences on the endometrium and lack of The approximately 1000–3000 GnRH-
cyclic hormonal response will result in patho-producing cells found in the arcuate nucleus
logical endometrial findings. For example, in of the hypothalamus arrive there via neuroen-
cases of unopposed estrogen due to anovula- docrine cell migration during embryogenesis
from the olfactory placode. Abnormalities in
tory cycles, as frequently seen in patients with
obesity, polycystic ovarian syndrome, or otherthis migratory pathway have clinical ramifica-
metabolic disorders, endometrial tissue can tions: Kallmann syndrome (KS) represents
respond with continuous proliferation, and a failure in olfactory and GnRH neuronal
potentially progress to hyperplasia or malig- migration from the olfactory placode to
nancy [29]. the hypothalamus resulting in GnRH defi-
ciency. A number of distinct genetic causes
for defects in GnRH migration have been
1.4 Endocrinology identified, including variants with X-linked,
of the Menstrual Cycle autosomal dominant, and autosomal reces-
sive inheritance patterns, though the X-linked
Human reproduction hinges on an intact form is the most common. Because KS genetic
HPO axis demanding an ordered response mutations impair cell migration in nasal areas,
across multiple organ systems. First, GnRH- patients experience both hypothalamic amen-
secreting neurons direct gonadotrophs to pro- orrhea and anosmia (inability to smell) [32,
duce LH and FSH. These hormones primarily 33]. The clinical spectrum of other isolated
act on ovarian tissue to promote synthesis of gonadotrophic-release hormone deficiencies
the major female sex hormones estradiol and also includes constitutional delay of puberty
progesterone. Finally, the sex hormones act and adult-onset hypothalamic hypogonadism.
on steroid receptors throughout the body to At least two GnRH isoforms have been
produce dramatic changes in gene transcrip- identified in humans and additional GnRH
tion, including dramatic effects on the endo- isoforms exist in fish, amphibians, and pro-
metrium. tochordates [31, 34]. In humans, GnRH-I is
11 1
the “classical” GnRH isoform that regulates 1.4.1 GnRH Agonists
synthesis and secretion of FSH and LH [35]. and Antagonists
The other main GnRH isoform in humans
is the “chicken-GnRH/GnRH-II” isoform. The half-life of GnRH is approximately
GnRH-II is conserved from fish to mammals 2–4 minutes, due to rapid cleavage of the
and differs from the classical GnRH-I by only bonds between amino acids 5–6, 6–7, and
three amino acids. However, its expression is 9–10. Chemical alteration of the amino acids
localized to specific nuclei (supraoptic, para- in GnRH at these positions, combined with
ventricular, suprachiasmatic) of the central carboxyl- and amino-terminal modifications,
nervous system and peripheral tissues (medial has enabled the synthesis of an array of GnRH
basal hypothalamus and female reproductive peptide analogues with distinct properties,
tissues including ovaries/placenta/endome- including longer half-life, pure agonist activ-
trium) but has a limited role in the menstrual ity, and pure antagonist activity (. Table 1.4).
cycle. Its role appears to be in regulating sex- A number of these peptide analogues have
ual behavior [36–38]. found clinical applications. Continuous use
GnRH pulse control is regulated by of GnRH agonists leads to high-affinity bind-
multiple hormones and neurotransmitters. ing to and occupancy of the GnRH receptor.
Among them, dopamine, secreted directly GnRH agonist binding to its receptor induces
into portal blood via the hypothalamic tuber- initial gonadotroph activation and FSH/LH
oinfundibular pathway, suppresses arcuate synthesis (the so-called “flare” effect), followed
GnRH production. In contrast, norepineph- by desensitization and downregulation of the
rine cell bodies located in the mesencephalon GnRH receptor, leading to suppressed FSH
and lower brainstem stimulate GnRH pro- and LH levels within 1–3 weeks [15, 39–41].
duction. GnRH antagonists do not produce this initial
.. Table 1.4 Properties of commercially available GnRH agonistsa
Structure and substitutions at Half-life Relative Route of administration

positions 6 and 10 potency
GnRH Native decapeptide 2–4 min 1 IV, SC

Nafarelin Decapeptide 3–4 h 200 Intranasal
6: D-Naphthylalanine for Gly
Triptorelin Decapeptide 3–4 h 36–144 SC, IM depot
6: D-Trp for Gly
Leuprolide Nonapeptide 1.5 h 50–80 SC, IM depot
6: D-Leu for Gly
10: NHEt for Gly
Buserelin Nonapeptide 1.5 h 20–40 SC, intranasal
6: Ser(OtBu) for Gly
10: NHEt for Gly
Goserelin Decapeptide 4.5 h 50–100 SC implant
6: Ser(OtBu) for Gly
10: AzaGly for Gly
Histrelin Decapeptide 50 min 100 SC
6: DHis for Gly
10: AzaGly for Gly

agonistic activity, and instead lead to immedi-

1 ate suppression of LH and FSH production
.. Table 1.5 Menstrual cycle variation in LH
pulse frequency and amplitudea
via competitive inhibition [42–44].
Non-peptide, small molecular GnRH antag- Cycle phase Mean Mean amplitude
onists have also been developed. These drugs frequency (mIU/mL)
mechanistically work as peptide GnRH antago- (min)
nists do but offer oral bioavailability, which is
Early 90 6.5
not possible with peptides. Elagolix, a competi- follicular
tive non-peptide GnRH receptor antagonist,
Mid-follicular 50 5
has FDA approval for treatment of moderate
to severe endometriosis [45, 46]. Another oral Late follicular 60–70 7
GnRH antagonist, relugolix, has been approved Early luteal 100 15
in Japan for treatment of uterine myomas.
Mid-luteal 150 12
Late luteal 200 8
1.4.2 Control of GnRH Pulsatility
aReproduced with permission from Falcone and
Hurd [110]
GnRH neurons retain the ability to synchro-
nize GnRH release into the hypothalamic-
hypophyseal portal vessels as pulses. Variations
in the GnRH pulse frequency and amplitude FSH production that is necessary to recruit a
lead to differential production of FSH and LH, cohort of follicles for the next cycle [51].
thus allowing one hormone to simultaneously
regulate the levels of its two primary targets.
Direct measurement of GnRH production is 1.4.3 Structure of Gonadotropins
technically challenging because the hormone
has a 2–4-minute half-life and is restricted to FSH, LH, TSH, and hCG are all glycoprotein
the hypophyseal portal vessels, though direct heterodimers composed of a shared 92 amino-
measurement via portal blood collection under acid alpha subunit and a unique beta subunit.
anesthesia has been performed in animal mod- The beta subunits in these hormones enable
els [47, 48]. Because LH has a much shorter their differential functions and pharmacology.
half-life than FSH (20 minutes versus 3 hours), FSH and LH beta subunit biosynthesis and
serum LH levels primarily reflect recent LH availability, controlled by GnRH, is the rate-
production under GnRH control. Thus, human limiting step of gonadotropin production.
studies attempting to measure GnRH levels
have used serial measurements of LH levels as
surrogate for GnRH production. Such studies 1.4.4 iological Sources of Sex
B
have demonstrated that low-frequency GnRH Steroids
pulses (<1 pulse/2–3 hours) preferentially stim-
ulate FSH, while high-frequency GnRH pulses Estradiol (E2), the most potent biologically
(1 pulse/60–90 min) preferentially stimulate produced estrogen, is the main secretory
LH production (. Table 1.5). GnRH pulsatil- product of the follicle. Additional estrogen
ity appears to be controlled by GnRH-I gene steroid hormones include estrone (E1) and
promoter activity in GnRH-producing hypo- estriol (E3). Estrone is formed principally
thalamic tissue [49]. In the absence of ovarian by peripheral conversion of androstenedi-
regulation, GnRH pulses occur approximately one, though smaller amounts are made from
once per hour [50]. The follicular phase is char- hepatic conversion of estradiol via 17-beta-
acterized by higher frequency, lower amplitude hydroxysteroid dehydrogenase activity. Estriol
GnRH pulses favoring LH production, while is the main form of estrogen formed by the
the luteal phase is characterized by lower fre- placenta in pregnancy and is only produced
quency, higher amplitude pulses favoring the at biologically active doses during pregnancy,
13 1
though some hepatic production outside of mediate conversion of 17-hydroxypregneno-
pregnancy occurs via 16α-hydroxylation of lone to androgens, which are then shuttled to
estradiol or estrone. neighboring granulosa cells for aromatization
Estrogens, including estradiol, are largely to estrogens (. Fig. 1.6). Androgens, includ-
bound to carrier proteins in the bloodstream. ing testosterone, androstenedione, dehydro-
Albumin and sex hormone-binding globu- epiandrosterone (DHEA), are produced by
lin bind 98% of total estradiol, leaving only the theca cells, with androstenedione being
2% circulating freely in the bloodstream and the major product. Testosterone is primarily
bioavailable. Unbound estradiol, like all sex derived from peripheral conversion of andro-
steroid hormones, is fat-soluble and freely stenedione via 17β-hydroxysteroid dehydro-
enters cells. Estrogens are only active in cells genase. Androstenedione and testosterone
expressing estrogen receptors. Inside the cyto- undergo aromatization in granulosa cells, at
plasm estradiol binds to its cognate steroid which point they are converted to estradiol
receptors, estrogen receptor-alpha and estro- (. Fig. 1.7).
gen receptor-beta, before undergoing nuclear
translocation and facilitating transcription of
a wide range of genes [52, 53]. 1.4.5 Follicular Phase
In preovulatory follicles, androgen and Endocrinology
estrogen synthesis is accomplished preferen-
tially via the “delta-5” steroidogenic pathway, The early follicular phase is marked by serum
involving the conversion of pregnenolone to estradiol levels typically <50 pg/mL. FSH
17-hydroxypregnenolone. Theca cells then begins rising a couple of days prior to menses
Blood Stream
Theca Cell Granulosa Cell
Cholesterol
Estradiol
CYP 11A1
Pregnenolone
17βHSD
LH cAMP cAMP FSH
CYP 17
17-OH-Pregnenolone Estrone
CYP 17
Aromatase
DHEA
3β-HSD
Androstenedione Androstenedione
.. Fig. 1.6 The two-cell theory of ovarian steroidogen- stimulates the aromatization of androgens to estrogens.
esis. Binding of luteinizing hormone (LH) to its receptor cAMP cyclic adenosine monophosphate, CYP11A1 side-
on ovarian theca cells stimulates the conversion of choles- chain cleavage enzyme, CYP17 17-hydroxylase, HSD
terol to androstenedione. Binding of follicle-stimulating hydroxysteroid dehydrogenase, 17-OH pregnenolone
hormone (FSH) to its receptor on ovarian granulosa cells 17-hydroxypregnenolone
Cholesterol
1 C27
P450scc ∆5 Pathway
P450c17 P450c17
Pregnenolone 17 Hydroxypregnenolone DHEA
C21 C21 C19
3βHSD 3βHSD
∆5 Pathway
P450c17 P450c17
Progesterone 17 Hydroxyprogesterone Androstenedione Testosterone
C21 C21 C19 17βHSD C19
Aromatase Aromatase
Estrone Estradiol
C18 17βHSD C18
.. Fig. 1.7 The Δ(delta)5 and Δ(delta)4 pathways. ehydroepiandrosterone (DHEA). In contrast, the corpus
d
The rate-limiting step in steroidogenesis is the con- luteum preferentially converts pregnenolone to proges-
version of cholesterol to pregnenolone via side-chain terone (Δ4 pathway) via 3β(beta) hydroxysteroid dehy-
cleavage (P450scc). In the follicular phase, pregneno- drogenase (3βHSD). (Reproduced with permission from
lone is preferentially converted to androstenedione via Falcone and Hurd [110])
the Δ5 pathway involving 17-hydroxypregnenlone and
and is critical for the recruitment of ovarian to continue expressing aromatase and synthe-
follicles (. Fig. 1.1). Increasing FSH levels size estrogens locally to further enhance FSH
lead to antral follicle growth of 2–6 mm/day. action despite the declining pituitary FSH
Each granulosa cell has approximately 1500 production during the late follicular phase
FSH receptors enabling rapid E2 production triggered by the rising serum estrogen. Thus,
[6]. In the presence of rising estradiol levels, the dominant follicle can continue to grow
FSH stimulates formation of LH receptors on while the other follicles undergo apoptosis.
granulosa cells permitting small progesterone Estradiol levels, produced by aromatase in the
and 17-hydroxyprogesterone production, ini- granulosa cells in the dominant follicle, con-
tially providing positive feedback to the pitu- tinue to rise during the follicular phase until
itary to augment LH release and supporting they peak at 200–250 pg/mL around the time
the biosynthesis of the androgen precursors of ovulation during a monofollicular ovula-
required for further estradiol biosynthesis. tory cycle.
However, rising estrogen levels during early
follicular development induce downregula-
tion of pituitary synthesis of the FSH beta 1.4.6 Luteal-Phase Endocrinology
subunit [54].
The follicle destined for ovulation (the so- The LH surge mediates the transition to the
called dominant follicle) is selected at approxi- luteal phase. LH levels can fluctuate more
mately cycle day 7. This follicle expresses the dramatically than FSH in part because LH
greatest concentration of FSH receptors on has a shorter half-life, approximately 20 min-
the surface of its granulosa cells, allowing it utes compared with several hours for FSH
15 1
(. Table 1.1). Although various sugars com- contain LH receptors. Gap junctions between
prise the carbohydrate components of these these two cell types enable rapid response to
glycoproteins, sialic acid is the critical regula- LH stimulation and efficient progesterone
tor of their half-life [55–57]. LH has fewer gly- production [62]. Luteal-phase progesterone
cosylation sites and therefore fewer sialic acid secretion causes a decline in GnRH pulse fre-
residues on average on its beta subunit than quency from the hypothalamus, thereby ter-
FSH, enabling more rapid elimination [58]. minating the LH surge.
LH levels begin to rise just prior to the There is large natural variation in luteal-
onset of menses and rise gradually through- phase plasma progesterone levels, ranging
out the follicular phase before peaking prior to from 2.3 to 40.1 pg/mL over 24 hours within
ovulation. This LH surge occurs secondary to the same healthy patient [57]. However, the
positive feedback from high levels of circulat- essential role of luteal progesterone is dem-
ing estrogen. LH levels then decline during the onstrated clearly in assisted reproduction
secretory phase (. Fig. 1.1). The LH surge cycles complicated by luteal-phase deficiency
triggers resumption of meiosis in the oocyte, a (LPD), a condition in which the corpus
switch toward increased progesterone produc- luteum produces insufficient progesterone to
tion from the theca-granulosa cells, produc- support a necessary secretory endometrium
tion of eicosanoids in the follicle, and finally for embryo implantation and survival. It is
follicular rupture to release the oocyte. speculated that this is due to hypothalamic/
Following ovulation, remaining granu- pituitary downregulation or disruption of
losa cells that are not released with the oocyte granulosa cells during oocyte retrieval. Use
enlarge and eventually vacuolate and luteinize. of either progesterone or hCG (to promote
These luteinized granulosa cells combine with endogenous progesterone production) dur-
theca-lutein cells and surrounding stroma to ing assisted reproduction cycles in the luteal
compose the corpus luteum. Intensive neo- phase improves live birth rates [63]. The ideal
vascularization stimulated by pituitary LH luteal progesterone level to support a preg-
is central to corpus luteum formation and is nancy and the optimal method for luteal sup-
mediated by VEGF, fibroblast growth factors, port in assisted reproduction cycles remains
angiopoietins, and insulin-like growth fac- unknown.
tors [59, 60]. The corpus luteum is the critical Progesterone, a steroid hormone largely
source of progesterone and estradiol, both of bound in the bloodstream to albumin and cor-
which are essential for preparing the endome- ticosteroid-binding globulin, exerts its effects
trium for pregnancy and then supporting it by binding of its unbound form to progester-
through the early first trimester. Progesterone one receptors (PRs). There are two predomi-
levels are typically <2 ng/mL in the follicular nant PR isoforms, PR-A and PR-B, which are
phase, while exceeding 5 ng/mL during its transcribed from alternate start sites in the
peak in the luteal phase, thanks to active pro- same gene. PR-A is the predominant form in
duction by the corpus luteum. The individual the uterus and the main mediator of decidu-
corpus luteum can survive for 11–17 days alization in humans. A shorter, N-terminally
(mean 14.2) independent of LH secretion [61]. truncated receptor isoform, PR-C, has been
Estradiol levels drop following ovulation detected by biochemical means. However, it
but rise again in the mid-luteal phase due to lacks the ability to initiate transcription and
increased production by the corpus luteum. does not appear to be a naturally occurring
Progesterone production from the corpus isoform [64]. PR-A and PR-B are induced in
luteum depends on availability of circulating preovulatory follicles in as few as 4–8 hrs in
cholesterol substrate. The granulosa cells pre- response to LH stimulation and are required
viously surrounding the follicle become luteal for LH-dependent follicular rupture [65].
cells, which have significant steroidogenic PR-A is transcriptionally less active than
capacity but lack LH receptors. Luteal cells PR-B and can function to inhibit PR-B. [66]
remain in close contact with theca cells, which However, PR-A alone is necessary and suf-
ficient to regulate ovulatory function [67]. again midcycle, and then remain low during
1 PR-A knockout mice develop mature func- the luteal phase. FSH secretion from the ante-
tional follicles with a severe impairment in rior pituitary is therefore regulated by nega-
the ability to rupture (ovulate), while PR-B tive feedback from FSH- promoted inhibin
knockout mice remain largely unaffected dur- release by granulosa cells [83, 84]. Inhibin A,
ing superovulation [68–70]. secreted by the corpus luteum, dominates the
luteal phase of the menstrual cycle and may
be involved in the gradual release of ovarian
1.4.7 Additional Mediators negative feedback on FSH secretion during
the final days of the menstrual cycle during
Follistatin is a highly glycosylated monomeric the luteal-follicular transition [85].
protein found in follicular fluid that binds The selective inhibitory role of inhibin on
activins with high affinity for important endo- FSH production was largely established from
crine regulation at the level of the pituitary experimental animal models. Administration
[71, 72]. The activin-inhibin-follistatin triad of serum containing anti-inhibin antibodies
together directs the synthesis and secretion of in rats and hamsters led to increased serum
FSH and thereby folliculogenesis. The bipha- FSH-beta mRNA but no change in LH-beta
sic release of FSH (in the late luteal/early fol- mRNA levels [86]. While the clinical utility
licular phase and then in the late follicular of monitoring inhibin levels during assisted
phase/periovulation) is attributed to the bal- reproduction cycles is limited, higher serum
ance of activin and follistatin. inhibin A and B levels are noted on the day of
Activins and inhibins are structurally ovulation trigger and overall in patients with
related protein heterodimers that, despite cycles complicated by ovarian hyperstimula-
structural similarity, function antagonistically. tion syndrome [87].
Activin is derived from ovarian granulosa Anti-Mullerian hormone (AMH), a mem-
cells and contains two subunits identical to ber of the transforming growth factor-beta
the beta subunits of inhibin A and B. Activin family of glycoprotein differentiation factors,
functions to augment FSH secretion and comes from the same gene family as activins
block prolactin, ACTH, and GH secretion and inhibins. AMH functions chiefly during
[73, 74]. It also increases FSH receptor num- embryogenesis to inhibit Mullerian duct for-
ber and binding in the granulosa cell and aug- mation [88, 89]. Its functions later in life are
ments stimulation of aromatization [75]. less clear, though AMH produced by granu-
Additionally, the ovarian granulosa cells, losa cells during adulthood has autocrine and
as well as pituitary gonadotropes, also pro- paracrine effects on oocyte maturation and
duce inhibins, which function to block FSH development [90]. AMH paracrine activity
secretion by the pituitary gland [73, 76, 77]. inhibits FSH-stimulated follicle growth, per-
There are two forms of inhibin, inhibin A and mitting selection of a dominant follicle [91].
inhibin B, differing only by their beta subunit. Circulating AMH levels are highest in the
Inhibin B predominates in the early follicular late follicular phase, peaking simultaneously
phase before decreasing and giving way for with inhibin A levels just prior to ovulation,
inhibin A production before ovulation, which though these findings are of limited clinical
then dominates during luteal phase [76, 78–80]. relevance and random AMH levels are rou-
Inhibin B production declines as follicles grow tinely obtained to measure ovarian reserve
above 10–14 mm, while inhibin A remains [81, 92].
actively produced. Inhibin B is secreted by Leptin, an adipokine produced by adi-
growing antral follicle granulosa cells during pose tissue, reflects levels of body fat and is
the early follicular phase and has been used primarily involved in energy homeostasis
historically as a marker for follicular health [93]. Leptin levels also regulate the reproduc-
and number [81, 82]. Inhibin B production is tive cycle and fluctuate in reproductive-age
positively regulated by FSH: levels peak early women during a menstrual cycle [94]. Higher
in the follicular phase, decline until they peak leptin concentrations are noted in the luteal
17 1
phase, and studies in goat model systems sug-
.. Table 1.6 Neurotransmitter effects on
gest that leptin upregulates angiogenic factors GnRH releasea
to support early corpus luteum formation [95,
96]. Moreover, leptin deficiency under various Neurotransmitter Effect
pathological conditions such as hypothalamic
amenorrhea or lipodystrophy leads to anovu- Dopamine Inhibits GnRH
release
lation, and replacement with recombinant
leptin can restore menstrual cycle regularity Endorphin Inhibits GnRH
and enable fertility [97, 98]. release
Kisspeptin, encoded by the KISS1 gene, Serotonin Inhibits GnRH
plays a crucial role as a regulator of normal release
reproductive function, gonadotropin secre- Norepinephrine, Stimulates GnRH
tion, sex hormone-mediated feedback, and epinephrine release
adult fertility [99]. Kisspeptin signals directly
to GnRH neurons to release GnRH into por- aReproduced with permission from Falcone and
tal circulation, enabling pulsatile LH secre- Hurd [110]
tion, implying that it also regulates ovulation.
Kisspeptin may support reproductive function
by maintaining LH-dependent expression of preproenkephalin B. These opioids retain
ovarian matrix metalloproteinases [68]. Loss- multiple endocrine functions, including medi-
of-function mutations of the KISS1R (kiss- ating secretion of FSH, LH, and prolac-
peptin receptor) have been linked to pubertal tin. An increase in endorphin release results
failure disorders, implying that kisspeptin is in a decrease in LH pulse frequency [106].
required for puberty onset and maintenance Consequently, an increase in endogenous opi-
of normal reproductive functions [100, 101]. oids is implicated in the pathogenesis of hypo-
More recent studies have centered on arcu- thalamic amenorrhea in female athletes [107].
ate nuclear co-expression of neurokinin, dyn- Conversely, opioid receptor blockers increase
orphin, and kisspeptin, forming the so-called LH pulse frequency [108]. For women with
KNDy neurons, known to play a role in the hypothalamic amenorrhea, treatment with
tonic control of gonadotropin secretion by opioid receptor antagonists can enable return
modulating GnRH release. The KNDy para- of cyclical menses [109]. Opioids affect
digm proposes that neurokinin stimulates and gonadotropin secretion primarily by modu-
dynorphin inhibits kisspeptin secretion onto lating GnRH and in feedback pathways with
GnRH neurons [102]. Additional support gonadal sex steroid hormones (. Table 1.6).
for this model derives from studies indicat-
ing neuronal hypertrophy in postmenopausal
mammalian animal models and hypogonado- 1.5 Review Questions
tropic hypogonadism in comparable species
during their reproductive periods [103]. ??1. What is the effect of progesterone on
Endogenous opioids are found widely the endometrium?
throughout the body, though they are found A. Cessation of proliferation of endo-
in greatest concentrations within the arcuate metrial glands, leading to increased
nucleus of the medial basal hypothalamus glandular tortuosity
and in hypophyseal portal blood [104, 105]. B. Hypertrophy and proliferation of
The three major endogenous opioid pep- glands
tide classes – endorphins, enkephalins, and C. Enzymatic degradation and vaso-
dynorphins – are derived from three precur- constriction
sor proteins, respectively: pre-opiomelano- D. Increase in stromal matrix and
cortin (POMC), preproenkephalin A, and elongation of terminal arterioles
??2. Which ligament provides the primary 6. Amsterdam A, Rotmensch S. Structure-function

1 neurovascular supply to the ovary? relationships during granulosa cell differen-
tiation*. Endocr Rev. 1987;8(3):309. https://doi.
A. Broad ligament
org/10.1210/edrv-8-3-309.
B. Infundibulopelvic ligament 7. Anobile C. Glycoform composition of serum
C. Ovarian ligament gonadotrophins through the normal menstrual
D. Uterosacral ligament cycle and in the post-menopausal state. Mol Hum
Reprod. 1998;4(7):631. https://doi.org/10.1093/
molehr/4.7.631.
??3. What is the effect of continuous GnRH
8. Cahill DJ, Wardle PG, Harlow CR, Hull
administration on long-term LH and MGR. Onset of the preovulatory luteinizing hor-
FSH release? mone surge: diurnal timing and critical follicular
A. No effect prerequisites. Fertil Steril. 1998;70(1):56. https://
B. Increase doi.org/10.1016/S0015-0282(98)00113-7.
9. Christian CA, Moenter SM. Estradiol induces diur-
C. Decrease
nal shifts in GABA transmission to gonadotropin-
D. Loss of cyclic release without net releasing hormone neurons to provide a neural
change signal for ovulation. J Neurosci. 2007;27(8):1913.
https://doi.org/10.1523/JNEUROSCI.4738-0 6.
2007.
10. Roberts CB, Best JA, Suter KJ. Dendritic pro-
1.6 Answers cessing of excitatory synaptic input in hypotha-
lamic gonadotropin releasing-hormone neurons.
vv1. A. Cessation of proliferation of endo- Endocrinology. 2006;147(3):1545. https://doi.
metrial glands, leading to increased org/10.1210/en.2005-1350.
glandular tortuosity 11. Fukumoto M, Yajima Y, Okamura H, Midori-
kawa O. Collagenolytic enzyme activity in human
ovary: an ovulatory enzyme system. Fertil Steril.
vv2. B. Infundibulopelvic ligament 1981;36(6):746. https://doi.org/10.1016/S0015-
0282(16)45920-0.
vv3. C. Decrease 12. Pauerstein CJ, Eddy CA, Croxatto HD, Hess R,
Siler-Khodr TM, Croxatto HB. Temporal rela-
tionships of estrogen, progesterone, and lutein-
izing hormone levels to ovulation in women and
References infrahuman primates. Am J Obstet Gynecol.
1978;130(8):876. https://doi.org/10.1016/0002-
1. Fraser I, Critchley H, Broder M, Munro M. The 9378(78)90264-8.
FIGO recommendations on terminologies and defi- 13. Miyazaki T, Tanaka M, Miyakoshi K, Minegi-
nitions for normal and abnormal uterine bleeding. shi K, Kasai K, Yoshimura Y. Power and colour
Semin Reprod Med. 2011;29(5):383. https://doi. Doppler ultrasonography for the evaluation of the
org/10.1055/s-0031-1287662. vasculature of the human corpus luteum. Hum
2. Munro MG, Critchley HOD, Broder MS, Fraser Reprod. 1998;13(10):2836. https://doi.org/10.1093/
IS. FIGO classification system (PALM-COEIN) for humrep/13.10.2836.
causes of abnormal uterine bleeding in nongravid women 14. Lopata A, Hay DL. The potential of early human
of reproductive age. Int J Gynecol Obstet. 2011;113(1): embryos to form blastocysts, hatch from their
3. https://doi.org/10.1016/j.ijgo.2010.11.011. zona and secrete HCG in culture. Human Reprod.
3. Hallberg L, Hôgdahl A-M, Nilsson L, Rybo 1989;4(suppl 1). https://doi.org/10.1093/humrep/4.
G. Menstrual blood loss–a population study: varia- suppl_1.87
tion at different ages and attempts to define normal- 15. Schwanzel-Fukuda M, Pfaff DW. Origin of
ity. Acta Obstet Gynecol Scand. 1966;45(3):320. luteinizing hormone-releasing hormone neurons.
https://doi.org/10.3109/00016346609158455. Nature. 1989;338(6211):161. https://doi.org/10.1038/
4. Hackelöer BJ, Fleming R, Robinson HP, Adam AH, 338161a0.
Coutts JR. Correlation of ultrasonic and endocri- 16. Silverman AJ, Jhamandas J, Renaud LP. Localiza-
nologic assessment of human follicular develop- tion of luteinizing hormone-releasing hormone
ment. Am J Obstet Gynecology. 1979;135(1):122–8. (LHRH) neurons that project to the median emi-
5. Young JR, Jaffe RB. Strength-duration character- nence. J Neurosci. 1987;7(8):2312–9.
istics of estrogen effects on gonadotropin response 17. Nikolics K, Mason AJ, Szőnyi É, Ramachandran J,
to gonadotropin-releasing hormone in women. Seeburg PH. A prolactin-inhibiting factor within the
II. Effects of varying concentrations of estradiol. precursor for human gonadotropin-releasing hor-
J Clin Endocrinol Metabol. 1976;42(3):432. https:// mone. Nature. 1985;316(6028) https://doi.org/10.
doi.org/10.1210/jcem-42-3-432. 1038/316511a0.
19 1
18. Mancall E, Brock D. Gray’s clinical neuroanat- ics in otorhinolaryngology. Basel: KARGER;
omy. The anatomic basis for clinical neuroscience. 2000. https://doi.org/10.1159/000059073.
1st ed. Philadelphia: Elsevier Saunders; 2011. 34. Morgan K, Millar RP. Evolution of GnRH ligand
19. Agur AM, Dalley AF. Moore’s essential clinical precursors and GnRH receptors in protochord-
anatomy. 6th ed. Philadelphia: Wolters Kluwer; ate and vertebrate species. Gen Comp Endocri-
2019. nol. 2004;139(3):191. https://doi.org/10.1016/j.
20. Carneiro J, Junqueira LC. Basic histology: text & ygcen.2004.09.015.
atlas. New York: McGraw Hill; 2005. 35. Fink G. Oestrogen and progesterone interactions
21. Kobayashi M, Nakano R, Ooshima A. Immuno- in the control of gonadotrophin and prolactin
histochemical localization of pituitary gonadotro- secretion. J Steroid Biochem. 1988;30(1–6):169.
phins and gonadal steroids confirms the “two-cell, https://doi.org/10.1016/0022-4731(88)90090-8.
two-gonadotrophin” hypothesis of steroidogenesis 36. Cole LW, Sidis Y, Zhang C, et al. Mutations in
in the human ovary. J Endocrinol. 1990;126(3):483. Prokineticin 2 and Prokineticin receptor 2 genes
https://doi.org/10.1677/joe.0.1260483. in human gonadotrophin-releasing hormone defi-
22. Kelsey TW, Anderson RA, Wright P, Nelson SM, ciency: molecular genetics and clinical spectrum. J
Wallace WHB. Data-driven assessment of the human Clin Endocrinol Metabol. 2008;93(9):3551. https://
ovarian reserve. Mol Hum Reprod. 2012;18(2): doi.org/10.1210/jc.2007-2654.
79. https://doi.org/10.1093/molehr/gar059. 37. Hong I-S, Cheung AP, Leung PCK. Gonadotropin-
23. Fleming R, Kelsey TW, Anderson RA, Wallace releasing hormones I and II induce apoptosis in
WH, Nelson SM. Interpreting human follicular human granulosa cells. J Clin Endocrinol Metabol.
recruitment and antimüllerian hormone concentra- 2008;93(8):3179. https://doi.org/10.1210/jc.2008-
tions throughout life. Fertil Steril. 2012;98(5):1097. 0127.
https://doi.org/10.1016/j.fertnstert.2012.07.1114. 38. Millar RP. GnRHs and GnRH receptors.
24. Anderson RA, Nelson SM, Wallace WHB. Mea- Anim Reprod Sci. 2005;88(1–2):5. https://doi.
suring anti-Müllerian hormone for the assess- org/10.1016/j.anireprosci.2005.05.032.
ment of ovarian reserve: when and for whom is 39. Belchetz P, Plant T, Nakai Y, Keogh E, Knobil
it indicated? Maturitas. 2012;71(1):28. https://doi. E. Hypophysial responses to continuous and inter-
org/10.1016/j.maturitas.2011.11.008. mittent delivery of hypopthalamic gonadotropin-
25. Csapo AI, Pulkkinen MO, Wiest WG. Effects of releasing hormone. Science. 1978;202(4368):631.
luteectomy and progesterone replacement therapy https://doi.org/10.1126/science.100883.
in early pregnant patients. Am J Obstet Gynecol. 40. Haisenleder DJ, Dalkin AC, Ortolano GA, Mar-
1973;115(6):759. https://doi.org/10.1016/0002- shall JC, Shupnik MA. A pulsatile gonadotropin-
9378(73)90517-6. releasing hormone stimulus is required to increase
26. Netter FH. Atlas of human anatomy. Philadel- transcription of the gonadotropin subunit genes:
phia: Elsevier; 1990. evidence for differential regulation of transcrip-
27. Saridogan E, Becker CM, Feki A, et al. Recommen- tion by pulse frequency in vivo*. Endocrinology.
dations for the surgical treatment of endometrio- 1991;128(1):509. https://doi.org/10.1210/endo-
sis—part 1: ovarian endometrioma. Gynecol Surg. 128-1-509.
2017;14(1):27. https://doi.org/10.1186/s10397-017- 41. Suarez-Quian CA, Wynn PC, Catt KJ. Receptor-
1029-x. mediated endocytosis of GnRH analogs: dif-
28. Critchley HOD, Saunders PTK. Hormone recep- ferential processing of gold-labeled agonist
tor dynamics in a receptive human endome- and antagonist derivatives. J Steroid Biochem.
trium. Reprod Sci. 2009;16(2):191. https://doi. 1986;24(1):183. https://doi.org/10.1016/0022-4731
org/10.1177/1933719108331121. (86)90049-X.
29. Deligdisch L. Hormonal pathology of the endo- 42. Halmos G, Schally AV, Pinski J, Vadillo-Buenfil
metrium. Mod Pathol. 2000;13(3):285. https://doi. M, Groot K. Down-regulation of pituitary recep-
org/10.1038/modpathol.3880050. tors for luteinizing hormone-releasing hormone
30. Schally AV, Arimura A, Baba Y, et al. Isolation and (LH-RH) in rats by LH-RH antagonist Cetrorelix.
properties of the FSH and LH-releasing hormone. Proc Natl Acad Sci. 1996;93(6):2398. https://doi.
Biochem Biophys Res Commun. 1971;43(2):393. org/10.1073/pnas.93.6.2398.
https://doi.org/10.1016/0006-291X(71)90766-2. 43. Hazum E, Conn PM. Molecular mechanism of
31. Millar RP, Lu Z-L, Pawson AJ, Flanagan CA, gonadotropin releasing hormone (GnRH) action.
Morgan K, Maudsley SR. Gonadotropin-releasing I. the GnRH receptor*. Endocr Rev. 1988;9(4):379.
hormone receptors. Endocr Rev. 2004;25(2):235. https://doi.org/10.1210/edrv-9-4-379.
https://doi.org/10.1210/er.2003-0002. 44. Ortmann O, Weiss J, Diedrich K. Gonadotrophin-
32. Stamou MI, Georgopoulos NA. Kallmann syn- releasing hormone (GnRH) and GnRH ago-
drome: phenotype and genotype of hypogonado- nists: mechanisms of action. Reprod Biomed
tropic hypogonadism. Metabolism. 2018;86:124. Online. 2002;5:1. https://doi.org/10.1016/S1472-
https://doi.org/10.1016/j.metabol.2017.10.012. 6483(11)60210-1.
33. Hardelin J-P, Soussi-Yanicostas N, Ardouin O, 45. Archer DF, Stewart EA, Jain RI, et al. Elagolix
Levilliers J, Petit C. Kallmann syndrome. In: Genet- for the management of heavy menstrual bleed-
ing associated with uterine fibroids: results from cycle. Clin Endocrinol. 1982;17(1):29. https://doi.
1 a phase 2a proof-of-concept study. Fertil Steril.
2017;108(1):152. https://doi.org/10.1016/j.fertn- 57.
org/10.1111/j.1365-2265.1982.tb02631.x.
Filicori M, Butler JP, Crowley WF. Neuroen-
stert.2017.05.006. docrine regulation of the corpus luteum in the
46. Lamb YN. Elagolix: first global approval. Drugs. human. Evidence for pulsatile progesterone secre-
2018;78(14):1501. https://doi.org/10.1007/s40265- tion. J Clin Investig. 1984;73(6):1638. https://doi.
018-0977-4. org/10.1172/JCI111370.
47. CLARKE IJ, CUMMINS JT. The temporal rela- 58. Morell AG, Gregoriadis G, Scheinberg IH,
tionship between gonadotropin releasing hormone Hickman J, Ashwell G. The role of sialic acid in
(GnRH) and luteinizing hormone (LH) secre- determining the survival of glycoproteins in the
tion in ovariectomized ewes 1. Endocrinology. circulation. J Biol Chem. 1971;246(5):1461–7.
1982;111(5):1737. https://doi.org/10.1210/endo- 59. Fraser HM, Dickson SE, Lunn SF, et al. Suppres-
111-5-1737. sion of luteal angiogenesis in the primate after
48. Sarkar DK, Chiappa SA, Fink G, Sherwood neutralization of vascular endothelial growth fac-
NM. Gonadotropin-releasing hormone surge in tor1. Endocrinology. 2000;141(3):995. https://doi.
pro-oestrous rats. Nature. 1976;264(5585):461. org/10.1210/endo.141.3.7369.
https://doi.org/10.1038/264461a0. 60. Martinez-Chequer JC, Stouffer RL, Hazzard TM,
49. Leclerc GM, Boockfor FR. Identification of a Patton PE, Molskness TA. Insulin-like growth
novel OCT1 binding site that is necessary for the factors-1 and -2, but not hypoxia, synergize with
elaboration of pulses of rat GnRH promoter gonadotropin hormone to promote vascular
activity. Mol Cell Endocrinol. 2005;245(1–2):86. endothelial growth factor-A secretion by monkey
https://doi.org/10.1016/j.mce.2005.10.026. granulosa cells from preovulatory follicles1. Biol
50. Marshall JC, Dalkin AC, Haisenleder DJ, Paul SJ, Reprod. 2003;68(4):1112. https://doi.org/10.1095/
Ortolano GA, Kelch RP. Gonadotropin-releasing biolreprod.102.011155.
hormone pulses: regulators of gonadotropin syn- 61. Lenton EA, Landgren B-M, Sexton L, Harper
thesis and ovulatory cycles. In: Proceedings of the R. Normal variation in the length of the follicu-
1990 Laurentian Hormone Conference. Elsevier; lar phase of the menstrual cycle: effect of chrono-
1991. https://doi.org/10.1016/B978-0-12-571147- logical age. BJOG. 1984;91(7):681. https://doi.
0.50009-3. org/10.1111/j.1471-0528.1984.tb04830.x.
51. McCartney CR, Gingrich MB, Hu Y, Evans 62. Brannian JD, Stouffer RL. Progesterone produc-
WS, Marshall JC. Hypothalamic regulation of tion by monkey luteal cell subpopulations at differ-
cyclic ovulation: evidence that the increase in ent stages of the menstrual cycle: changes in agonist
gonadotropin-releasing hormone pulse frequency responsiveness1. Biol Reprod. 1991;44(1):141.
during the follicular phase reflects the gradual https://doi.org/10.1095/biolreprod44.1.141.
loss of the restraining effects of progesterone. J 63. van der Linden M, Buckingham K, Farquhar C,
Clin Endocrinol Metabol. 2002;87(5) https://doi. Kremer JA, Metwally M. Luteal phase support
org/10.1210/jcem.87.5.8484. for assisted reproduction cycles. Cochrane Data-
52. Kuiper GG, Enmark E, Pelto-Huikko M, Nils- base Syst Rev. 2015;(7):CD009154. https://doi.
son S, Gustafsson JA. Cloning of a novel receptor org/10.1002/14651858.CD009154.pub3.
expressed in rat prostate and ovary. Proc Natl Acad 64. Samalecos A, Gellersen B. Systematic expression
Sci. 1996;93(12):5925. https://doi.org/10.1073/ analysis and antibody screening do not support
pnas.93.12.5925. the existence of naturally occurring progester-
53. Mosselman S, Polman J, Dijkema R. ERβ: iden- one receptor (PR)-C, PR-M, or other truncated
tification and characterization of a novel human PR isoforms. Endocrinology. 2008;149(11):5872.
estrogen receptor. FEBS Lett. 1996;392(1):49. https://doi.org/10.1210/en.2008-0602.
https://doi.org/10.1016/0014-5793(96)00782-X. 65. Robker RL, Russell DL, Espey LL, Lydon
54. Miller CD, Miller WL. Transcriptional JP, O’Malley BW, Richards JS. Progesterone-
repression of the ovine follicle-stimulating regulated genes in the ovulation process:
hormone-beta gene by 17 beta-estradiol. Endocri- ADAMTS-1 and cathepsin L proteases. Proc Natl
nology. 1996;137(8):3437. https://doi.org/10.1210/ Acad Sci. 2000;97(9):4689. https://doi.org/10.1073/
endo.137.8.8754772. pnas.080073497.
55. Wide L, Eriksson K, Sluss PM, Hall JE. Serum 66. Mulac-Jericevic B, Lydon JP, DeMayo FJ, Con-
half-life of pituitary gonadotropins is decreased by neely OM. Defective mammary gland morpho-
sulfonation and increased by sialylation in women. genesis in mice lacking the progesterone receptor
J Clin Endocrinol Metabol. 2009;94(3):958. https:// B isoform. Proc Natl Acad Sci. 2003;100(17):9744.
doi.org/10.1210/jc.2008-2070. https://doi.org/10.1073/pnas.1732707100.
56. Bäckström CT, McNeilly AS, Leask RM, Baird 67. Natraj U, Richards JS. Hormonal regulation,
DT. Pulsatile secretion of lh, fsh, prolactin, oestra- localization, and functional activity of the proges-
diol and progesterone during the human menstrual terone receptor in granulosa cells of rat preovu-
21 1
latory follicles. Endocrinology. 1993;133(2):761. cycling women. Hum Reprod. 1997;12(8):1714.
https://doi.org/10.1210/endo.133.2.8344215. https://doi.org/10.1093/humrep/12.8.1714.
68. Chappell PE, Lydon JP, Conneely OM, Malley 79. Wen X, Tozer A, Butler S, Bell C, Docherty S, Iles
BWO, Levine JE. Endocrine defects in mice car- R. Follicular fluid levels of inhibin A, inhibin B,
rying a null mutation for the progesterone receptor and activin A levels reflect changes in follicle size
gene*. Endocrinology. 1997;138(10):4147. https:// but are not independent markers of the oocyte’s
doi.org/10.1210/endo.138.10.5456. ability to fertilize. Fertil Steril. 2006;85(6):1723.
69. Conneely OM, Mulac-Jericevic B, Lydon JP, de https://doi.org/10.1016/j.fertnstert.2005.11.058.
Mayo FJ. Reproductive functions of the proges- 80. Wen X, Tozer AJ, Li D, Docherty SM, Al-Shawaf
terone receptor isoforms: lessons from knock-out T, Iles RK. Human granulosa-lutein cell in vitro
mice. Mol Cell Endocrinol. 2001;179(1–2):97. production of progesterone, inhibin A, inhibin
https://doi.org/10.1016/S0303-7207(01)00465-8. B, and activin A are dependent on follicular size
70. Shao R, Markström E, Friberg PA, Johansson and not the presence of the oocyte. Fertil Steril.
M, Billig H. Expression of progesterone recep- 2008;89(5):1406. https://doi.org/10.1016/j.fertn-
tor (PR) A and B isoforms in mouse granulosa stert.2007.03.086.
cells: stage-dependent PR-mediated regulation of 81. Wunder DM, Bersinger NA, Yared M, Kretschmer
apoptosis and cell proliferation1. Biol Reprod. R, Birkhäuser MH. Statistically significant changes
2003;68(3):914. https://doi.org/10.1095/biolre- of antimüllerian hormone and inhibin levels dur-
prod.102.009035. ing the physiologic menstrual cycle in reproductive
71. Seachrist DD, Keri RA. The Activin Social age women. Fertil Steril. 2008;89(4):927. https://
Network: activin, inhibin, and follistatin in doi.org/10.1016/j.fertnstert.2007.04.054.
breast development and cancer. Endocrinology. 82. Laven JSE, Fauser BCJM. Inhibins and adult ovar-
2019;160(5):1097. https://doi.org/10.1210/en.2019- ian function. Mol Cell Endocrinol. 2004;225(1–
00015. 2):37. https://doi.org/10.1016/j.mce.2004.02.011.
72. Ueno N, Ling N, Ying SY, Esch F, Shimasaki S, 83. Bicsak TA, Tucker EM, Cappel S, et al. Hormonal
Guillemin R. Isolation and partial character- regulation of granulosa cell inhibin biosynthe-
ization of follistatin: a single-chain Mr 35,000 sis*. Endocrinology. 1986;119(6):2711. https://doi.
monomeric protein that inhibits the release of org/10.1210/endo-119-6-2711.
follicle-stimulating hormone. Proc Natl Acad 84. Rivier C, Rivier J, Vale W. Inhibin-mediated feed-
Sci. 1987;84(23):8282. https://doi.org/10.1073/ back control of follicle-stimulating hormone secre-
pnas.84.23.8282. tion in the female rat. Science. 1986;234(4773):205.
73. Blumenfeld Z. Response of human fetal pituitary https://doi.org/10.1126/science.3092356.
cells to activin, inhibin, hypophysiotropic and 85. Stouffer RL, Dahl KD, Hess DL, Woodruff TK,
neuroregulatory factors in vitro. Early Pregnancy. Mather JP, Molskness TA. Systemic and intralu-
2001;5(1):41–2. teal infusion of inhibin A or activin A in rhesus
74. Kitaoka M, Kojima I, Ogata E. Activin-A: a mod- monkeys during the luteal phase of the menstrual
ulator of multiple types of anterior pituitary cells. cycle1. Biol Reprod. 1994;50(4):888. https://doi.
Biochem Biophys Res Commun. 1988;157(1):48. org/10.1095/biolreprod50.4.888.
https://doi.org/10.1016/S0006-291X(88)80009-3. 86. Kishi H, Okada T, Otsuka M, Watanabe G, Taya
75. Xiao S, Robertson DM, Findlay JK. Effects of K, Sasamoto S. Induction of superovulation by
activin and follicle-stimulating hormone (FSH)- immunoneutralization of endogenous inhibin
suppressing protein/follistatin on FSH receptors through the increase in the secretion of follicle-
and differentiation of cultured rat granulosa cells. stimulating hormone in the cyclic golden ham-
Endocrinology. 1992;131(3):1009. https://doi. ster. J Endocrinol. 1996;151(1):65. https://doi.
org/10.1210/endo.131.3.1505447. org/10.1677/joe.0.1510065.
76. Groome NP, Illingworth PJ, O’Brien M, et al. 87. Luisi S, Florio P, Reis FM, Petraglia F. Inhibins in
Measurement of dimeric inhibin B throughout female and male reproductive physiology: role in
the human menstrual cycle. J Clin Endocrinol gametogenesis, conception, implantation and early
Metabol. 1996;81(4):1401. https://doi.org/10.1210/ pregnancy. Hum Reprod Update. 2005;11(2):123.
jcem.81.4.8636341. https://doi.org/10.1093/humupd/dmh057.
77. Schneyer AL, Fujiwara T, Fox J, et al. Dynamic 88. Teixeira J, He WW, Shah PC, et al. Develop-
changes in the intrafollicular inhibin/activin/fol- mental expression of a candidate müllerian
listatin axis during human follicular development: inhibiting substance type II receptor. Endocri-
relationship to circulating hormone concentra- nology. 1996;137(1):160. https://doi.org/10.1210/
tions*. J Clin Endocrinol Metabol. 2000;85(9): endo.137.1.8536608.
3319. https://doi.org/10.1210/jcem.85.9.6767. 89. Visser JA. AMH signaling: from receptor to tar-
78. Magoffin DA, Jakimiuk AJ. Inhibin A, inhibin B get gene. Mol Cell Endocrinol. 2003;211(1–2):65.
and activin A in the follicular fluid of regularly https://doi.org/10.1016/j.mce.2003.09.012.
90. Kim JH, Seibel MM, MacLaughlin DT, et al. 101. Ferin M, Rosenblatt H, Carmel PW, Antunes
1 The inhibitory effects of müllerian-inhibiting
substance on epidermal growth factor induced
JL, Wiele VRL. Estrogen-induced gonadotropin
surges in female rhesus monkeys after pituitary
proliferation and progesterone production of stalk section*. Endocrinology. 1979;104(1):50.
human granulosa-luteal cells. J Clin Endocrinol https://doi.org/10.1210/endo-104-1-50.
Metabol. 1992;75(3):911. https://doi.org/10.1210/ 102. Pineda R, Garcia-Galiano D, Roseweir A, et al.
jcem.75.3.1517385. Critical roles of kisspeptin in female puberty and
91. Durlinger A, Visser J, Themmen A. Regulation of preovulatory gonadotropin surges as revealed by
ovarian function: the role of anti-Mullerian hor- a novel antagonist. Endocr Rev. 2009;30(7):928.
mone. Reproduction. 2002;124:601. https://doi. https://doi.org/10.1210/edrv.30.7.9994.
org/10.1530/rep.0.1240601. 103. Rometo AM, Krajewski SJ, lou Voytko M, Rance
92. la Marca A, Malmusi S, Giulini S, et al. Anti- NE. Hypertrophy and increased kisspeptin gene
Müllerian hormone plasma levels in sponta- expression in the hypothalamic infundibular
neous menstrual cycle and during treatment nucleus of postmenopausal women and ovariec-
with FSH to induce ovulation. Hum Reprod. tomized monkeys. J Clin Endocrinol Metabol.
2004;19(12):2738. https://doi.org/10.1093/hum- 2007;92(7):2744. https://doi.org/10.1210/jc.2007-
rep/deh508. 0553.
93. Considine RV, Sinha MK, Heiman ML, et al. 104. Wehrenberg WB, Wardlaw SL, Frantz AG, Ferin
Serum immunoreactive-leptin concentrations M. β-endorphin in hypophyseal portal blood:
in normal-weight and obese humans. N Engl J variations throughout the menstrual cycle*.
Med. 1996;334(5):292. https://doi.org/10.1056/ Endocrinology. 1982;111(3):879. https://doi.
NEJM199602013340503. org/10.1210/endo-111-3-879.
94. Ajala OM, Ogunro PS, Elusanmi GF, Ogunyemi 105. Wardlaw SL, Wehrenberg WB, Ferin M, Car-
OE, Bolarinde AA. Changes in serum leptin dur- mel PW, Frantz AG. High levels of β -endorphin
ing phases of menstrual cycle of fertile women: in hypophyseal portal blood*. Endocrinology.
relationship to age groups and fertility. Int J 1980;106(5) https://doi.org/10.1210/endo-106-
Endocrinol Metab. 2012;11(1):27. https://doi. 5-1323.
org/10.5812/ijem.6872. 106. Rabinovici J, Rothman P, Monroe SE, Neren-
95. Wiles JR, Katchko RA, Benavides EA, et al. The berg C, Jaffe RB. Endocrine effects and phar-
effect of leptin on luteal angiogenic factors dur- macokinetic characteristics of a potent new
ing the luteal phase of the estrous cycle in goats. gonadotropin- releasing hormone antagonist
Anim Reprod Sci. 2014;148(3–4):121. https://doi. (Ganirelix) with minimal histamine-releasing
org/10.1016/j.anireprosci.2014.05.002. properties: studies in postmenopausal women.
96. Faustmann G, Tiran B, Maimari T, et al. Circu- J Clin Endocrinol Metabol. 1992;75(5):1220.
lating leptin and NF-κB activation in peripheral https://doi.org/10.1210/jcem.75.5.1385467.
blood mononuclear cells across the menstrual 107. CRÉE C de. Endogenous opioid peptides in the
cycle. Biofactors. 2016;42(4):376. https://doi. control of the normal menstrual cycle and their
org/10.1002/biof.1281. possible role in athletic menstrual irregularities.
97. Chou SH, Chamberland JP, Liu X, et al. Leptin Obstet Gynecol Surv. 1989;44(10):720. https://
is an effective treatment for hypothalamic amen- doi.org/10.1097/00006254-198910000-00003.
orrhea. Proc Natl Acad Sci. 2011;108(16):6585. 108. Evans WS, Weltman JY, Johnson ML, Weltman
https://doi.org/10.1073/pnas.1015674108. A, Veldhuis JD, Rogol AD. Effects of opioid
98. Maguire M, Lungu A, Gorden P, Cochran E, receptor blockade on luteinizing hormone (LH)
Stratton P. Pregnancy in a woman with con- pulses and interpuise LH concentrations in nor-
genital generalized lipodystrophy. Obstet Gyne- mal women during the early phase of the men-
col. 2012;119:452. https://doi.org/10.1097/AOG. strual cycle. J Endocrinol Investig. 1992;15(7):525.
0b013e31822cecf7. https://doi.org/10.1007/BF03348799.
99. Enskog A, Nilsson L, Brännström M. Peripheral 109. Wildt L, Sir-Petermann T, Leyendecker G,
blood concentrations of inhibin B are elevated Waibel-Treber S, Rabenbauer B. Opiate antago-
during gonadotrophin stimulation in patients who nist treatment of ovarian failure. Human Reprod.
later develop ovarian OHSS and inhibin A con- 1993;8(suppl 2). https://doi.org/10.1093/hum-
centrations are elevated after OHSS onset. Hum rep/8.suppl_2.168
Reprod. 2000;15(3):532. https://doi.org/10.1093/ 110. Mahutte NG, Ouhilal S. In: Falcone T, Hurd
humrep/15.3.532. WW, editors. “Ovarian hormones: structure, bio-
100. Lents CA, Heidorn NL, Barb CR, Ford JJ. Cen- synthesis, function, mechanism of action, and
tral and peripheral administration of kisspeptin laboratory diagnosis” and “Hypothalamic-pitu-
activates gonadotropin but not somatotropin itary-ovarian axis and control of the menstrual
secretion in prepubertal gilts. Reproduction. cycle”. Clinical reproductive medicine and sur-
2008;135(6):879. https://doi.org/10.1530/REP- gery. St. Louis: Mosby/Elsevier; 2007.
07-0502.
23 2
Female and Male

Gametogenesis
Nina Desai, Jenna M. Rehmer, Jennifer Ludgin,
Rakesh Sharma, Raj Kumar Anirudh, and Ashok Agarwal
Contents
2.2 Structure of the Ovary – 25
2.3 Overview of Oogenesis – 26

2.3.1 ocyte Development and Meiosis – 27
O
2.3.2 Follicle Development – 28
2.3.3 Oocyte Growth – 30
2.3.4 Resumption of Meiosis and Ovulation – 30
2.4 Additional Regulatory Mechanisms – 31

2.4.1 c AMP – 31
2.4.2 TGF-β Growth Factor Family – 31
2.4.3 Anti-Müllerian Hormone – 33
2.4.4 Growth Differentiation Factor-9 (GDF-9) and Bone Mor-
phogenetic Proteins – 33
2.4.5 Activin and Inhibin – 33
2.4.6 c-Kit and Kit Ligand – 33
2.5 Advances, Future Directions, and Challenges – 34
2.6 Male Gametogenesis – 35
2.7 Organization of the Testis – 36

2.7.1 S upporting Cells – 36
2.7.2 Leydig Cells – 36
2.8 The Sertoli Cell – 37

https://doi.org/10.1007/978-3-030-99596-6_2
2.9 Spermatogenesis – 39
2.9.1 T ypes of Spermatogonia – 40
2.9.2 Spermatocytogenesis – 40
2.9.3 Mitosis – 40
2.9.4 Meiosis – 40
2.9.5 Spermiogenesis – 42
2.9.6 Nuclear Development – 42
2.9.7 Spermiation – 43
2.9.8 The Cycle or Wave of Seminiferous Epithelium – 43
2.9.9 Efficiency of Spermatogenesis – 44
2.10 Structure of the Spermatozoa – 44

2.10.1 ead – 45
H
2.10.2 Neck – 45
2.10.3 Tail – 45
2.11 Regulation of Spermatogenesis – 46

2.11.1 I ntrinsic Regulation – 46
2.11.2 Extrinsic Influences – 46
2.12 The Epididymis – 47
2.13 Sperm Entry into Cervical Mucus – 48
2.14 Capacitation and Acrosome Reaction – 48
2.15 Concluding Remarks – 49
2.17 Answers – 50
References – 50
Female and Male Gametogenesis
25 2
one purpose: to deliver the male contribution
Key Points of the genetic makeup to the embryo. The
55 The process of oogenesis begins prior biology of gamete production is different in
to birth when diploid oogonium goes males compared to females. Gamete produc-
through mitosis to produce a primary tion in females is intricately part of the endo-
oocyte. This primary oocyte arrests crine responsibility of the ovary. If there are
after the first meiotic division, creat- no gametes, then hormone production is dras-
ing a finite pool of oocytes in the adult tically curtailed. Depletion of oocytes implies
female. depletion of the major hormones of the
55 Maintenance of the primordial follicle ovary. In the male, this is not the case. Andro-
pool, follicle recruitment, atresia, selec- gen production will proceed normally without
tion of dominant follicle, and ovulation a single spermatozoon in the testes.
is a complex process involving many This chapter presents basic aspects of
regulatory mechanisms. human ovarian follicle growth, oogenesis, and
55 Advances in oocyte cryopreservation some of the regulatory mechanisms involved
for fertility preservation and in vitro [1], as well as some of the basic structural
maturation of oocytes for artificial morphology of the testes and the process of
reproduction. development to obtain mature spermatozoa.
55 Testis as an immune-privileged organ.
55 Understanding the process of sper-
matogenesis. Case Vignette
55 Regulation of spermatogenesis.
A 41-year-old woman consult for infertility
of 1-year duration. She was on birth con-
trol from age 16 until age 40. She inquires if
2.1 Introduction suppression of ovulation during that period
of time has preserved her oocyte quantity.
Oogenesis is an area that has long been of
interest in medicine, as well as biology, eco-
nomics, sociology, and public policy. Almost 2.2 Structure of the Ovary
four centuries ago, the English physician
William Harvey (1578–1657) wrote ex ovo The ovary, which contains the germ cells, is
omnia—“all that is alive comes from the egg.” the main reproductive organ in the female. It
During a woman’s reproductive life span, also functions as an endocrine organ, secret-
only 300–400 of the nearly 1–2 million oocytes ing estrogen and progesterone in response to
present in her ovaries at birth are ovulated. The gonadotropin and paracrine signaling. Ova-
process of oogenesis begins with migratory ries exist as a pair of glands, approximately
primordial germ cells (PGCs). It results in the 3 cm in length, 2.5 cm in height, and 1.5 cm
production of meiotically competent oocytes in width, on either side of the uterus. Within
containing the correct genetic material, pro- the abdominal cavity, ovaries are found clos-
teins, mRNA transcripts, and organelles that est to the lateral wall of the pelvis, attached to
are necessary to create a viable embryo. This is the back portion of the uterus by the utero-
a tightly controlled process involving not only ovarian ligament [2]. This area is known as the
ovarian paracrine factors but also signaling ovarian fossa and is surrounded by the exter-
from gonadotropins secreted by the pituitary. nal iliac vessels, the umbilical artery, and the
The contribution of the male to the biol- ureter [2, 3].
ogy of reproduction is to produce geneti- The ovary comprises several different layers
cally intact spermatozoa that will fertilize an and types of tissues, shown in . Fig. 2.1. The
oocyte. The end product of male gametogen- innermost layer, originating from the meso-
esis, the mature spermatozoa, is designed for nephric cells, is the medulla, which houses
26 N. Desai et al.
Blood vessels
Secondary Tertiary follicle
Primary
Primordial follicle
follicle Cortex
2 follicle
Mature follicle
Oocyte
Medulla
Corpus
albicans
Corona
radiata
Corpus
luteum
Ovulated
Ruptured ovum
Tunica albuginea follicle
Developing corpus luteum Germinal epithelium
.. Fig. 2.1 This schematic of the ovary depicts the strong connective tissue layer known as the tunica albu-
developing follicle and oocyte in the ovarian cortex. The ginea. The medulla, located at the center of the ovary,
outermost layer comprises a thin layer of epithelial cells houses blood vessels and ligaments that are vital to the
known as the germinal epithelium, which gives rise to pri- survival and function of the ovary
mordial oocytes during fetal growth. Just below there is a
the blood vessels essential to supporting the tal ridge [6–9]. PGCs undergo rapid mitotic
ovary. To the outside of this is the ovarian division during this migration. The genital
cortex, which contains the follicles, embedded ridge, formed at around 3.5–4.5 weeks of
in stromal tissue from mesenchymal cells. The gestation, is composed of mesenchymal cells
outermost layer is the tunica albuginea or the overlaid with coelomic epithelial cells. Upon
ovarian surface epithelium (ovarian mesothe- arrival, the PGCs give rise to oogonia or germ
lium) and is made up of cuboidal epithelium stem cells (GSCs) that continue to prolifer-
[4]. Ovum production and oocyte maturation ate to further expand the germ cell pool. The
occur within the cortex of the ovary [5]. As number of oogonia increases from 600,000 by
primordial follicles are recruited and develop, the eighth week of gestation to over ten times
they move closer to the outer edge of the that number by 20 weeks. At around 7 week
ovary, eventually bursting through the surface gestation, these cells form the primitive med-
during ovulation [3]. ullary cords and the sex cords, respectively.
Follicle formation begins at around week
16–18 of fetal life. Oogonia are enveloped by
2.3 Overview of Oogenesis somatic epithelial cells derived from genital
ridge mesenchymal cells, forming primordial
In humans, oogenesis begins approximately follicles. The oogonia then cease mitotic activ-
3 weeks after fertilization. PGCs arise from ity and enter meiosis [8, 10, 11].
the yolk sac and migrate via amoeboid-like Once meiosis has been initiated, the oogo-
movements, through the hindgut, to the geni- nial germ cell is termed a primary oocyte.
27 2
The surrounding mesenchymal somatic cells Primary
secrete the follicle’s basement membrane DNA replication;
Oocyte
chromosome pairing
and give rise to the granulosa cell layer. By (2N)
20 weeks of gestation, the ovary has its maxi-
mum number of oocytes, between five and
seven million. This number decreases dra-
matically to one–two million by birth and less Tetrad formation
than 500,000 by puberty [12]. The primordial Oocyte (2N) arrested
Meiosis I
follicles containing these immature oocytes in Prophase I
remain essentially dormant. Through the next until it reaches
35–40 years of a woman’s reproductive life Meiotic Competence
span, a small number of follicles are steadily Anaphase I
released into the growing pool [13–15].
2.3.1 Oocyte Development First polar body

and Meiosis extruded
Secondary
Oogenesis is the process by which the mature Oocyte
ovum is differentiated. It is not clear whether (N)
the signals controlling germline entry into
meiosis are cell-autonomous or dependent
on the mesonephric somatic cells. Meiosis
is unique to germ cells. It results in the pro-
duction of daughter cells with haploid DNA
content as a result of a two-step division. Oocyte (N) arrested
in Metaphase II
During oogenesis, cell division is unequal.
Meiosis II
The result is a single ovum, with excess

genetic material extruded as polar bodies
[16]. This is quite unlike spermatogenesis,
where meiosis results in four identical hap-
loid daughter cells [17]. Second
polar body Sperm
The four main stages of meiosis are pro-
extruded
phase, metaphase, anaphase, and telophase Meiosis II is completed
(. Fig. 2.2). DNA replication, chromo- Ovum upon fertilization
(N)
some pairing, and recombination, steps that
are integral to sexual reproduction, all occur
during prophase. Prophase can be subdi- .. Fig. 2.2 The stages of meiosis I and II leading to the
vided into four stages: leptotene, zygotene, ovulation of a haploid ovum are depicted. Unlike with
spermatogenesis, meiosis during oogenesis results in dis-
pachytene, and diplotene. DNA replication is
proportionate cell division with the production of a single
finalized in preleptotene, while in leptotene, ovum with extraneous genetic material being extruded in
sister chromatids search for their homologous the first and second polar bodies. During this division,
counterparts. Interaction between homolo- the majority of the cytoplasm, containing important pro-
gous chromosomes is facilitated by the forma- teins, organelles, and growth factors, remains within the
oocyte
tion of recombination nodules. In zygotene,
homologous chromosomes pair and begin to
synapse. The synapses are maintained by the pachytene, and by the diplotene stage, homol-
synaptonemal complex. The crossing over ogous chromosomes are held together mainly
and recombination of chromosomes occur at sites of chiasmata. Oocytes in primordial
in the pachytene stage, prior to the formation follicles are arrested at the diplotene stage of
of ovarian follicles. Synapsis is completed in the first meiotic prophase [1, 18].
28 N. Desai et al.
a b
2
GV Nucleus
c d
Polar Body
.. Fig. 2.3 Various stages of oocyte maturation: a ogy typically associated with mature oocytes at the time
immature oocyte in prophase I of meiosis I; b metaphase of ovulation; d mature metaphase II oocyte
I oocyte; c cumulus/oocyte complex exhibiting morphol-
The nucleus in the prophase oocyte is dial pool to join the growing pool but, in the
called the germinal vesicle. Ooplasmic factors absence of follicle-stimulating hormone (FSH),
prevent the resumption of meiosis in the pro- undergo atresia. After puberty, once the hypo-
phase oocyte until it reaches a specific diam- thalamus–pituitary–ovarian axis has been acti-
eter and stage [13, 19–22]. This stage, referred vated during the follicular phase, elevated FSH
to as “meiotic competence,” occurs in the levels rescue the growing cohort of follicles.
antral follicle. Once meiosis resumes, there is The ovarian paracrine signaling induces the
rapid progression through the metaphase, ana- continued growth of follicles from this cohort
phase, and telophase stages of the first meiotic in a process called initial recruitment [23]. The
division. The oocyte then arrests at metaphase recruited growing follicles, known as primary
2 of the second meiosis until sperm entry with follicles, will subsequently grow into secondary
fertilization. Oocyte morphology at different and antral follicles. . Figure 2.4 illustrates the
stages of maturity is shown in . Fig. 2.3. different stages of follicle development. Ulti-
mately, a single follicle will be selected from
this cohort to become the dominant follicle. It
2.3.2 Follicle Development will release a mature oocyte after exposure to
increased levels of luteinizing hormone (LH).
Folliculogenesis within the ovary is a very com- Almost 90% of follicles undergo apoptosis or
plex process with a high rate of follicle loss. programmed cell death without ever becoming
Follicles periodically leave the resting primor- meiotically competent [24].
29 2
into two distinct stages based on responsive-
ness to the gonadotropins: FSH and LH. The
Primordial follicle first stage is relatively slow in humans, tak-
ing over 120 days [13, 25], and is not directly
dependent on gonadotropin levels. Key
growth mediators at this early stage may
include transforming growth factor-β (TGF-
β), activin, bone morphogenetic proteins
Primary follicle (BMPs), anti-Müllerian hormone (AMH),
insulin, estrogen, and androgens. Follicle and
oocyte diameters increase, growing in size
from 30 to 40 μm in primordial follicles to 100–
200 μm in pre-antral follicles (see . Fig. 2.4).
The single layer of squamous granulosa cells
present in the primordial follicles start to pro-
liferate, and the oocyte becomes surrounded
Seondary follicle by several layers of cuboidal granulosa cells.
Precursor thecal cells are recruited from sur-
rounding stroma and a basement membrane
Basement
forms around the follicle.
membrane
The second stage of follicular growth is
far more rapid. The follicle is now responsive
to the gonadotropins, FSH and LH. Granu-
Oocyte losa cell secretions result in the formation of a
Zona pellucida fluid-filled cavity or antrum. During the early
antral stage of follicle development, follicle
Tertiary follicle
size increases from 200 μm to 2–5 mm.
Antrum Corona radiata The formation of a fluid-filled antrum and
Theca interna synthesis of steroid hormones mark the transi-
Theca externa tion to the antral stage of follicle development.
During this stage, and with the influence of
FSH, granulosa cells differentiate and become
capable of aromatizing androgen, secreted by
thecal cells, into estrogen. The local estrogenic
environment, combined with high FSH lev-
els, promotes further granulosa cell prolifera-
tion and an increase in FSH receptors. This,
Granulosa cells
in turn, makes the follicles even more sensi-
Mature follicle tive to FSH. The negative feedback of rising
estrogen levels on the hypothalamus–pituitary
.. Fig. 2.4 Depicted is a sequential illustration of fol- axis limits FSH secretion. Thus, only follicles
liculogenesis within the human ovary. The process begins with increased FSH receptors will be able to
with the oocyte enclosed within single layer of granulosa
cells known as the primordial follicle and ends with a fully
continue to develop, while other follicles in the
developed multilayered follicle with antrum containing a cohort will undergo atresia. It is through this
secondary oocyte mechanism that a single dominant follicle is
selected. Continued growth of the selected fol-
Critical to this process is the interaction licle occurs despite the midcycle fall in FSH
between the somatic cell components and the concentrations as a result of granulosa cells
oocyte itself. Follicle growth from the primor- now acquiring LH receptors [26–28]. While
dial to the preovulatory stage can be divided granulosa cells of the early antral follicle are
30 N. Desai et al.
only responsive to FSH, late antral stage fol- Gene knockout experiments in the mouse
licles become responsive to both FSH and LH model have identified specific gap junction
and continue to secrete high levels of estra- proteins and their critical role in folliculogen-
2 diol [29, 30]. The layers of specialized granu- esis. Absence of connexin-37 interferes with
losa cells bordering the oocyte are known as antral follicle formation [48, 49], while fol-
cumulus cells, which are also called corona licles in mice lacking the gene for connexin-43
radiata. These cells not only support cytoplas- arrest in the early pre-antral stage and are
mic maturation but are pivotal in maintenance unable to produce meiotically competent
of meiotic arrest and induction of ovulation. oocytes [50]. Phosphorylation and several dif-
The preovulatory follicle, also known as a ferent protein kinases appear also to be asso-
Graafian follicle, measures over 18 mm in size, ciated with the activation and regulation of
and oocyte diameter is close to its final size of gap junctions [51, 52].
about 120 μm [31]. The multilayer follicle is The oocyte is metabolically active from its
enclosed in a basement membrane that sepa- early growth stage, synthesizing the maternal
rates it from the underlying vascularized the- RNA pool necessary to support early embry-
cal cell layer. onic events after fertilization. Oocytes synthe-
size over 400 different proteins. Shortly after
follicle activation and entry into the growing
2.3.3 Oocyte Growth pool, the oocyte secretes a thick glycoprotein
coat [53, 54]. This matrix coat, known as the
Coordinated growth of this diplotene-arrested zona pellucida, encircles the oocyte and is
oocyte and follicle is dependent on bidirec- composed of three zona pellucida proteins:
tional communication between the oocyte ZP1, ZP2, and ZP3. Thickness of the zona
and the surrounding granulosa cells [32, 33]. pellucida increases as the oocyte grows, reach-
This communication occurs via gap junctions ing about 15 μm. The zona pellucida plays
connecting the granulosa cells and the oocyte an important role in protecting the oocyte/
[33–39]. These membrane channels enable the embryo as it traverses the reproductive tract.
sharing of small essential molecules, includ- The zona mediates sperm binding, confers
ing inorganic ions, second messengers, small species specificity, and serves as a block to
metabolites, and secreted paracrine factors, polyspermic fertilization. Release of corti-
that allow growth of both cell types [39–42]. cal granules by the oocyte cytoplasm at the
The oocyte is unable to transport certain time of fertilization results in a hardening of
amino acids, carry out biosynthesis of choles- the zona and deters additional sperm from
terol, or undergo glycolysis without a supply penetrating into the oocyte.
of the necessary factors by the granulosa cells.
Similarly, evidence suggests that granulosa cell
proliferation as well as select other metabolic 2.3.4 Resumption of Meiosis
processes require oocyte-derived secretions and Ovulation
[43–46]. In vitro studies on cultured follicles
demonstrate that severing of gap junctions Meiotic progression of the oocyte is highly
and intercellular communications trigger pre- dependent on a delicate balance between fac-
mature ovulation and eventual degeneration tors keeping the oocyte in meiotic rest and
of the released oocyte [47]. factors promoting oocyte maturation [55–
Gap junctions are comprised of a variety 61]. Cyclic AMP (cAMP) is one of the intra-
of connexin proteins [37]. The basic structure cellular signaling molecules that keep the
of connexins consists of four membrane- oocyte in meiotic arrest. cAMP, produced by
spanning domains, two extracellular loops, granulosa cells, is transported via gap junc-
a cytoplasmic loop, and cytoplasm N- and tions to the oocytes. As long as the cAMP
C-termini. Different connexins contain differ- threshold is maintained, meiosis is inhibited.
ent properties, providing increased complex- This occurs through FSH binding to G-pro-
ity in the regulation of designated molecules. tein receptors.
31 2
Meiotic competence is also linked to 2.4 Additional Regulatory
oocyte size, presumably because increasing Mechanisms
volume corresponds to increasing cytoplas-
mic accumulation of synthesized proteins. Clear maintenance of the primordial follicle
Oocytes that measure less than 70–80 μm pool, follicle recruitment, follicle atresia, and
have lower rates of meiotic competence com- selection of a dominant follicle, combined
pared to 100 μm fully grown follicles, which with controlling oocyte maturation, and syn-
are usually able to resume meiosis. Activation chronous growth of the follicular unit, is a
of maturation or M-phase promoting factor complex process. In this section, we discuss a
(MPF) is required to resume meiosis [62, 63]. few of the most important ovarian paracrine
MPF levels increase with oocyte growth and factors involved in the coordination of events
eventually reach a threshold, at which point during folliculogenesis (. Table 2.1).
the oocyte becomes meiotically competent.
MPF is composed of a regulatory unit, cyclin
B, and its protein kinase CDK1 (also called 2.4.1 cAMP
p34cdc2).
The onset of the LH surge triggers a cas- As mentioned earlier, FSH and LH, working
cade of events culminating in the ovulation in concert, are two of the most important hor-
of the oocyte from the Graafian follicle and mones involved in folliculogenesis. An impor-
initiation of oocyte maturation. LH induces tant component of this system is the second
a shift in steroidogenesis by granulosa cells messenger cAMP, which amplifies the signal
to progesterone [64]. Cumulus cell expansion induced by FSH and LH. This amplification
just prior to ovulation results in the severing allows for a much larger response to the FSH
of cumulus:oocyte connections, thus reduc- and LH hormones than they are able to cre-
ing intracellular cAMP levels in the oocyte ate alone [65]. Two important sets of enzymes
levels and therein reducing its inhibitory influ- control intracellular cAMP homeostasis:
ence on meiosis. Subsequent MPF activation adenylyl cyclases, which generate cAMP, and
drives the oocyte toward meiosis, starting phosphodiesterases (PDEs), which break
first with breakdown of the germinal vesicle down cAMP. Binding of FSH and LH to
(GVBD). Neosynthesis of cyclin B may be a their respective receptors, along with adeny-
rate-limiting step, accounting for the observed lyl cyclase, activates the generation of cAMP
lag time between resumption of meiosis and from ATP in follicular granulosa cells. The
GVBD, as well as transition from metaphase I cAMP molecules activate a cascade of pro-
to metaphase II. tein kinases, dissociating their catalytic com-
After the breakdown of GVBD, bivalents ponent, which then works to phosphorylate
start to become organized and then align at transcription factors. These factors bind to
the metaphase plate, forming a meiotic spin- DNA upstream of genes at positions known
dle. The oocyte remains arrested at the meta- as cAMP response elements, regulating vari-
phase II stage until sperm penetration. An ous follicular events such as the growth of the
intracellular Ca2+ signal triggered by either dominant follicle [66]. In the oocyte, a high
the binding of sperm to oocyte receptors or concentration of this second messenger pre-
else the release of a soluble sperm- derived vents meiosis.
factor during oocyte–sperm fusion initiates
the destruction of endogenous cyclin [63].
The oocyte is now able to complete meiosis, 2.4.2 TGF-β Growth Factor Family
with chromosome segregation beginning at
the metaphase–anaphase transition. Defec- Several key regulators involved in folliculo-
tive chromosome segregation at this stage can genesis belong to the transforming growth
lead to aneuploidy in the resulting egg and factor-β (TGF-β) family, many of which
embryo. utilize gap junctions for communications.
32 N. Desai et al.
.. Table 2.1 Human oogenesis and folliculogenesis beginning with the primordial germ cells (key
modulators and their points of action are shown)
2 Developmental event Key regulators
Primordial germ cells

3 weeks post-conception BMP4, BMP8b
Formation c-KIT, SCF

Migration and proliferation
Colonization of the forming gonad
Post-migratory survival
Oogonia
Proliferation by mitosis
Oocyte meiotic prophase 1
Preleptotene: replication of DNA
Leptotene: start of homologous pairing
Zygotene
Pairing of homologs
Synapsis
Pachytene
Crossing over
Recombination
DNA repair
Diplotene: meiotic arrest cAMP
Primordial follicle Activins, AMH, TGF β, BMPs, insulin, estrogen ,
androgens, c-KIT
16–18 weeks post-conception
Diplotene-arrested oocyte
Single flat granulose cell layer
Primary follicle Activins, AMH
Cuboidal granulose cell layer
Pre-antral secondary follicle Activins, Inhibins, AMH
Late folliculogenesis
Granulosa proliferation GDF-9, BMP-15
Theca precursor formation
Antral/Graafian follicle Inhibins, AMH, cAMP, FSH/FSH receptor, LH/LH
receptor
Formation of antrum

Formation of preovulatory follicles and corpus
luteum
Cumulus expansion LH signaling, PGE2
Meiotic resumption MPF
Ovulation COX-2, LH
Oocyte maturation and fertilization Ca2+
33 2
Important members of this group include expressed on granulosa cells [71]. They serve
AMH, growth differentiation factor-9 (GDF- to modulate the actions of FSH on the syn-
9), BMPs, activin, and inhibin. thesis of the essential steroids estradiol and
progesterone [72].
Oocyte paracrine signaling is responsible
2.4.3 Anti-Müllerian Hormone for activating pathways involved in regulat-
ing cumulus cell differentiation. BMP-15
AMH is secreted by granulosa cells when a and GDF-9 are two factors secreted by the
woman is reproductively active. In studies uti- oocyte to control its local microenvironment
lizing the mouse model, AMH has been shown and ultimately oocyte quality [45]. BMP-15
to have two important roles during folliculo- works alongside GDF-9 to activate signaling
genesis. First, AMH inhibits the recruitment pathways responsible for the regulation of
of additional primordial follicles when there is cumulus cell differentiation and maintenance
already a growing cohort of follicles. By this of their phenotype [45]. The absence of these
means, AMH prevents women from speed- oocyte-specific factors has been demonstrated
ing too quickly through their oocyte reserve. to result in sterility [73, 74]. During in vitro
Second, AMH decreases the response of these culture of ovarian cortical slices, GDF-9
growing follicles to FSH. Studies in humans supplementation was observed to increase the
have suggested that each follicle has a unique number of secondary oocytes present after
FSH threshold that must be met in order to 7 days of growth and also enhanced follicle
proceed to the preovulatory stage. AMH may density after 14 days of culture. GDF-9 may
influence how responsive a follicle is to the also serve to prevent atresia [75].
FSH surge during cyclic recruitment [67].
AMH has also been used as a measure of
a woman’s ovarian reserve [68]. AMH levels 2.4.5 Activin and Inhibin
decrease along with the size of a woman’s fol-
licle pool. Concomitantly, lower AMH levels Activin and inhibin are produced by granulosa
fail to adequately inhibit the primordial pool, cells in the follicle and work in an antagonistic
and as a result, there is an increase in the rate relationship. Activin, produced by many dif-
of depletion of the follicular reserve [69]. ferent tissues, including the gonad and ante-
rior pituitary, stimulates the release of FSH
by acting as a transcription factor activator
2.4.4 Growth Differentiation of the FSHβ-subunit gene [76]. Meanwhile,
Factor-9 (GDF-9) and Bone inhibin hinders the secretion of FSH from
Morphogenetic Proteins the pituitary, balancing the actions of activin.
While it is believed that inhibin plays an
BMPs play a variety of roles in oogenesis and important role in the production of steroids
are produced by a variety of cells. While little and gonadotropins, little else is known about
is known about specific BMP function in the its role in the recruitment and differentiation
human ovary, results from numerous animal of thecal cells [77].
studies have contributed to our understand-
ing of the biological activities of BMPs dur-
ing follicular development. Evidence from the 2.4.6 c-Kit and Kit Ligand
rat model proposes that BMPs influence the
primordial–primary transition as well as the Another important signaling pathway involved
subsequent transition to a secondary follicle. in the regulation of primordial follicles involves
It has also been suggested that a drop in BMP the c-Kit receptor and its granulosa cell pro-
levels may be indicative of dominant follicle duced ligand (frequently referred to as KL,
selection [70, 71]. In the rat, thecal cells of stem cell factor or SCF) [78]. Little is known
secondary follicles have expressed BMP-4 about the specific role of this receptor/ligand
and BMP-7, while their respective receptors combination in the early development of fol-
34 N. Desai et al.
licles. The presence of the mRNA encoding One of the most significant advances in
for c-Kit and KL has been detected in early the reproductive lab has been the use of vit-
antral follicles present in human ovarian tissue, rification, not only for embryo freezing, but
2 oocytes, and granulosa cells [78]. Much of what also for oocyte cryopreservation [87]. Oocyte
is known about c-Kit comes from research in cryopreservation (OC) was limited to investi-
the mouse model. Here, c-Kit and KL play a gational protocols prior to 2013, but increas-
role in PGC survival, activation, migration, ing evidence showed no significant difference
proliferation of granulosa cells, recruitment between fresh and frozen oocytes in terms of
of thecal cells, maintenance of meiotic com- pregnancy rates, pregnancy complications,
petence, and the development of follicles [79]. live birth rates, and neonatal outcomes [88]. It
was, therefore, deemed no longer experimen-
tal by the American Society for Reproductive
2.5 dvances, Future Directions,
A Medicine in 2013. OC has emerged as a new
and Challenges treatment option for cancer patients who are
unable to or do not desire to freeze embryos.
Increasing our understanding of the com- The use of OC is also increasing among
plex regulation of ovarian folliculogenesis women seeking to preserve their future fertil-
and the interactions between the oocyte and ity, allowing for delayed childbearing. Model-
granulosa–thecal cell layers has contributed ing tools to predict the probability of having
significantly to the advancement of infertility a live birth have been developed to assist in
treatment. Medications and ovarian stimula- patient counseling based on age and number
tion regimens have been designed, which per- of eggs frozen. One such model predicted the
mit the manipulation of a women’s menstrual probability of a live birth to be 90%, 75%, or
cycle, resulting in the production of multiple 37% for patients aged 34, 37, or 42, respec-
mature competent oocytes. This, combined tively, with 20 mature oocytes frozen [89].
with advances in our ability to treat male fac- What was especially striking was that to have
tor infertility, has dramatically altered preg- a 75% likelihood of a live birth, a 42 years old
nancy outcomes with in vitro fertilization over would need to have 61 eggs frozen versus 10
the last two decades. and 20 for 34 and 37 years old, respectively.
One hurdle that has been challenging to A 2020 systematic review and meta-
overcome has been poor ovarian reserve. The analysis showed utilization of banked oocytes
continuous loss and eventual elimination of to be occurring between 22 and 58 months.
a woman’s follicle pool through accelerated Of those oocytes utilized, 9% resulted in live
atresia is considered to be the impetus lead- births. The study also showed that OC is most
ing to menopause. This is based on the belief cost-efficient at age 35 or less, and after age
set forth over 50 years ago that oogenesis can- 38, it is more cost-efficient to defer planned
not occur in the adult ovary and so, at birth, OC in favor of undergoing two IVF cycles
the female ovary contains a finite oocyte pool with creation of embryos [90].
[80]. Recently, exciting data have emerged Fertility preservation for young women
that question this basic established dogma diagnosed with cancer who cannot delay the
[81, 82]. The intriguing study, first presented onset of their treatment to undergo ovarian
in 2004 by Johnson and colleagues, questions stimulation is particularly challenging. Radia-
the concept of a “non-renewing oocyte pool” tion and chemotherapy during cancer treat-
[83]. An increasing body of evidence indicates ment can result in fertility loss through damage
that oogenesis may in fact occur in the adult to the ovarian follicle reserve. Ovarian tissue
mammalian ovary [82, 84, 85]. The potential cryopreservation (OTC) has been increasingly
existence of germ cells in the adult ovary and applied to preserve fertility in cancer patients.
the development of techniques to manipulate In 2020, the American Society for Reproduc-
such cells may open up new avenues for fertil- tive Medicine deemed ovarian tissue banking
ity treatment [86]. as an acceptable fertility- preservation tech-
35 2
nique that is no longer considered experi- oocytes can be retrieved from a handful of
mental. This recommendation was based different clinical scenarios: (1) from women
on overall evidence of safety of procuring unable to undergo a full controlled ovarian
ovarian tissue, cryopreserving the tissue, and stimulation (COS) prior to cancer treatment
transplanting thawed tissue. The removal of and (2) by isolation of primary/pre-antral fol-
the experimental label from OTC allows for licles from fresh or frozen ovarian tissue and
an increase in fertility preservation access, and extended growth in vitro. Following IVM,
the hope for improved legislative coverage for the oocytes can then either be cryopreserved
patients. A study out of the Netherlands from as metaphase II oocytes or fertilized and
2002 to 2015 showed an 8.7% usage rate of then frozen as embryos [93]. IVM has several
the cryopreserved tissue with a live birth rate advantages over COS; however, clinical out-
of 57%, proving it to be an effective method to comes remain suboptimal. Many centers are
restore fertility [91]. So far, more than 130 live not equipped to perform IVM, and long-term
births have been reported after ovarian tissue data on reproductive outcomes and neonatal
transplantation [92]. outcomes are lacking. Maturing human fol-
One population that is still vastly under- licles in vitro and creating competent oocytes
represented is peri- and prepubertal females. is even more challenging and may take years
While OTC is being utilized in this popula- to become mainstream. It will be fueled by
tion, there is a paucity of data on long-term our growing understanding of the complex
outcomes. We anticipate more data in the next interactions between the oocyte and its sup-
decade as these women become of childbear- porting granulosa and thecal cell components.
ing age and may seek orthotopic transplanta- Maintenance of spheroid follicle architecture
tion of their ovarian tissue. during culture may be critical for proper bidi-
Although the main objective in OTC is to rectional signaling between the oocyte and
preserve the ovarian cortex which contains its surrounding cells. Design of 3-D culture
the majority of primordial follicles or ovar- models has therefore been the focus of much
ian reserve, during the tissue processing, small research [94]. The successful maturation of
antral follicles in the medulla are disrupted human oocytes in vitro will ultimately herald
and cumulus oocyte complexes (COCs) are a new age in reproductive medicine and the
released into the media (13–15). In a process treatment of infertility.
referred to as ex vivo in vitro maturation (ex
vivo IVM), these COCs can be recovered
and matured in vitro to obtain eggs arrested 2.6 Male Gametogenesis
at metaphase of meiosis II (MII) which can
be cryopreserved for future use. Our data Male gametogenesis or spermatogenesis is
and those of others demonstrate that ex vivo a temporal event whereby relatively undif-
IVM is successful in producing mature MIIs ferentiated germ cell called spermatogonia
in ~25–36% of the COCs collected from ovar- slowly evolves into highly specialized testicu-
ian tissue processing, and live births have been lar spermatozoa over a span of several weeks.
reported from this egg source (13, 15, 16). Ex Spermatogenesis takes place in the testis.
vivo IVM is performed clinically in a subset Spermatozoa are transported to the epididy-
of sites around the globe but is not considered mis where they attain maturity and motility
standard of care (13). The majority of the before being released into the seminal ejacu-
results have come from the adult population, late along with the other accessory gland
and more research is required to determine secretions. In this section, we will cover the
how to mature prepubertal gametes into high- following topics:
quality eggs that could be a potential source 1. Organization of the testis: describe the
for fertility preservation for patients with lim- structure of the testis and function, mainly
ited options. the production of hormone and the sper-
An alternate solution is in vitro matura- matozoa and the role of supporting cells,
tion (IVM) of immature oocytes. Immature i.e., Leydig cells and Sertoli cells.
36 N. Desai et al.
2. Define the terms and explain the process divided into a series of lobules. Most of the
of spermatogenesis and the main steps volume of the testis is made up of seminifer-
involved and also explain the types of ous tubules, which are looped or blind-ended
2 spermatogonia, spermatocytogenesis, and and packed in connective tissue within the
the processes of mitosis and meiosis, sper- confines of the fibrous septae (see . Fig. 2.5).
miogenesis, nuclear development, and The fibrous septae divide the parenchyma
release of spermatozoa in the lumen or into about 370 conical lobules consisting of
spermiation. Explain what is the cycle or the seminiferous tubules and the intertubular
wave of seminiferous epithelium and effi- tissue. The seminiferous tubules are separated
ciency of spermatogenesis. by groups of Leydig cells, blood vessels, lym-
3. Describe the structure of spermatozoa. phatics, and nerves. The seminiferous tubules
4. Explain the regulation of spermatogenesis are the site of sperm production. The wall of
and the difference between the intrinsic each tubule is made up of myoid cells of lim-
regulation and extrinsic influences on ited contractility and also of fibrous tissue.
spermatogenesis. Each seminiferous tubule is about 180 μm in
5. Epididymis and its role in storage and diameter, the height of the germinal epithe-
maturation of sperm. lium measures 80 μm, and the thickness of the
6. Process of sperm entry into cervical mucus, peritubular tissue is about 8 μm. The germinal
physiological process of capacitation, and epithelium consists of cells at different stages
acrosome reaction and subsequent fertil- of development located within the invagina-
ization. tions of Sertoli cells, namely, spermatogonia,
7. The new 2010 World Health Organization primary and secondary spermatocytes, and
guidelines and concluding remarks. spermatids. Both ends of the seminiferous
tubules open into the spaces of the rete testis.
The fluid secreted by the seminiferous tubules
Case Vignette is collected in the rete testis and delivered in
the ductal system of the epididymis.
A 41-year-old male presents with his part-
ner for infertility of 1-year duration. He is
referred because his sperm count is low and 2.7.1 Supporting Cells
his FSH is high but his testosterone is nor-
mal. He asks if there is anything you can do. The supporting cells of the testes refer to cells
that are part of the cellular development that
leads to a mature sperm. The two most impor-
2.7 Organization of the Testis tant cells are the Leydig and Sertoli cells.
The testes are ellipsoid in shape, measuring

2.5 × 4 cm in diameter and engulfed by a 2.7.2 Leydig Cells
capsule (tunica albuginea) of strong connec-
tive tissue [95]. Along its posterior border, the The Leydig cells are irregularly shaped cells
testis is loosely connected to the epididymis, with granular cytoplasm present individually
which gives rise to the vas deferens at its lower or more often in groups within the connec-
pole [96]. The testis has two main functions: tive tissue [97, 98]. Leydig cells are the prime
it produces hormones, in particular testos- source of the male sex hormone testosterone.
terone, and it produces the male gamete— The pituitary hormone, luteinizing hormone
the spermatozoa. The spermatozoa express (LH), acts on Leydig cells to stimulate the
unique antigens that are not formed until production of testosterone. This acts as a neg-
puberty. The blood–testis barrier develops as ative “feedback” on the pituitary to suppress
these autoantigens develop. The blood–tes- or modulate further LH secretion. Compared
tis barrier makes the testis an immunologi- with the testosterone levels in the blood, the
cally privileged site. The testis is incompletely intratesticular concentration of testosterone
37 2
Sperm and Testicle

Spermatic cord
Acrosome cap Blood vessels & nerves
Head
Nucleus
Ductus (vas) deferens
Nuclear membrane
Epididymis (head)
Efferent ductule
Proximal centriole Seminiferous
tubule
Segmented column
Midpiece
Mitochondrea
Dense fibers
Annulus
Rete testis
Flagellum Lobule
Tail
Fibrous sheath Epididymis (tail)
.. Fig. 2.5 The human testis and the epididymis. The tozoon. (All Rights Reserved Sperm Chromatin, ed. Zini
testis shows the tunica vaginalis and tunica albuginea, A and Agarwal A, Biological and Clinical applications
seminiferous tubule septae, rete testis, and the overlying in Male Infertility and Assisted Reproduction, Springer
head, body, and tail of the epididymis. To the left is a Science + Business Media 2011)
diagrammatic representation of a fully mature sperma-
is many times higher, especially near the base- matogenesis to occur in an immunologically
ment membrane of the seminiferous tubule. privileged site. Sertoli cells serve as “nurse”
cells for spermatogenesis, nourishing germ
cells as they develop. These also participate
2.8 The Sertoli Cell in germ cell phagocytosis. Multiple sites of
communication exist between Sertoli cells and
The seminiferous tubules are lined with highly developing germ cells for the maintenance of
specialized Sertoli cells that rest on the tubular spermatogenesis within an appropriate hor-
basement membrane and extend into the lumen monal milieu. FSH binds to the high-affinity
with a complex ramification of cytoplasm (see FSH receptors found on Sertoli cells signal-
. Fig. 2.6). Spermatozoa are produced at ing the secretion of androgen-binding pro-
puberty, but are not recognized by the immune tein. High levels of androgens are also present
system that develops during the first year of within the seminiferous tubule.
life. The seminiferous tubule space is divided The two most important hormones
into basal (basement membrane) and luminal secreted by the Sertoli cells are AMH and
(lumen) compartments by strong intercellular inhibin. AMH is a critical component of
junctional complexes called “tight junctions.” embryonic development and is involved in the
These anatomic arrangements, complemented regression of the Müllerian ducts. Inhibin is
by closely aligned myoid cells that surround a key macromolecule in pituitary FSH regu-
the seminiferous tubule, form the basis for lation. Some of the functions of the Sertoli
the blood–testis barrier. The blood–testis bar- cell are (1) maintenance of integrity of semi-
rier provides a microenvironment for sper- niferous epithelium, (2) compartmentaliza-
38 N. Desai et al.
Annulus
2
Microtubule Lumen
Residual body Spermatozoa
Lysosome
Spermatids
Acrosomal vesicle
Mitochondria
Secondary
spermatocytes
Golgi apparatus
Adluminal
compartment
Basal compartment
Junctional Primary
complex spermatocytes
Myoid cell
Spermatogonia
Spermatogonium A
Basal lamina
Smooth endoplasmic reticulum
Sertoli nucleus Interstitial space
Spermatogonium B Rough endoplasmic reticulum
.. Fig. 2.6 Section of the germinal epithelium in the (All Rights Reserved Sperm Chromatin, ed. Zini A and
seminiferous tubule. Sertoli cells divide the germinal epi- Agarwal A, Biological and Clinical applications in Male
thelium into a basal and adluminal compartment, via the Infertility and Assisted Reproduction, Springer Science +
Sertoli cell. Spermatozoa are released into the lumen. Business Media 2011)
tion of seminiferous epithelium, (3) secretion metabolism, (8) movement of cells within
of fluid to form tubular lumen to transport the epithelium, (9) secretion of inhibin and
sperm within the duct, (4) participation in androgen-binding protein, (10) regulation of
spermiation, (5) phagocytosis and elimina- spermatogenic cycle, and (11) providing a tar-
tion of cytoplasm, (6) delivery of nutrients get for hormones LH, FSH, and testosterone
to germ cells, (7) steroidogenesis and steroid receptors present on Sertoli cells.
39 2
2.9 Spermatogenesis the entire life span of the individual. It takes
place in the lumen of seminiferous tubules. In
The process of differentiation of a spermato- fact, 90% of the testis volume is determined
gonium into a spermatid is known as sper- by the seminiferous tubules and their constit-
matogenesis. It is a complex, temporal event uent germ cells at various stages of develop-
whereby primitive, totipotent stem cells divide ment. Once the gonocytes have differentiated
to either renew them or produce daughter cells into fetal spermatogonia, an active process of
that become into a specialized testicular sper- mitotic replication is initiated very early in the
matozoa over a span of weeks (see . Fig. 2.7). embryonic development. This appears to be
Spermatogenesis involves both mitotic and under FSH control and develops the baseline
meiotic proliferation as well as extensive cell number of precursor cells of the testicle.
remodeling. Spermatogenesis can be divided Within the seminiferous tubule, germ cells
into three major phases: (1) proliferation and are arranged in a highly ordered sequence
differentiation of spermatogonia, (2) meiosis, from the basement membrane to the lumen.
and (3) spermiogenesis, a complex metamor- Spermatogonia lie directly on the basement
phosis that transforms round spermatids aris- membrane, followed by primary spermato-
ing from the final division of meiosis into a cytes, secondary spermatocytes, and sperma-
complex structure called the spermatozoon. tids as they progress toward the tubule lumen.
In humans, the process of spermatogenesis The tight junction barrier supports spermato-
starts at puberty and continues throughout gonia and early spermatocytes within the
.. Fig. 2.7 A diagram-
Basal compartment
matic representation of Major Events in the Spermatogonia
major events in the life Life of a Sperm
of a sperm involving
spermatogenesis, spermio- Spermatogenesis Primary
genesis, and spermiation
Mitosis Spermatocyte
during which the develop-
ing germ cells undergo Meiosis
mitotic and meiotic
Adluminal compartment
Spermiogenesis
division to reduce the Secondary
chromosome content. (All Head Spermatocytes
Rights Reserved Sperm Midpiece
Chromatin, ed. Zini A and Tail
Agarwal A, Biological
Capacitation
and Clinical applications Spermatids
in Male Infertility and Lifespan of a spermatozoa
Assisted Reproduction, Puberty through life
Springer Science + Busi- 30 x 106 per day
ness Media 2011)
60 to 75 days for sperm
production Spermatozoa
10 to 14 days transport
Lumen
(epididymis)
20 to 100 million per
milliliter of ejaculate
40 N. Desai et al.
basal compartment and all subsequent germ facilitate biochemical interactions, allowing
cells within the luminal compartment. synchrony of germ cell maturation [102].
Spermatogenesis can also be disturbed by
2 a number of external factors, including nutri-
tion, therapeutic drugs, increased scrotal tem- 2.9.2 Spermatocytogenesis
perature, and X-radiation.
The purpose of spermatogenesis is to pro-
duce genetic material necessary for the rep-
2.9.1 Types of Spermatogonia lication of the species through mitosis and
meiosis. Spermatocytogenesis takes place in
Spermatogonia represent a population of the basal compartment. Primary spermato-
cells that divide by mitosis, providing a renew- cytes enter the first meiotic division to form
ing stem cell population as well as spermato- secondary spermatocytes. The prophase of
gonia that are committed to enter the meiotic the first meiotic division is very long; thus,
process. Germ cells are staged by their mor- the primary spermatocyte has the longest life
phologic appearance; there are dark type A span. Secondary spermatocytes undergo the
(Adark), pale type A (Apale), and type B sper- second meiotic division to produce sperma-
matogonia, primary spermatocytes (prelep- tids. Secondary spermatocytes are short-lived
totene, leptotene, zygotene, and pachytene), (1.1–1.7 days).
secondary spermatocytes, and spermatids
(Sa, Sb, Sc, Sd1, and Sd2). Other proliferative
spermatogonia include Apaired (Apr), resulting 2.9.3 Mitosis
from dividing Aisolated (Ais), and subsequently
dividing to form Aaligned (Aal). Differentiated Mitosis involves proliferation and mainte-
spermatogonia include type A1, A2, A3, A4, nance of spermatogonia. It is a precise, well-
intermediate, and type B, each a result of orchestrated sequence of events involving
the cellular division of the previous type. In duplication of the genetic material (chromo-
humans, four spermatogonial cell types have somes), breakdown of the nuclear envelope,
been identified; these are Along, Adark, Apale, and equal division of the chromosomes and
and B [99, 100]. In the rat, type Aisolated (Ais) cytoplasm into two daughter cells [103]. DNA
is believed to be the stem cell [101]; however, is also spatially organized into loop domains
it is not clear which human type A spermato- on which specific regulatory proteins inter-
gonia is the stem cell. Some investigators act during cellular replication [103–105]. The
have proposed that the type Adark spermato- mitotic phase involves spermatogonia (types
gonia represent the reserve or nonprolifera- A and B) and primary spermatocytes (sper-
tive spermatogonial population that gives rise matocytes I). Developing germ cells intercon-
to Apale [100]. Type B spermatogonia possess nected by intracellular bridges produce the
considerably more chromatin within the inner primary spermatocyte through a series of
nuclear envelope than intermediate or type mitotic divisions. Once the baseline number
A spermatogonia (see . Fig. 2.8). Type B of spermatogonia is established after puberty,
spermatogonia represent the cells that differ- the mitotic component will proceed in order
entiate and enter into the process of meiosis, to continue to provide precursor cells and to
where they are called primary spermatocytes start the process of differentiation and matu-
[100]. They are the differential precursors to ration.
preleptotene spermatocytes. This last mitotic
division helps maintain a pool of stem cells so
that the process can continue indefinitely. 2.9.4 Meiosis
Spermatogonia do not separate completely
after meiosis but remain joined by intercel- Meiosis is a complex process with specific reg-
lular bridges, which persist throughout all ulatory mechanisms of its own [106]. The pro-
stages of spermatogenesis and are thought to cess commences when type B spermatogonia
41 2
.. Fig. 2.8 Schematic
representation of the Germ Cell Line
development of a diploid
undifferentiated germ cell Gonocytes
into a fully functional
haploid spermatozoon
Basal compartment
Spermatogonia
along the basal to the
Fetal
adluminal compartment
and final release into the
lumen. Different steps Spermatogonia
in the development of Transitional
primary, secondary, and
spermatid stages are also
shown and the irreversible Spermatogonia Spermatogonia
and reversible morpho- Type AD (Dark) Type AL(Long)
logical abnormalities that
may occur during various Clonal Spermatogonia Spermatogonia
stages of spermatogen- synchrony Type AP (Pole) AC(Cloudy)
esis. (All Rights Reserved
Sperm Chromatin, ed.
Zini A and Agarwal A, Irreversible Spermatogonia 1) Prophase
Biological and Clini- morphologic Type B a) Preleptotene
cal applications in Male b) Leptotene
abnormalities
Infertility and Assisted
(inherent Spermatocytes c) Zygotene
Reproduction, Springer
Science + Business Media causes) Primary d) Pachytene
2011) e) Diplotene
©CCF 2010
f ) Diakinesis
2) Metaphase
3) Anaphase
4) Telophase
1) Prophase
Spermatocytes
Secondary 2) Metaphase
3) Anaphase
4) Telophase
Adluminal compartment
1) Stage I (Sa1)
2) Stage II (Sa2)
Reversible or Spermatids
3) Stage III (Sb1)
irreversible 4) Stage IV (Sb2)
morphologic 5) Stage V (Sc1)
abnormalities 6) Stage VI (Sc2)
(caused by
environment
Lumen
or stress)
Spermatozoa
lose their contact with the basement membrane actually result, because some germ cells are
to form preleptotene primary spermatocytes. lost due to the complexity of meiosis. The pri-
Thus, each primary spermatocyte can theo- mary spermatocytes are the largest germ cells
retically yield four spermatids, although fewer of the germinal epithelium. Meiosis is char-
42 N. Desai et al.
acterized by prophase, metaphase, anaphase, formation of haploid chromosomal comple-

and telophase. In this, two successive cell ment, homologous recombination or random
divisions yield four haploid spermatids from mixing of paternal and maternal chromo-
2 one diploid primary spermatocyte. As a con- somes and crossing over increases genetic
sequence, the daughter cells contain only half diversity and involves primary and secondary
of the chromosome content of the parent cell. spermatocytes, which give rise to spermatids.
The primary spermatocyte undergoes the first The meiotic phase involves primary sper-
meiotic or reductional division, to produce matocytes until spermatids are formed; during
secondary spermatocytes (2C DNA content). this process, chromosome pairing, crossover,
Prophase is divided into four stages—lepto- and genetic exchange are accomplished until
tene, zygote, pachytene, and diplotene. This is a new genome is determined. In turn, a post-
the longest stage and in humans takes 22 days. meiotic phase involving spermatids all the
In leptotene stage, each homologous chromo- way up to spermatozoa develops, ending in
some is two sister chromatids attached to the the formation of the specialized cell.
inner membrane of the nuclear envelop. The
synapsis of the homologous chromosomes
begins and development of the synaptone- 2.9.5 Spermiogenesis
mal complex begins in the zygotene stage. In
the pachytene stage, the synapsis is complete Spermiogenesis is a process during which the
when the entire homologous chromosome morphologic changes occur during the differ-
becomes completely linked and crossing over entiation of the spermatid into the spermato-
of sister chromatids or homologous recom- zoon. It begins once the process of meiosis is
bination begins. In the diplotene stage, the completed. It involves the development of the
chromosomes appear double and dysjunction acrosome, involving the Golgi phase, acro-
takes place when crossing over ends. In this somal phase and maturation phase. Six dif-
stage, the chromosomes remain attached at ferent stages have been described in the
specific points called the chiasmata. The chro- process of spermatid maturation in humans,
mosomes detach from the nuclear membrane, as Sa-1 and Sa-2, Sb-1 and Sb-2, and Sc-1 and Sc-2
shorten, and become thicker, synaptonemal (see . Fig. 2.9). Each of these stages can be
complex disassembles and a microtubule identified by the morphologic characteristics.
spindle formation begins and crossing over During the Sa-1 stage, both the Golgi complex
ends during diakinesis and the cells rapidly and mitochondria are well developed and dif-
progress to metaphase, and the chromosomes ferentiated, the acrosomal vesicle appears, the
move to the poles in anaphase. chromatid body develops in one pole of the
After the first meiotic division (reduction cell opposite from the acrosomal vesicle, and
division), each daughter cell contains one the proximal centriole and the axial filament
partner of the homologous chromosome pair, appear. During Sb-1 and Sb-2 stages, acrosome
and they are called secondary spermatocytes. formation is completed, the intermediate piece
These cells rapidly enter the second meiotic is formed, and the tail develops. This process
division (equational division), in which the is completed during the Sc stages.
chromatids then separate at the centromere to
yield two spermatids with a haploid chromo-
some complement (1C DNA content). At the 2.9.6 Nuclear Development
prophase stage, these cells are 46C (44 XY/X)
with 4 N of DNA. In this division, the number During spermatogenesis, a number of changes
of chromosomes is reduced in half (22 + X or occur to the nucleus and its contents. The
22 + Y), and the DNA per cell is reduced from nucleus of the spermatozoa elongates and
4 N to 2 N. These cells promptly undergo the flattens from step 1 to step 8 of spermiogen-
second division to reduce the DNA in half esis [107], giving the head its characteristic
again (2 N to 1 N with 23 chromosomes form- oval shape. The necessity of this compaction
ing haploid spermatids). Meiosis involves the has been debated, but it is widely believed to
43 2
.. Fig. 2.9 Differentia-
tion of a human diploid Sequential Stages in Human Spermatogenesis
germ cell into a fully func- Spermatogonia: Along Apale Adark
tional spermatozoon. (All Stem Cells
Rights Reserved Sperm (2N)
Chromatin, ed. Zini A and
Agarwal A, Biological
and Clinical applications
in Male Infertility and
Assisted Reproduction, B Spermatogonia:
Springer Science + Busi- Differentiating
ness Media 2011)
Spermatocytes:
Primary
(4N) L
P-L Sd2
Z
Secondary Sd1
(2N)
P
Spermatids Sc
(1N)
Sa
Sb1 Sb2
facilitate the penetration of the oocyte and to of the tubule as a spermatozoon is known as
help optimize the swimming capability of the spermiation. Spermiation involves the active
spermatozoa [108]. participation of the Sertoli cell. This may also
The compaction of the nucleus includes involve actual cell movement as the sperma-
modification of the chromatin material. Dur- tids advance toward the lumen of the semi-
ing the last post-meiotic phase of spermiogen- niferous tubules [112]. The mature spermatids
esis, the histone molecules, around which the close their intracellular bridges, disconnect
DNA is organized, are converted into transi- their contact to the germinal epithelium, and
tional proteins, which are then converted to become free cells called spermatozoa. Portions
protamines [109]. Protamines contain large of the cytoplasm of the Sertoli cell known as
amounts of cysteine, which aid in the forma- cytoplasmic droplet may remain as part of the
tion of protamine disulfide bonds as the sperm spermatozoon during the process of spermia-
matures in the epididymis [110–112]. Within tion. This is a morphological feature present
2–4 h of fertilization, the protamines in the on the immature sperm in semen [113].
chromatin of the spermatozoa are replaced by
histones from the oocyte.
2.9.8 he Cycle or Wave
T
of Seminiferous Epithelium
2.9.7 Spermiation
A cycle of spermatogenesis involves the divi-
The process whereby a mature spermatid frees sion of primitive spermatogonial stem cells
itself from the Sertoli cell and enters the lumen into subsequent germ cell types through the
44 N. Desai et al.
process of meiosis. Type A spermatogonial cells at different stages can be observed histo-
divisions occur at a shorter time interval com- logically on cross-section, and many germ cell
pared to the entire process of spermatogenesis. cohorts are seen only in association with certain
2 Therefore, at any given time, several cycles of other germ cells. This has led to the description
spermatogenesis coexist within the germinal of six stages of the seminiferous tubule epithe-
epithelium. There are six stages in man—stages lium in men. To add another level of complexity,
I through VI constitute one cycle. Groups of the steps of the spermatogenic cycle within the
adjacent resting spermatogonia initiate a new space of seminiferous tubules demonstrate a spe-
cycle every 16 ± 1 days. Approximately four cific spatial organization, termed spermatogenic
cycles of the epithelium are required for a type waves. In humans, this wave appears to describe
A spermatogonium to mature into a sperma- a spiral cellular arrangement as one progresses
tozoon; thus, one cycle of seminiferous epi- down the tubule. This spatial arrangement prob-
thelium lasts 16 days, and the entire process ably exists to ensure that sperm production is a
of spermatogenesis is estimated to occur in continuous rather than a pulsatile process.
four cycles at 64 days [114]. Spermatogenesis
is not random throughout the seminiferous
epithelium. Germ cells are localized in spatial 2.9.9 Efficiency of Spermatogenesis
units referred to as stages and represent consis-
tent associations of germ cell steps [115, 116]. Spermatogenic efficiency varies between dif-
In rodent spermatogenesis, one stage can be ferent species but appears to be relatively
found in a cross-section of seminiferous tubule. constant in man. The time for the differentia-
Each stage is recognized by development tion of a spermatogonium into a mature sper-
of the acrosome, meiotic divisions and shape matid is estimated to be 70 ± 4 days [117]. In
of the nucleus, and release of the sperm into comparison to animals, the spermatogenetic
lumen of the seminiferous tubule. The cycle efficiency in man is poor. The daily rate of
of spermatogenesis can be identified for each spermatozoa production is calculated at 3–4
species, but the duration of the cycle varies for million per gram of testicular tissue [118].
each species [100]. The stages of spermatogen- A higher number of spermatozoa should be
esis are sequentially arranged along the length expected in the ejaculate than the 20 million/
of the tubule. This arrangement of the stages mL described by the World Health Organiza-
of spermatogenesis is such that it results in a tion manual in 1999 [119] and the 15 million/
“wave of spermatogenesis” along the tubule. mL in 2010 and 2016 [120, 121]. A majority of
This wave is in space but the cycle is in time the cells developed (>75%) are lost as a result
[116]. Along the length of the seminiferous of apoptosis or degeneration; of the remain-
tubule there are only certain cross-sections ing, more than half are abnormal. Therefore,
where spermatozoa are released. In the rat, only about 12% of the spermatogenetic poten-
all stages are involved in spermatogenesis, but tial is available for reproduction [122]. An age-
spermatozoa are released only in stage VIII. related reduction in daily sperm production in
The stages of spermatogenesis are orga- men, which is associated with a loss of Sertoli
nized spatially as well as in time [116]. Thus, a cells, is also seen.
position in the tubule that is occupied by cells
comprising stage I will become stage II, fol-
lowed by stage III, until the cycle repeats. In 2.10 Structure of the Spermatozoa
humans, the duration of the cycle is 16 days,
and the progression from spermatogonia to Spermatozoa are highly specialized and con-
spermatozoa takes 70 days, or four and a half densed cells that neither grow nor divide. A
cycles of the seminiferous cycle. spermatozoon consists of the head, which
During spermatogenesis, cytoplasmic bridges contains the paternal material (DNA) and the
link cohorts of germ cells that are at the same acrosome, the neck, and the tail, which pro-
point in development, and these cells pass vides motility. The spermatozoon is endowed
through the process together. Groups of such with a large nucleus but lacks the large cyto-
45 2
plasm characteristic of most body cells. Men motility apparatus of the spermatozoa and
are unique in the morphologic heterogeneity propels by waves generated in the neck region
of the ejaculate. and pass along the tail like a whiplash. It is
formed during spermiogenesis due to the dif-
ferentiation of the centriole into three parts,
2.10.1 Head which can be clearly observed under scan-
ning electron microscopy: the midpiece, the
The head of the spermatozoa is ovular, measur- main or principal piece, and the endpiece. The
ing about 4.0–5.5 μm in length and 2.5–3.5 μm mitochondria are organized helically around
in width. The normal length-to-width ratio is the midpiece. The mitochondrial sheath of the
about 1.50–1.70 [121]. Under bright-field illu- midpiece is relatively short but slightly longer
mination, the most commonly observed aberra- than the combined length of the head and
tions include head shape/size defects, including neck. The axoneme or the central core of the
large, small, tapering, piriform, amorphous, sperm tail originates within the mitochondrial
vacuolated (>20% of the head surface occu- sheath and extends into the length of the tail.
pied by unstained vacuolar areas), and double The axoneme consists of two central micro-
heads, or any combination [121]. tubules surrounded by a concentric ring of
The head also contains the acrosome, nine microtubule doublets, often referred to
which is a cap-like structure represented by as 9 + 2 configuration.
the Golgi complex and covers about two Each axonemal doublet is composed of
thirds of the anterior head area [121]. The two subfibers, A and B. Subfiber A is complete
apical thickening seen in many other species is while Subfiber B is a “C-shaped” microtubule
missing; however, the acrosome shows a uni- attached to Subfiber A. Radial spokes or arms
form thickness/thinning toward the equato- composed of dynein extend from each Subfi-
rial segment and covers about 40–70% of the ber A to the adjacent Subfiber B [123]. The
sperm head. During fertilization of the egg, presence the dynein arms is crucial for proper
the fusion of the outer acrosomal membrane flagellar movement occurring as a result of
with the plasma membrane at multiple sites the sliding of the microtubules when pow-
releases the acrosomal enzymes at the time ered by ATP hydrolysis along each other also
of the acrosome reaction. The anterior half called the “sliding microtbule theory” [123].
of the head is devoid of the plasma and outer If the arms are absent, the sperm will display
acrosomal membrane and is covered only by complete asthenozoospermia (no motility).
the inner acrosomal membrane. The posterior Kartagener syndrome or the immotile sperm
region of the sperm head is covered by a sin- or immotile cilia syndrome is a hereditary
gle membrane called the postnuclear cap. The condition characterized by ciliary immotil-
overlap of the acrosome and the postnuclear ity due to the absence of dynein arms [124].
cap results in an equatorial segment which Men with this syndrome exhibit infertility due
does not participate in the acrosome reaction. to immotile sperm. The principal piece, the
longest part of the tail, provides most of the
propellant machinery. The coarse nine fibrils
2.10.2 Neck of the outer ring diminish in thickness and
finally disappear, leaving only the inner fibrils
This forms a junction between the head and in the axial core for most of the length of the
tail. It is fragile and the presence of decapi- principal piece. The fibrils of the principal
tated spermatozoa is a common abnormality. piece are surrounded by a fibrous tail sheath,
which consist of branching and anastomos-
ing semicircular strands or ribs held together
2.10.3 Tail by their attachment to two bands that run
lengthwise along opposite sides of the tail.
The sperm tail is 40–50 μm long and arises The tail terminates in the endpiece with a
at the spermatid stage. The tail contains the length of 4–10 μm and a diameter of less than
46 N. Desai et al.
1 μm. The small diameter is due to the absence spermatids. Testosterone and and/or FSH
of the outer fibrous sheath and a distal fading effects on spermatogenesis may also be medi-
of the microtubules. Common tail abnormali- ated by KL and GNDF. In addition there are
2 ties include tail absence, bent tails, distended a number of other growth factors expressed in
or irregular/bent midpiece, abnormally thin the testis. Leukemia inhibitory factor (LIF) is
midpiece (no mitochondrial sheath), and produced by myoid cells, Sertoli cells, Leydig
short, multiple, hairpin, and broken tails, tails cells and spermatogonia. Insulin-like growth
of irregular width, coiling tails with terminal factor (IGF1) is produced by Sertoli cells in
droplets, or any of these combinations [120]. response to FSH. Sertoli cells provide lactate
and pyruvate to support germ cell metabolism
in addition to transferrin and ceruloplasmin
2.11 Regulation transporting iron and copper to germ cells.
of Spermatogenesis Many growth factors are expressed by the tes-
tis, but only the Sertoli cell products KL and
The spermatogenic process is maintained by GNDF have been identified as necessary for
different intrinsic and extrinsic influences. male fertility [126, 127]. Altogether these fac-
tors represent an independent intratesticular
regulation of spermatogenesis.
2.11.1 Intrinsic Regulation
Leydig cells secrete hormone (testosterone), 2.11.2 Extrinsic Influences

neurotransmitters (neuroendocrine sub-
stances), and growth factors to neighboring The local regulation of spermatogenesis is
Leydig cells, blood vessels, lamina propria controlled by the hypothalamus and pituitary
of the seminiferous tubules, and Sertoli cells (hypophysis), or the hypothalamus–pitu-
[97, 122, 125]. They help maintain the nutri- itary–testicular axis is a closely integrated
tion of the Sertoli cells and the cells of the series of closed-loop feedback system involv-
peritubular tissue and influence the contrac- ing the higher centers in the central nervous
tility of myofibroblasts, thereby regulating the system, the hypothalamus, the pituitary, and
peristaltic movements of seminiferous tubules the testicular endocrine as well as the ger-
and transportation of the spermatozoa. Ley- minal compartments. Pulsatile secretion of
dig cells also help in the regulation of blood gonadotropin-releasing hormone of cell func-
flow in the intertubular microvasculature [95]. tions and developmental GNRH a decapep-
In addition, different growth factors are deliv- tide is responsible for the release of pituitary
ered from Sertoli cells and various germ cells gonadotropins. The secretion of GNRH is
participating in a complicated regulation of episodic or pulsatile and initiates the release
cell functions and developmental processes of LH from the anterior pituitary in response,
of germ cells. The survival, renewal, and the Leydig cells produce testosterone. Testos-
growth differentiation of the spermatogenic terone not only influences spermatogenesis,
cells are regulated by the Sertoli cell products but is also distributed throughout the body.
in conjunction with the various growth fac- It thus provides feedback to the pituitary that
tors such as kit ligand/stem cell factor (KL) regulates the secretory activity of Leydig cells.
and glial cell line-derived neurotrophic factor Stimulation of Sertoli cells by FSH is neces-
(GDNF). Stem spermatogonia are the targets sary for maturation of the germ cells. Com-
for GNDF. When GNDF is underexpressed, plete qualitative spermatogenesis requires
there is a loss of spermatogonial stem cell as both FSH and LH. The interaction between
a result of differentiation and repressed when the endocrine and paracrine mechanisms
GNDF is overexpressed. In mature testis, KL determines the functions within the testis
is expressed at high levels in differentiating [128]. Inhibin B secreted by Sertoli cells func-
spermatogonia and in meiotic cells, KL acts tions in the feedback mechanism directed to
as a survival factor for spermatocytes and the pituitary. Thus, both growth and differen-
47 2
tiation of testicular germ cells involves a series be described simplistically as increasing the
of complex interactions both between somatic concentration, maturation, and storage of the
and germinal elements [129, 130]. spermatozoa.
Hormonal control can be direct or indi- Much of the testicular fluid that trans-
rect. Direct hormonal control involves the ports spermatozoa from the seminiferous
transformation of the primordial germ cells to tubules is resorbed in the caput, increasing the
the primitive Type A spermatogonia requiring concentration of the spermatozoa by 10–100-
testosterone the ontogeny of the fetal testis. fold. The epididymal epithelium secretes the
The initial division to Type B spermatogonia epididymal plasma in which the spermatozoa
and subsequent steps to the pachytene stage are suspended. As the newly developed sper-
do not require gonadotropins but may require matozoa pass through these regions of the
growth hormones. Testosterone is required for epididymis, many changes occur, including
the formation of primary to secondary sper- alterations in net surface charge, membrane
matocytes (reductive division). Hormonal protein composition, immunoreactivity, phos-
control is not required for early stages of pholipid and fatty acid content, and adenyl-
spermiogenesis but spermiation requires the ate cyclase activity. Many of these changes
action of testosterone. are thought to improve the structural integ-
Indirect hormonal requirement includes rity of the sperm membrane and also increase
the binding of FSH to Sertoli cells to elicit the fertilization ability of the spermatozoa.
its effects via the cAMP signal transduction The capacities for protein secretion and stor-
pathway. The androgen receptors are present age within the epididymis are known to be
on the Sertoli cells, and the action of testos- extremely sensitive to temperature and repro-
terone on the developing germ cells is medi- ductive hormone levels, including estrogens.
ated by Sertoli cell. Testosterone biosynthesis As many as half of the spermatozoa
is regulated by LH which binds to the Leydig released from the testis die and disintegrate
cells. LH binds to the receptors on Leydig within the epididymis and are resorbed by the
cells and result in the activation of enzymes epididymal epithelium. The remaining mature
involved in conversion of cholesterol to testos- spermatozoa are stored in the cauda epididy-
terone. LH indirectly affects spermatogenesis mis, which contain about 70% of all sperma-
by stimulating adequate levels of androgen tozoa present in the male tract. The capacity
production. Prolactin synergizes with LH to for sperm storage decreases distally; sperma-
stimulate production of testosterone. Prolac- tozoa in the vas deferens may only be motile
tin receptors are present on Leydig cells, and for a few days. In humans, it is not a perfect
prolactin can cause an increase in the number storage organ, and the spermatozoa do not
of LH receptors on Leydig cells and potenti- remain in a viable state indefinitely. After
ate LH action. prolonged sexual activity, caudal spermato-
zoa first lose their fertilizing ability, followed
by their motility and then their vitality; they
2.12 The Epididymis finally disintegrate. Unless these older, senes-
cent spermatozoa are eliminated from the
The epididymis lies along the dorsolateral male tract at regular intervals, their relative
border of each testis. It is made up of the contribution to the next ejaculate(s) increases,
efferent ductules, which emanate from the rete thus reducing semen quality, even though
testis, and the epididymal ducts. The epididy- such ejaculates do have a high sperm concen-
mis opens into the vas deferens, which then tration. The transit time of sperm through the
passes through the inguinal canal into the fine tubules of the epididymis is thought to be
peritoneal cavity and opens into the urethra 10–15days in humans.
adjacent to the prostate. It is divided into three As spermatozoa traverse the epididymis,
functionally distinct regions: head, body, and they are exposed to a continuously chang-
tail or caput epididymis, corpus epididymis, ing milieu of the luminal fluid derived from
and cauda epididymis. Their functions can the rete testis and modified by the secretory
48 N. Desai et al.
and absorptive activity of the epididymal cavity from the internal cervical os by virtue
epithelium. In nonhuman mammals, there of their own motility. From here the sperma-
is compelling evidence that the epididymal tozoa traverse to the site of fertilization in the
2 epithelium does provide essential factors for ampulla of the fallopian tube or the oviduct.
sperm maturation [131, 132]. In humans, most
of the information is obtained from treatment
of pathologic cases rather than from normal 2.14 Capacitation and Acrosome
fertile men. Both epididymal maturation and Reaction
capacitation are necessary before fertilization.
The epididymis is limited to a storage role Animal studies in rats and rabbits indi-
because spermatozoa that have never passed cate that spermatozoa that are stored in the
through the epididymis and that have been female tract are unable to penetrate the ova.
obtained from the efferent ductules in men They have to spend time in the female tract
with congenital absence of vas deferens can before they acquire this ability. Capacitation
fertilize the human oocyte in vitro and result is a series of cellular or physiological changes
in pregnancy with live birth (as well as with that spermatozoa must undergo in order to
intracytoplasmic sperm injection with sperm fertilize [136]. It represents a change in the
obtained after testicular biopsy). molecular organization of the intact sperm
plasma membrane that is characterized by
the ability to undergo the acrosome reaction,
2.13 perm Entry into Cervical
S to bind to the zona pellucida, and to acquire
Mucus hypermotility.
Capacitation involves the removal of semi-
At the moment of ejaculation, spermatozoa nal plasma factors that coat the surface of the
from the cauda epididymis are mixed with sperm, modification of the surface charge,
secretions of the various accessory glands in and modification of the sperm membrane and
a specific sequence and deposited around the of the sterols, lipids, and glycoproteins and
external cervical os and in the posterior fornix the outer acrosomal membrane lying imme-
of the vagina. Spermatozoa in the first frac- diately under it. It also involves an increase
tion of the ejaculate have significantly better in intracellular-free calcium [137]. Changes
motility and survival than the later fractions. in sperm metabolism, increase in 3′,5′-cyclic
The majority of the spermatozoa penetrate monophosphate, and activation of acroso-
cervical mucus within 15–20 min of ejacula- mal enzymes are believed to be components
tion [133]. The ability to migrate across the of capacitation. Sperm capacitation may be
semen–mucus interphase is highly dependent initiated in vivo during migration through
on the specific movement pattern of the sper- cervical mucus [138]. Capacitation may be an
matozoa [134]. At the time of sperm penetra- evolutionary consequence of the development
tion into the cervical mucus, further selection of a storage system for inactive sperm in the
of the spermatozoa occurs based on the dif- caudal epididymis.
ferential motility of the normal vs. abnormal Capacitation can also be achieved by cul-
spermatozoa. This is further modified once ture medium supplemented with appropriate
the “vanguard” spermatozoon is within the substrates for energy and in the presence of
cervical mucus [135]. The receptivity of the protein or biological fluid such as serum or
cervical mucus to the penetration by the sper- follicular fluid. Usually, it takes about 2 h for
matozoa is cyclic, increasing over a period of sperm to undergo capacitation in vitro. Fur-
about 4 days before ovulation and decreasing ther modifications occur when capacitated
rapidly after ovulation. Maximum receptivity sperm reach the vicinity of the oocyte.
is seen the day before and on the day of the The acrosome reaction confers the abil-
LH peak [135]. Spermatozoa enter the uterine ity to penetrate the zona pellucida and also
49 2
confers the fusogenic state in the plasma- ??2.
Activin, produced by granulosa cells
lemma overlying the nonreactive equatorial in the follicle and anterior pituitary, is
segment, which is needed for interaction with responsible for:
the oolemma. There are distinct fusion points A. Secretion of FSH secretion from
between the outer acrosomal membrane and the pituitary
the plasma membrane. The fusion begins B. Inhibition of FSH secretion from
posteriorly around the anterior border of the pituitary
equatorial segment, which is always excluded C. Inhibition of recruitment of pri-
from the reaction. The changes, termed acro- mordial follicles
some reaction, prepare the sperm to fuse with D. Down regulation of follicular
the egg membrane. The removal of choles- response to FSH
terol from the surface membrane prepares the
sperm membrane for the acrosome reaction ??3. Spermatogenesis is a complex process
[139]. In addition, d-mannose-binding lectins of differentiation where:
are also involved in the binding of human A. Type A spermatogonia divide to
sperm to the zona pellucida [140]. produce primary spermatids
Thus, these series of changes are necessary B. Spermatogonia are differentiated
to transform the stem cells into fully mature, to form fully mature spermatozoa
functional spermatozoa equipped to fertilize C. Primary spermatocytes are differ-
the egg. entiated into spermatids
D. Spermatogonia cross the blood–
testis barrier
2.15 Concluding Remarks
??4.
The time for the differentiation of a
spermatogonium into a mature sperma-
Spermatogenesis involves a complex series of
tid is estimated to be:
events that produces the fully functional sper-
A. 60 ± 4 days
matozoa capable of fertilization. However,
B. 70 ± 4 days
many events whether pre-testicular, testicular,
C. 90 ± 10 day
or post-testicular can significantly influence
D. 60–90 days
both the quality and the number of spermato-
zoa that are released in the ejaculate. Accord-
??5.
A number of growth factors are
ing to the 2010 WHO guidelines, the reference
expressed in the testis. These are impor-
values have significantly changed especially
tant for survival, renewal, and growth
for sperm concentration, motility, and normal
differentiation. Of these, kit ligand
sperm morphology, and there is an ongoing
(KL) and glial cell line-derived neuro-
debate on the declining sperm counts and
trophic factor (GDNF) are involved in:
their clinical implication in the management
A. Regulation of cell function
of male infertility.
B. Germ cell metabolism
C. Male fertility
D. Transport of spermatozoa
2.16 Review Questions
??6. The secretion of GNRH results in the
??1. Just prior to fertilization, the oocyte is release of LH from the anterior pitu-
in: itary and GNRH secretion occurs:
A. Prophase I A. Daily
B. Prophase II B. In the morning
C. Metaphase I C. In a pulsatile manner
D. Metaphase II D. In a continuous manner
50 N. Desai et al.
??7. The action of testosterone on the devel- and squash preparation study. Am J Obstet Gyne-
oping germ cells is mediated by andro- col. 1986;155(1):189–95.
9. Witschi E. Migration of the germ cells of human
gen receptors which are present on the:
embryo from the yolk sac to the primitive gonadal
2 A. Leydig cells
B. Sertoli cells
folds. Contrib Embryol Carnegie Inst. 1948;32:
69–80.
C. Spermatogonia 10. Byskov AG. Differentiation of mammalian embry-
D. Primary spermatocytes onic gonad. Physiol Rev. 1986;66(1):71–117.
11. Goto T, Adjaye J, Rodeck CH, Monk M. Identifica-
tion of genes expressed in human primordial germ
cells at the time of entry of the female germ line into
2.17 Answers meiosis. Mol Hum Reprod. 1999;5(9):851–60.
12. Baker TG. A quantitative and cytological study of
vv1. D. Metaphase II germ cells in human ovaries. Proc R Soc Lond B
Biol Sci. 1963;158:417–33.
13. Gougeon A. Regulation of ovarian follicular devel-
vv2. A. Secretion of FSH secretion from the opment in primates: facts and hypotheses. Endocr
pituitary Rev. 1996;17(2):121–55.
14. Hardy K, Wright CS, Franks S, Winston RM. In
vv3. B. Spermatogonia are differentiated to vitro maturation of oocytes. Br Med Bull.
2000;56(3):588–602.
form fully mature spermatozoa 15. Hansen KR, Knowlton NS, Thyer AC, Charleston
JS, Soules MR, Klein NA. A new model of repro-
vv4. B. 70 ± 4 days ductive aging: the decline in ovarian non-growing
follicle number from birth to menopause. Hum
vv5. C. Male fertility Reprod. 2008;23(3):699–708.
16. Paulson RJ. Oocytes from development to fertiliza-
tion. 3rd ed. Boston: Blackwell; 1991.
vv6. C. In a pulsatile manner 17. University of Alabama at Birmingham. Oogen-
esis 2012 [cited 21 2012]. http://main.uab.edu/show.
vv7. B. Sertoli cells asp?durki=19786.
18. Gilbert S. Developmental biology. 6th ed. Sunder-
land: Sinauer; 2000.
19. Canipari R. Oocyte–granulosa cell interactions.
References Hum Reprod Update. 2000;6(3):279–89.
20. Durinzi K, Saniga E, Lanzendorf S. The rela-
1. Yao MWM, Batchu K. Oogenesis. In: Falcone T, tionship between size and maturation in vitro
Hurd WW, editors. Clinical reproductive medicine in the unstimulated human oocyte. Fertil Steril.
and surgery. 1st ed. Philadelphia: Mosby/Elsevier; 1995;63:404–6.
2007. p. 51–67. 21. Eppig J, Wigglesworth K, Pendola F. The mam-
2. Coutsoukis P. The ovaries 2007 [cited 31 2012]. malian oocyte orchestrates the rate of ovarian fol-
http://www.t heodora.c om/anatomy/the_ovaries. licular development. Proc Natl Acad Sci U S A.
html. 2002;99:2890.
3. Body GS, Aot H. The ovaries [Online Webpage]. 22. Matzuk M, Burns K, Viveiros M, Eppig JJ.
2009 [cited 31 2012]. http://education.yahoo.com/ Intercellular communication in the mammalian

reference/gray/subjects/subject/266. ovary: oocytes carry the conversation. Science.
4. Heffner LJ, Schust DJ. The reproductive system at a 2002;296:2178–80.
glance. 3rd ed. New York: Wiley; 2010. 23. McGee EA, Hsueh AJ. Initial and cyclic recruitment
5. Histology test atlas book. Chapter 18: The female of ovarian follicles. Endocr Rev. 2000;21(2):200–14.
reproductive system. http://www.visualhistology. 24. Zeleznik AJ. The physiology of follicle selection.
com/products/atlas/VHA_Chpt18_The_Female_ Reprod Biol Endocrinol. 2004;2:31.
Reproductive_System.html. 25. Gougeon A. Dynamics of follicular growth in the
6. Fujimoto T, Miyayama Y, Fuyuta M. The origin, human: a model from preliminary results. Hum
migration and fine morphology of human primor- Reprod. 1986;1(2):81–7.
dial germ cells. Anat Rec. 1977;188(3):315–30. 26. Vegetti W. FSH and folliculogenesis: from physiol-
7. Gondos B, Bhiraleus P, Hobel CJ. Ultrastructural ogy to ovarian stimulation. Reprod Biomed Online.
observations on germ cells in human fetal ovaries. 2006;12(6):684–94.
Am J Obstet Gynecol. 1971;110(5):644–52. 27. Van Fauser BC, Heusden AM. Manipulation of
8. Gondos B, Westergaard L, Byskov AG. Initiation of human ovarian function: physiological concepts and
oogenesis in the human fetal ovary: ultrastructural clinical consequences. Endocr Rev. 1997;18(1):71–106.
51 2
28. Sullivan MW, Stewart-Akers A, Krasnow JS, Berga 43. Eppig J. Mouse oocytes control metabolic co-
SL, Zeleznik AJ. Ovarian responses in women to operativity between oocytes and cumulus cells.
recombinant follicle-stimulating hormone and Reprod Fertil Dev. 2005;17(1–2):1–2.
luteinizing hormone (LH): a role for LH in the final 44. Zheng P, Dean J. Oocyte-specific genes affect fol-
stages of follicular maturation. J Clin Endocrinol liculogenesis, fertilization, and early development.
Metab. 1999;84(1):228–32. Semin Reprod Med. 2007;25(4):243–51.
29. Zeleznik AJ, Hillier SG. The role of gonadotropins 45. Gilchrist RB, Lane M, Thompson JG. Oocyte-
in the selection of the preovulatory follicle. Clin secreted factors: regulators of cumulus cell func-
Obstet Gynecol. 1984;27(4):927–40. tion and oocyte quality. Hum Reprod Update.
30. Zelinski-Wooten MB, Hess DL, Wolf DP, Stouffer 2008;14(2):159–77.
RL. Steroid reduction during ovarian stimulation 46. Coskun S, Uzumcu M, Lin YC, Friedman CI, Alak
impairs oocyte fertilization, but not folliculogen- BM. Regulation of cumulus cell steroidogenesis by
esis, in rhesus monkeys. Fertil Steril. 1994;61(6): the porcine oocyte and preliminary characteriza-
1147–55. tion of oocyte-produced factor(s). Biol Reprod.
31. Griffin J, Emery BR, Huang I, Peterson CM, Car- 1995;53(3):670–5.
rell DT. Comparative analysis of follicle morphol- 47. Eppig JJ, Pendola FL, Wigglesworth K, Pendola
ogy and oocyte diameter in four mammalian species JK. Mouse oocytes regulate metabolic cooperativ-
(mouse, hamster, pig, and human). J Exp Clin Assist ity between granulosa cells and oocytes: amino acid
Reprod. 2006;3:2. transport. Biol Reprod. 2005;73(2):351–7.
32. Sugiura K, Pendola FL, Eppig JJ. Oocyte control 48. Carabatsos MJ, Sellitto C, Goodenough DA,
of metabolic cooperativity between oocytes and Albertini DF. Oocyte-granulosa cell heterologous
companion granulosa cells: energy metabolism. Dev gap junctions are required for the coordination of
Biol. 2005;279(1):20–30. nuclear and cytoplasmic meiotic competence. Dev
33. Kidder GM, Vanderhyden BC. Bidirectional com- Biol. 2000;226(2):167–79.
munication between oocytes and follicle cells: 49. Simon AM, Goodenough DA, Li E, Paul
ensuring oocyte developmental competence. Can J DL. Female infertility in mice lacking connexin 37.
Physiol Pharmacol. 2010;88(4):399–413. Nature. 1997;385(6616):525–9.
34. Buccione R, Schroeder AC, Eppig JJ. Inter- 50. Juneja SC, Barr KJ, Enders GC, Kidder GM. Defects
actions between somatic cells and germ cells in the germ line and gonads of mice lacking con-
throughout mammalian oogenesis. Biol Reprod. nexin43. Biol Reprod. 1999;60(5):1263–70.
1990;43(4):543–7. 51. Lampe PD, Lau AF. Regulation of gap junctions by
35. Buccione R, Vanderhyden BC, Caron PJ, Eppig phosphorylation of connexins. Arch Biochem Bio-
JJ. FSH-induced expansion of the mouse cumu- phys. 2000;384(2):205–15.
lus oophorus in vitro is dependent upon a spe- 52. Lampe PD, Lau AF. The effects of connexin phos-
cific factor(s) secreted by the oocyte. Dev Biol. phorylation on gap junctional communication. Int J
1990;138(1):16–25. Biochem Cell Biol. 2004;36(7):1171–86.
36. Eppig JJ, Schroeder AC. Capacity of mouse oocytes 53. Rankin T, Soyal S, Dean J. The mouse zona pellu-
from preantral follicles to undergo embryogen- cida: folliculogenesis, fertility and pre-implantation
esis and development to live young after growth, development. Mol Cell Endocrinol. 2000;163(1–
maturation, and fertilization in vitro. Biol Reprod. 2):21–5.
1989;41(2):268–76. 54. Soyal SM, Amleh A, Dean J. Figalpha, a
37. Kidder GM, Mhawi AA. Gap junctions and ovarian germ cell-specific transcription factor required
folliculogenesis. Reproduction. 2002;123(5):613–20. for ovarian follicle formation. Development.
38. Murray A, Spears N. Follicular development 2000;127(21):4645–54.
in vitro. Semin Reprod Med. 2000;18(2):109–22. 55. Heikinheimo O, Gibbons WE. The molecular mech-
39. Eppig JJ. Intercommunication between mammalian anisms of oocyte maturation and early embryonic
oocytes and companion somatic cells. BioEssays. development are unveiling new insights into repro-
1991;13(11):569–74. ductive medicine. Mol Hum Reprod. 1998;4(8):
40. Downs SM, Hunzicker-Dunn M. Differential regu- 745–56.
lation of oocyte maturation and cumulus expansion 56. Jamnongjit M, Hammes SR. Oocyte maturation:
in the mouse oocyte-cumulus cell complex by site- the coming of age of a germ cell. Semin Reprod
selective analogs of cyclic adenosine monophos- Med. 2005;23(3):234–41.
phate. Dev Biol. 1995;172(1):72–85. 57. Mehlmann LM. Stops and starts in mammalian
41. Fagbohun CF, Downs SM. Metabolic coupling oocytes: recent advances in understanding the reg-
and ligand-stimulated meiotic maturation in the ulation of meiotic arrest and oocyte maturation.
mouse oocyte-cumulus cell complex. Biol Reprod. Reproduction. 2005;130(6):791–9.
1991;45(6):851–9. 58. Rajesh C, Pittman DL. Cell cycle regulation in
42. Granot I, Dekel N. Phosphorylation and expres- mammalian germ cells. Results Probl Cell Differ.
sion of connexin-43 ovarian gap junction protein 2006;42:343–67.
are regulated by luteinizing hormone. J Biol Chem. 59. Sun QY, Miao YL, Schatten H. Towards a
1994;269(48):30502–9. new understanding on the regulation of mam-
52 N. Desai et al.
malian oocyte meiosis resumption. Cell Cycle. 75. Hreinsson JG, Scott JE, Rasmussen C, Swahn ML,
2009;8(17):2741–7. Hsueh AJ, Hovatta O. Growth differentiation fac-
60. Tripathi A, Kumar KV, Chaube SK. Meiotic cell tor-9 promotes the growth, development, and sur-
cycle arrest in mammalian oocytes. J Cell Physiol. vival of human ovarian follicles in organ culture. J
2 2010;223(3):592–600. Clin Endocrinol Metab. 2002;1:316.
61. Zhang M, Xia G. Hormonal control of mammalian 76. Systems RD. BMPs influence FSH synthesis
oocyte meiosis at diplotene stage. Cell Mol Life Sci. [Online Website]. Technical Information > Lit-
2012;69(8):1279–88. erature > Cytokine Bulletin [cited 21 2012]. http://
62. Gautier J, Minshull J, Lohka M, Glotzer M, www.r ndsystems.c om/cb_detail_objectname_
Hunt T, Maller JL. Cyclin is a component of FA01_BMPs.aspx.
maturation-promoting factor from Xenopus. Cell. 77. Young JM, McNeilly AS. Theca: the forgotten cell
1990;60(3):487–94. of the ovarian follicle. Reproduction. 2010;140:
63. Jones KT. Turning it on and off: M-phase promot- 489–504.
ing factor during meiotic maturation and fertiliza- 78. Carlsson IB, Laitinen MP, Scott JE, Louhio H,
tion. Mol Hum Reprod. 2004;10(1):1–5. Velentzis L, Tuuri T, et al. Kit ligand and c-Kit are
64. Bowen R. Gonadotropins: luteinizing and follicle expressed during early human ovarian follicular
stimulating hormones. Colorado State University; development and their interaction is required for
2006 [updated 30 April 2006; cited 29 2012]. http:// the survival of follicles in long-term culture. Repro-
www.v ivo.c olostate.e du/hbooks/pathphys/endo- duction. 2006;131(4):641–9.
crine/hypopit/lhfsh.html. 79. Hutt KJ, McLaughlin EA, Holland MK. Kit ligand
65. Simoni M, Gromoll J, Nieschlag E. The follicle- and c-Kit have diverse roles during mammalian
stimulating hormone receptor: biochemistry, oogenesis and folliculogenesis. Mol Hum Reprod.
molecular biology, physiology and pathophysiology. 2006;12(2):61–9.
Endocr Rev. 1997;18(6):739. 80. Zuckerman S. The number of oocytes in the
66. Williams CJ, Erickson GF. Morphology and physi- mature ovary. Recent Prog Horm Res. 1951;95(6):
ology of the ovary. Endotext.org; 2012. http://www. 63–108.
endotext.org/female/female1/femaleframe1.htm. 81. Tilly JL, Niikura Y, Rueda BR. The current status
67. Durlinger AL, Visser JA, Themmen AP. Regulation of evidence for and against postnatal oogenesis in
of ovarian function: the role of anti-mullerian hor- mammals: a case of ovarian optimism versus pes-
mone. Reproduction. 2002;124:601–9. simism? Biol Reprod. 2009;80(1):2–12.
68. Visser JA, de Jong FH, Laven JS, Themmen 82. Virant-Klun I, Stimpfel M, Skutella T. Stem cells
AP. Anti-Mullerian hormone: a new marker for in adult human ovaries: from female fertility to
ovarian function. Reproduction. 2006;131(1):1–9. ovarian cancer. Curr Pharm Des. 2012;18(3):
69. Weenen C, Laven JS, Von Bergh AR, Cranfield M, 283–92.
Groome NP, Visser JA. Anti-Mullerian hormone 83. Johnson J, Canning J, Kaneko T, Pru JK, Tilly
expression pattern in the human ovary: potential JL. Germline stem cells and follicular renewal in
implications for initial and cyclic follcile recruit- the postnatal mammalian ovary. Nature. 2004;428
ment. Mol Hum Reprod. 2003;10(2):77–83. (6979):145–50.
70. Shimasaki S, Moore RK, Otsuka F, Erick- 84. White YA, Woods DC, Takai Y, Ishihara O, Seki
son GF. The bone morphogenetic protein sys- H, Tilly JL. Oocyte formation by mitotically active
tem in mammalian reproduction. Endocr Rev. germ cells purified from ovaries of reproductive-age
2004;25(1):72–101. women. Nat Med. 2012;18(3):413–21.
71. Shimasaki S, Zachow RJ, Li D, Kim H, Iemura S, 85. Virant-Klun I, Stimpfel M, Skutella T. Ovarian
Ueno N, et al. A functional bone morphogenetic pluripotent/multipotent stem cells and in vitro
protein system in the ovary. Proc Natl Acad Sci U S oogenesis in mammals. Histol Histopathol.
A. 1999;96:7282–7. 2011;26(8):1071–82.
72. Lee WS, Otsuka F, Moore RK, Shimasaki S. The 86. Tilly JL, Telfer EE. Purification of germline stem
effect of bone morphogenetic protein-7 on fol- cells from adult mammalian ovaries: a step closer
liculogenesis and ovulation in the rat. Biol Reprod. towards control of the female biological clock? Mol
2001;65:994–9. Hum Reprod. 2009;15(7):393–8.
73. Dong J, Albertini DF, Nishimori K, Kumar TR, 87. Rienzi L, Gracia C, Maggiulli R, LaBarbera AR,
Lu N, Matzuk MM. Growth differentiation factor- Kaser DJ, Ubaldi FM, et al. Oocyte, embryo and
9 is required during early ovarian folliculogenesis. blastocyst cryopreservation in ART: systematic
Nature. 1996;383(6600):531–5. review and meta-analysis comparing slow-freezing
74. Galloway SM, McNatty KP, Cambridge LM, versus vitrification to produce evidence for the
Laitinen MP, Juengel JL, Jokiranta TS, et al. development of global guidance. Hum Reprod
Mutations in an oocyte-derived growth factor Update. 2017;23(2):139–55.
gene (BMP15) cause increased ovulation rate and 88. Noyes N, Boldt J, Nagy ZP. Oocyte cryopreserva-
infertility in a dosage-sensitive manner. Nat Genet. tion: is it time to remove its experimental label? J
2000;25(3):279–83. Assist Reprod Genet. 2010;27(2–3):69–74.
53 2
89. Goldman RH, Racowsky C, Farland LV, Munné bly on scaffold-associated regions. J Mol Biol.
S, Ribustello L, Fox JH. Predicting the likelihood 1989;210:573–85.
of live birth for elective oocyte cryopreservation: a 105. Adachi Y, Kas E, Laemmli UK. Preferential coop-
counseling tool for physicians and patients. Hum erative binding of DNA topoisomerase II to scaf-
Reprod. 2017;32(4):853–9. fold-associated regions. EMBO J. 1989;13:3997.
90. Fuchs Weizman N, Baram S, Montbriand J, 106. Giroux CN. Meiosis: components and process
Librach CL. Planned oocyte cryopreservation in nuclear differentiation. Dev Genet. 1992;13:
(planned OC): systematic review and meta-analysis 387–91.
of cost-efficiency and patients' perspective. BJOG. 107. Auger J, Dadoune JP. Nuclear status of human
2021;128(6):950–62. sperm cells by transmission electron micros-
91. Hoekman EJ, Louwe LA, Rooijers M, van der copy and image cytometry: changes in nuclear
Westerlaken LAJ, Klijn NF, Pilgram GSK, et al. shape and chromatin texture during spermiogen-
Ovarian tissue cryopreservation: low usage rates esis and epididymal transit. Biol Reprod. 1993;49:
and high live-birth rate after transplantation. Acta 166–75.
Obstet Gynecol Scand. 2020;99(2):213–21. 108. Miller D, Brinkworth M, Iles D. Paternal DNA
92. Rivas Leonel EC, Lucci CM, Amorim CA. Cryo- packaging in spermatozoa: more than the sum
preservation of human ovarian tissue: a review. of its parts? DNA, histones, protamines and epi-
Transfus Med Hemother. 2019;46(3):173–81. genetics. Reproduction. 2010;139:287–301.
93. Telfer EE. Future developments: in vitro growth 109. Braun RE. Packaging paternal chromosomes with
(IVG) of human ovarian follicles. Acta Obstet protamine. Nat Genet. 2001;28:10–2.
Gynecol Scand. 2019;98(5):653–8. 110. Balhorn R. The protamine family of sperm nuclear
94. Desai N, Alex A, AbdelHafez F, Calabro A, Gold- proteins. Genome Biol. 2007;8:227.
farb J, Fleischman A, et al. Three- dimensional 111. Bedford JM, Calvin H, Cooper GW. The matura-
in vitro follicle growth: overview of culture models, tion of spermatozoa in the human epididymis. J
biomaterials, design parameters and future direc- Reprod Fertil Suppl. 1973;18:199–213.
tions. Reprod Biol Endocrinol. 2010;8:119. 112. Russell L. Morphological and functional evidence
95. Middendorff R, Muller D, Mewe M, Mukhopad- for Sertoli-germ cell relationship. In: Russell LD,
hyay AK, Holstein AF, Davidoff MS. The tunica Griswold MD, editors. The Sertoli cell. Clearwa-
albuginea of the human testis is characterized by ter: Cache Press; 1993. p. 365–90.
complex contraction and relaxation activities reg- 113. Breucker H, Schafer E, Holstein AF. Morpho-
ulated by cyclic GMP. J Clin Endocrinol Metab. genesis and fate of the residual body in human
2002;87:3486–99. spermiogenesis. Cell Tissue Res. 1985;240:
96. de Kretser DM, Temple-Smith PD, Kerr JB. Chap- 303–9.
ter 16: Anatomical and functional aspects of the 114. Heller CG, Clermont Y. Spermatogenesis
male reproductive organs. In: Bandhauer K, Fricks in man: an estimate of its duration. Science.
J, editors. Handbook of urology. Berlin: Springer; 1963;140(3563):184–6.
1982. p. 1–31. 115. Clermont Y, Perey B. The stages of the cycle of
97. de Kretser DM, Kerr JB. The cytology of the testis. the seminiferous epithelium of the rat: practi-
In: Knobill E, Neil JD, editors. The physiology of cal definitions in PA-Schiff-hematoxylin and
reproduction. New York: Raven; 1994. p. 1177–290. hematoxylin-eosin stained sections. Rev Can Biol.
98. Christensen AK. Leydig cells. In: Hamilton DW, 1957;16:451–62.
Greep RO, editors. Handbook of physiology. Bal- 116. Perey B, Clermont Y, LeBlonde CP. The wave of
timore: Williams & Wilkins; 1975. p. 57–94. seminiferous epithelium in the rat. Am J Anat.
99. Clermont Y. The cycle of the seminiferous epithe- 1961;108:47–77.
lium in man. Am J Anat. 1963;112:35–51. 117. Heller CH, Clermont Y. Kinetics of the germi-
100. Clermont Y. Kinetics of spermatogenesis in mam- nal epithelium in man. Recent Prog Horm Res.
mals: seminiferous epithelium cycle and spermato- 1964;20:545–75.
gonial renewal. Physiol Rev. 1972;52:198–236. 118. Schulze W, Rehder U. Organization and morpho-
101. Huckins C. The spermatogonial stem cell popula- genesis of the human seminiferous epithelium. Cell
tion in adult rats. I. Their morphology, prolifera- Tissue Res. 1984;237:395–407.
tion and maturation. Anat Rec. 1971;169:533–57. 119. World Health Organization. Laboratory manual
102. Dym M, Fawcett DW. Further observations on the for the examination of human semen and sperm–
numbers of spermatogonia, spermatocytes, and cervical mucus interaction. 4th ed. New York:
spermatids connected by intercellular bridges in the Cambridge University Press; 1999.
mammalian testis. Biol Reprod. 1971;4:195–215. 120. World Health Organization. Laboratory manual
103. Paulson JR, Laemmli UK. The structure of for the examination of human semen and sperm–
histone- depleted metaphase chromosomes. Cell. cervical mucus interaction. 5th ed. New York:
1977;12:817–28. Cambridge University Press; 2010.
104. Izaurralde E, Kas E, Laemmli UK. Highly 121. WHO laboratory manual for the examination and
preferential nucleation of histone H1 assem- processing of human semen. 6th ed. Geneva. 2021.
54 N. Desai et al.
122. Sharpe RM. Regulation of spermatogenesis. In: Significance of timing for the postcoital evalu-
Knobill E, Neil JD, editors. The physiology of ation of cervical mucus. Am J Obstet Gynecol.
reproduction. New York: Raven; 1994. p. 1363–434. 1975;121:387–93.
123. Amelar RD, Dubin L, Schoenfeld C. Sperm motil- 134. Mortimer D. Objective analysis of sperm motility
2 ity. Fertil Steril. 1980;34(3):197–215. and kinematics. In: Keel BA, Webster BW, editors.
124. Aitken RJ, Ross A, Lees MM. Analysis of sperm Handbook 35. Katz DF, Drobnis E, Overstreet
function in Kartagener's syndrome. Fertil Steril. JW. Factors regulating mammalian sperm migra-
1983;40(5):696–8. tion through the female reproductive tract and
125. Barros C, Franklin B. Behaviour of the gamete oocyte vestments. Gamete Res. 1989;22:443–69.
membranes during sperm entry into the mamma- 135. Mortimer D. Sperm transport in the human
lian egg. J Cell Biol. 1968;37:13. female reproductive tract. In: Finn CA, editor.
126. Schlatt S, Meinhardt A, Nieschlag E. Paracrine Oxford reviews of reproductive biology. Oxford,
regulation of cellular interactions in the testis: UK: Oxford University Press; 1983. p. 30–61.
factors in search of a function. Eur J Endocrinol. Chapter 5.
1997;137(2):107–17. 136. Yanagamachi R. Mammalian fertilization. In:
127. Skinner MK, Norton JN, Mullaney BP, Rosselli Knobill E, O’Brien NJ, editors. The physiology of
M, Whaley PD, Anthony CT. Cell-cell interactions reproduction. New York: Raven; 1994.
and the regulation of testis function. Ann N Y 137. Thomas P, Meizel S. Phosphatidylinositol
Acad Sci. 1991;637:354–63. 4,5-bisphosphate hydrolysis in human sperm
128. Bellve AR, Zheng W. Growth factors as autocrine stimulated with follicular fluid or progester-
and paracrine modulators of male gonadal func- one is dependent upon Ca2+ influx. Biochem J.
tions. J Reprod Fertil. 1989;85:771–93. 1989;264:539–46.
129. Skinner MK. Cell-cell interactions in the testis. 138. Overstreet JW, Katz DF, Yudin AI. Cervical mucus
Endocr Rev. 1991;12:45–77. and sperm transport in reproduction. Semin Peri-
130. Sharpe T. Intratesticular control of steroidogen- natol. 1991;15:149–55.
esis. Clin Endocrinol. 1990;33:787–807. 139. Parks JE, Ehrenwald E. Cholesterol efflux from
131. Bedford JM. Effect of duct ligation on the fertil- mammalian sperm and its potential role in capaci-
izing capacity of spermatozoa in the epididymis. J tation. In: Bavister BD, Cummins J, Roldan ERS,
Exp Zool. 1967;166:271–81. editors. Fertilization in mammals. Norwell: Serono
132. Orgebin-Crist M. Maturation of spermatozoa Symposia; 1990.
in the rabbit epididymis: fertilizing ability and 140. Benoff S, Hurley I, Cooper GW, Mandel FS,
embryonic mortality in does inseminated with epi- Hershlag A, Scholl GM, et al. Fertilization
didymal spermatozoa. Ann Biol Anim Biochim potential in vitro is correlated with head-specific
Biophys. 1967;7:373–9. mannose- ligand receptor expression, acrosome
133. Tredway DR, Settlage DS, Nakamura RM, status and membrane cholesterol content. Hum
Motoshima M, Umezaki CU, Mishell DR Jr. Reprod. 1993;8:2155–66.
55 3
Normal Puberty
and Pubertal Disorders
Siddhi Mathur, Joseph S. Sanfilippo,
and M. Jonathon Solnik
Contents
3.2 Normal Puberty – 57
3.3 Onset of Puberty – 58
3.4 Characteristics of Sexual Development – 59
3.5 Thelarche – 60
3.6 Adrenarche – 61
3.7 Growth Spurt – 61
3.8 Menarche – 61
3.9 Precocious Puberty – 62

3.9.1 E ffects of Precocious Puberty on Adult Height – 63
3.9.2 Central Precocious Puberty (See Central Precocious
Puberty) – 63
3.9.3 Laboratory Findings – 63
3.9.4 Treatment – 64
3.9.5 Hypothalamic Suppression – 64
3.9.6 Recombinant Growth Hormone – 66
3.9.7 GnRH-Independent Precocious Puberty
(See GnRH-Independent Precocious Puberty) – 66
3.9.8 Autonomous Ovarian Estrogen Production – 66
3.9.9 McCune–Albright Syndrome – 67

https://doi.org/10.1007/978-3-030-99596-6_3
3.9.10 T reatment – 67
3.9.11 Premature Thelarche – 67
3.9.12 Premature Adrenarche – 67
3.10 Delayed Puberty and Primary Amenorrhea – 68

3.10.1 ypergonadotropic Hypogonadism – 68
H
3.10.2 Hypogonadotropic Hypogonadism – 69
3.10.3 Primary Amenorrhea with Otherwise Normal Sexual
Development – 69
3.10.4 Evaluation – 70
3.10.5 Imaging – 71
3.10.6 Treatment of Delayed Puberty – 72
3.12 Answers – 75
References – 75
Normal Puberty and Pubertal Disorders
57 3
spective when caring for such young patients
Key Points when normal puberty drifts awry.
55 Timing of puberty and its trajectory is
determined by genetic, environmental,
and neurobehavioural factors. The typi- 3.2 Normal Puberty
cal span is from age 8 to 13 years.
55 Adrenarche is the first biochemical The activation of the hypothalamic–pitu-
change seen in puberty and the initiating itary–gonadal (HPG) axis represents the
signals arise from hypothalamic–adrenal beginning of reproductive life in the adoles-
pathways rather than gonaladal path- cent female, originally described by Ernst
ways. Knobil in 1980 at the University of Pitts-
55 Adolescents with central precocious burgh [1]. In the higher cortical centers, from
puberty can be successfully suppressed the arcuate nucleus of the hypothalamus,
with GnRH agonists. The addition of gonadotropin- releasing hormone (GnRH)
recombinant growth hormone may be is synthesized and released [2]. Through its
of benefit in select individuals, but over- effect on the anterior pituitary, GnRH regu-
all, has not been shown to increase final lates the synthesis, storage, and release of the
adult height. pituitary gonadotropins, follicle-stimulating
55 In adolescents with delayed puberty hormone (FSH), and luteinizing hormone
who require induction with estrogen (LH). These hormone levels approach that
administration, titrate slowly over a of an adult in the fetal circulation by mid-
longer period of time to avoid abnor- gestation. However, with increasing maternal
mal breast development. steroid hormone production toward term,
55 Exploring gender identity and experi- gonadotropin levels decline. Shortly after
ence with youth and adolescents can be delivery, as the maternal source of estrogen
an important aspect of pubertal devel- is withdrawn, gonadotropin levels are noted
opment. to increase as a result of the release from the
negative-feedback circuit [3].
This sequence of events demonstrates the
functional capability of the hypothalamic-
3.1 Introduction pituitary-ovarian (HPO) axis early in devel-
opment and results in follicular growth in the
Sexual development involves a complex series prepubertal ovary and an increase in circulat-
of events that, if orchestrated in an appro- ing estradiol. This effective and exquisitely sen-
priate sequence, results in the normal tran- sitive negative-feedback system, often referred
sition from childhood to young adulthood. to as the gonadostat, develops rapidly. In the
Although from an evolutionary perspective, years preceding puberty, gonadotropin levels
the ultimate goal is procreation, puberty rep- remain low in response to suppression by low
resents a monumental time in the life of an levels of circulating estrogen (10 pg/mL).
adolescent, one of biological and psychologi- It is thought that the two primary inhibi-
cal challenges, potentially heightened even tory influences on the pulsatile release of
when subtle variances to societal norms occur. GnRH and the downregulation of the HPO
This segment will first describe normal axis during childhood are the (1) intrinsic
pubertal development, and then focus on central nervous system (CNS) inhibition via
mechanisms that result in both precocious and γ(gamma)-aminobutyric acid (GABA) and the
delayed development, emphasizing presenta- (2) negative-feedback system driven by ovarian
tion and pattern recognition for generating steroid hormones [4, 5]. With continued matu-
differential diagnoses, and providing useful ration of the CNS after birth, a more profound
algorithms and treatment strategies for a wide internal inhibitory effect can be noted in refer-
range of specialists who can bring a unique per- ence to GnRH-secreting neurons. In premature
58 S. Mathur et al.
infants with less developed neuronal pathways, Plasma concentrations of leptin, an adi-
for example, pituitary gonadotropins are pocyte-derived hormone, correlate well with
higher than in term counterparts, presumably body composition and have been shown to rise
due to a weaker inhibitory influence [6]. The throughout puberty in female patients [16].
presence of a nonsteroidal regulator of these Specific leptin deficiencies have been shown
pathways is further substantiated by the abil- to prevent sexual maturation, which can then
3 ity of patients with gonadal agenesis to secrete be triggered by restoring normal levels [17].
moderate levels of gonadotropins in response Nevertheless, the role of leptin in pubertal
to GnRH [7]. development has not been clearly elucidated.
The normal age range of puberty is The concept of intrauterine growth restric-
7–13 years for white girls and 6–13 for Black tion, imprinting, and subsequent develop-
girls [8]. Mean age at menarche is 12.9 (+/−1.2) mental disorders follows a common thread,
years in white girls and 12.1 (+/−1.2) years in since early exposure to a spendthrift, “low-
Black girls [7]. On average, thelarche occurs calorie” environment may have a contrary
1.2 years before pubarche. Menarche usually effect in childhood, as suggested by the Barker
correlates with pubarche Stage IV and gener- hypothesis, resulting in early onset menarche
ally is 2–2.5 years after thelarche [9]. and adrenarche [18–20].
Another molecule that may play a role
in the reversal of the HPO downregula-
3.3 Onset of Puberty tion is neuropeptide Y (NPY). Circulating
levels are regulated by steroid hormones as
Pulsatile secretion of GnRH from the arcu- well as nutritional status, with a net influ-
ate nucleus of the hypothalamus leads ence in gonadotropin synthesis through an
to gonadarche, documented by profound alteration in GnRH pulsatility and pituitary
increases in sex steroid hormone produc- response to GnRH [21]. Increased levels of
tion [2]. Early pubertal changes are tempo- NPY have been documented in females with
rally associated with an increase in GnRH eating disorders such as anorexia nervosa
pulse frequency, primarily during the sleep and bulimia [22], representing another pos-
cycle [10]. As menarche approaches, GnRH sible correlation with percent body fat and
pulses increase in amplitude and can be reproductive potential.
detected throughout the day, similar to that Kisspeptin is a strong stimulator of the
of an adult [11, 12]. HPO axis, acting through GnRH neuronal
Both genetic and environmental effects activity, and may be a key player in early
may play a role with the initiation of puber- pubertal development [23]. Although the
tal development. It has been suggested that exact mechanisms on the gonadotropic axis
appropriate weight gain and percent body are not well defined, receptor mutations have
fat are required for these events to occur [13]. been identified in women with precocious
This concept is substantiated by data from puberty, and when administered to women
adolescent females who suffer from chronic with hypothalamic amenorrhea, kisspeptin
illness, and malnutrition or have low body agonists have successfully stimulated gonado-
mass indices due to vigorous exercise. These tropin secretion.
young girls frequently experience delays in Insulin-like growth factor I plays a role
sexual maturation and may present with pri- and appears to be under the control of
mary amenorrhea, resulting from hypotha- gonadotropin releasing hormone (GnRH);
lamic hypogonadism. Accordingly, normal furthermore, this appears to be tied into the
menstrual cycles resume with reversal of their growth hormone axis [24, 25]. Low levels of
nutritional status [14]. Investigators who fol- estrogen appear to stimulate bone growth in
lowed healthy females throughout puberty part through the growth hormone-insulin-like
found that body composition did not change growth factor I axis [26]. Please see . Fig. 3.1
prior to, but rather along with, the increase in outlining the neuroendocrine basis for puber-
GnRH secretion [15]. tal development [27].
59 3
Hypothalamus
GHRH GnRH
CRH
HPG axis
GH axis
Anterior
Pituitary
FSH
GH & LH
ACTH HPA axis
Testes
Liver &
Ovaries
Epiphyses
Adrenal gland FSH LH
zona reticularis FSH LH
Leydig
Sertoli cells &
IGF-1 Ovarian Interstitial cells cells
ST seminiferous
IGF-2 3β follicles (theca cells) tubules
DHEAS DHEA A4
Androgens
17β AT
Estrogen Androgens (testosterone)
Estrogen
progesterone (testosterone) Inhibin
pulsatile secretion Testosterone Estradiol
Inhibin sperm
Ova
.. Fig. 3.1 Simplified diagram of the hypothalamic– of estrogen is needed to produce a positive feedback to
pituitary–gonadal (HPG) axes, hypothalamic–pituitary– stimulate the LH surge that leads to ovulation. In males,
adrenal (HPA) axes, and growth hormone (GH) axes. The FSH stimulates Sertoli cells and seminiferous tubules
hypothalamus releases gonadotropin-releasing hormone to produce estrogen, inhibin, and sperm. LH stimulates
(GnRH), corticotropin-releasing hormone (CRH), and theca cells in females and Leydig cells in males to produce
growth hormone-releasing hormone (GHRH), which androgens. On the HPA axis, ACTH stimulates the zona
stimulate the anterior pituitary gland to release follicle- reticularis of the adrenal gland to secrete dehydroan-
stimulating hormone (FSH) and luteinizing hormone drosterone (DHEA). DHEA is then converted to dehy-
(LH), adrenocorticotropic hormone (ACTH), and growth droandrosterone sulfate (DHEAS) via sulfotransferase
hormone (GH), respectively. GnRH, LH, GHRH, and (ST), and to androstenedione (A4) via 3b-hydroxysteroid
GH are released in a pulsatile fashion that varies with dehydrogenase (3b). A4 is then converted to testosterone
pubertal stage. In the HPG axis, FSH stimulates the via 17b-hydroxysteroid dehydrogenase (17b) and estra-
ovarian follicles to produce estrogen (from androgenic diol via aromatase (AT). In the GH axis, GH stimulates
precursors produced from theca cells), inhibin, progester- the liver and epiphyses of bone to produce insulin-like
one, and ova. Estrogen provides both a positive and nega- growth factor 1 (IGF-1) and insulin-like growth factor 2
tive feedback on GnRH. In females, a critical amount (IGF-2)
3.4 Characteristics of Sexual Maturity Rating (SMR) Scale) [28] (. Fig. 3.2).
Development These publications raise the notion of endocrine-
disrupting chemicals, and although there is little
The predictable and ordered series of events, doubt that persistent exposure may adversely
which have historically been referred to as the affect developmental pathways and promote dis-
standard for sexual development and somatic ease progression, the association with pubertal
growth, were initially described by Tanner development remains tentative and weakly caus-
and Marshall more than 30 years ago (Sexual ative from an epidemiological perspective.
60 S. Mathur et al.
.. Fig. 3.2 Timing of Breast Pubic Hair

events of puberty. 1969
data from a study of
British schoolchildren.
1997 data from a study of
American schoolchildren.
(Reproduced with permis- Prepubertal I Prepubertal
3 sion from Solnik and
Sanfilippo [29]; adapted
from [28])
Breast and papilla Spare, lightly

are elevated as a II pigmented
small mound. chiefly along
Areolar diameter the medial
increases border of the
labia majora
Further
enlargement
of the breast Darker, beginning
bud with loss III to curl, increased
of the contour amount spreading
separation over the mons
between breast
and areola
Increased
Areola and papilla amount of,
form a secondary IV coarse, curly
mound but limited
to the mons
Adult feminine
Mature areola is triangle with
part of the general
V
spread to the
breast contour medial surface
of the thighs
3.5 Thelarche to Tanner and Marshall, this initial event

occurs between 8 and 13 years of age in most
The first clinical sign of development in the females, with a mean of 10.6 years. The tran-
majority of white females is breast bud- sition period from Stage II to Stage V breast
ding, denoted by Tanner Stage II. According development may last 4.2 years [28].
61 3
3.6 Adrenarche twentieth century, in part due to the improve-
ment in general health and nutrition [31].
Adrenal activation occurs independent of the Nonetheless, few reports have documented any
hypothalamic–pituitary–gonadal axis and further changes since the mid-twentieth century.
typically occurs between 6 and 81 years of age, There is good evidence that African–
reaching adult hair distribution by age 14, and American girls have an earlier onset of puberty
preceding gonadal activation by approximately compared to white girls [32, 33]. This was
2 years. Since adrenarche may occur before well demonstrated by the Pediatric Research
thelarche and at a fairly young age in normally in Office Settings (PROS) study published by
developing females, it can result in undue stress Herman-Giddens in 1999 [32]. This multicenter,
for parents. While early onset may be associated cross-sectional study evaluated over 17,000
with hyperandrogenism, it may be more familial female patients between 3 and 12 years of age
and not represent pathological development. [32]. On average, African–American females
show early signs of puberty up to 1.5 years ear-
lier than their white counterparts. By 7 years of
3.7 Growth Spurt age, 27.2% of African-American girls and 6.7%
of white girls showed breast or pubic hair devel-
The growth spurt (peak growth velocity), dur- opment. Menarche was achieved almost a year
ing which adolescents achieve approximately earlier. The mean age for onset of breast devel-
20% of their adult final height, occurs with opment was 8.87 years in African–American
the onset of puberty [28]. Peak growth veloc- girls and 9.96 years in white girls. At each
ity (2–3 cm/year) precedes menarche and consecutive stage of development, African–
typically occurs earlier in girls than in boys. Americans were more advanced per year than
Rapid growth of the extremities occurs first, white. Girls of other ethnic backgrounds may
followed by a gradual lengthening within the also have a characteristic difference in onset of
vertebral column. The timing of the growth pubertal maturation. However, only white and
spurt varies according to ethnicity. African–American girls were included in this
Predicted final height has traditionally been study. Please see . Fig. 3.3 for a visual repre-
based on the methodology described by Bayley sentation of pubertal timelines.
and Pinneau [30]. Target height (cm) considers PROS was the first large publication to
genetic potential and is calculated from the aver- address current and demographically relevant
ages of the height of the child’s parents: male— standards for assessing normal and abnor-
[father’s height + mother’s height + 13]/2 and mal onset of puberty. Updated guidelines
female: [father’s height − 13 + mother’s height]/2. have since been proposed and recommend a
formal evaluation for precocious puberty be
initiated in African–American girls who pres-
3.8 Menarche ent before the age of 6 and white girls who
present before the age of 7. Although this
According to Tanner, girls in the UK in 1969 provocative investigation has drawn much
had their first menses at the average age of criticism, it does invite us to reconsider the
13.5 years, with a range of 9–16 years [28]. current standards (. Fig. 3.2). As recent as
The mean age of menarche for a white adoles- 2016, authors reported on findings from 5839
cent in the USA is approximately 12.7 years. girls from the UK Millennium Cohort Study,
At the time of menarche, most have achieved a cohort born between 2000 and 2002. They
Tanner Stage IV breast development, and the evaluated variables that were associated with
interval from initial breast development to menstruation at age 11 years in this longitu-
menarche on average is 2.3 years [28]. dinal study: disadvantaged minorities (espe-
There seems to have been a decline in the cially from Pakistan, Bangladesh, and Black
average age of menarche in the first half of the African descent), higher BMI, and exposure
to psychosocial stress were more linked to
early onset of menarche [34] (. Fig. 3.3).
1 Reference? Previous notation 11–12 years
62 S. Mathur et al.
Adrenarche
Thelarche
Growth Spurt
3 Pubarche
Menarche
Age (years)
6 7 8 9 10 11 12 13 14 15
.. Fig. 3.3 Anticipated timelines for mean onset and of puberty is 7–13 years. Thelarche occurs 1.2 years
duration of pubertal trajectories [7 https://pedsinreview- before pubarche. Mean age at menarches is 12.9(+/– 1.2)
aappublications-org.myaccess.library.utoronto.ca/con- years, 2–2.5 years after thelarche. *Ages may vary based
tent/pedsinreview/37/7/292.full.pdf]. Typical age range on ethnicity., BMI, nutritional status
3.9 Precocious Puberty sexual characteristics [28]. As referred to ear-

lier, the traditional definition was challenged
The definition of precocious puberty has by Herman-Giddens, who strongly suggested
since remained stable, such that any female that normal pubertal development may begin
who presented prior to 8 years of age was as early as 6 years of age [32]. Causes of pre-
observed, if not evaluated, for progression of cocious puberty are listed in 7 Box 3.1.
Box 3.1 Causes of Precocious Puberty

Central precocious puberty (GnRH dependent) (a) Granulosa cell
1. Idiopathic (b) Functional cyst
2. Central nervous system tumors 3. Adrenal tumors
(a) Craniopharyngioma 4. McCune–Albright syndrome
(b) Trauma
(c) Infection Heterosexual precocious puberty
(d) Primary hypothyroidism 1. Exogenous steroid hormone exposure
3. Syndromes associated with elevated (androgens)
gonadotropins 2. Adrenal and ovarian androgen-producing
(a) Silver’s syndrome (dwarf-like char- tumors
acteristics)
aUrgent assessment in girls with precocious
Peripheral precocious puberty (GnRH indepen- puberty presenting with rapid onset symptoms,
dent) contrasexual development (i.e., virilization),
1. Exogenous steroid hormone exposure vaginal bleeding without other secondary sex-
(estrogens) ual characteristics, and focal neurological find-
2. Ovarian tumors ings suggestive of space-occupying lesion
63 3
zz Environmental Factors growth velocity during the growth spurt.
Although the activation of the HPO axis Conversely, high levels promote closure of the
results in normal onset of sexual develop- epiphyseal plates. Girls who present early in
ment, alternate sources of steroid hormone the course of precocious puberty are generally
production may signal abnormally early taller than their age-respective cohorts due to
development in adolescent girls. Such agents increased levels of steroids and the actions of
include organic pesticides, soy-based prod- IGF-I. This growth is premature and limited,
ucts, and shampoos containing placental so that the final height in untreated patients
extract. Investigators have suggested several will likely be less than 155 cm [30]. As a
possible pathways by which these agents influ- result, by the time most adolescents achieve
ence development, including direct activation menarche, they have likely reached their final
of the HPO axis and steroid hormone-like height. Notwithstanding the apparent risk
activity [35–37]. An area of upcoming study for short stature, a significant number of
is endocrine-disrupting chemicals that are untreated patients with idiopathic disease will
a group of exogenous chemical (EDS) or a likely attain relatively normal adult height,
combination of chemicals that interfere with greater than the third percentile [30]. Some
any hormone action. They can affect any specialists in the field believe that the diagno-
component of the hypothalamic–pituitary sis of precocious puberty cannot be assigned
axis. Examples of EDCs include herbicides, unless symptoms are also associated with an
plastics, parabens, plastics, and fungicides. accelerated growth spurt.
Many of these EDCs are estrogen/androgen
agonists. In animal models, they have been
shown to affect menstrual cycle, development 3.9.2 entral Precocious Puberty
C
of the Müllerian tract, and risk of developing (See Central Precocious
breast cancer [38]. These associations are to Puberty)
be further studied in human models.
CPP is more frequently noted among girls,
zz Neurobehavioral Factors with an incidence of 1:5000–1:10,000 [40]. It
Puberty timing has been shown to be influenced results from the premature activation of the
by demographic, ethnic, genetic, endocrine, hypothalamic GnRH neurons. Approximately
and environmental factors. The transition 70–95% of such cases are idiopathic in nature;
from youth to adolescence can also be affected however, other potential etiologies must first
by biobehavioral factors and neurodevelop- be considered, since the level of urgency and
mental disorders such as autism spectrum need for management of individual causes
disorders (ASD). ASD is a complex neurode- will vary [41, 42]. For a full list of etiologies,
velopmental disorder with an estimated preva- see 7 Box 3.1.
lence of 2% among children 6–17 years of age.
Research on the effect of ASD on pubertal
timing has been limited. Corbett et al., in one 3.9.3 Laboratory Findings
of the largest longitudinal studies to study the
impact of ASD on pubertal timing, reported Baseline gonadotropin levels in the pubertal
that females with ASD showed earlier pubertal range with a predominant LH response are sug-
onset than males with ASD [39]. gestive of CPP. Random daytime levels may be
of less use in early central pubertal development
because the initial increase in pulsatility occurs
3.9.1 ffects of Precocious Puberty
E at night. To help distinguish CPP from GnRH-
on Adult Height independent forms of precocious puberty, a
GnRH stimulation test should be performed.
Low levels of estrogens have been shown to To accomplish this, 100 μg of GnRH (gonad-
promote bone growth, as is manifest by rapid orelin acetate) is administered intravenously,
64 S. Mathur et al.
and gonadotropin levels are drawn at baseline for precocious puberty, and a disparity of
and at 20, 40, and 60 min. One of the earliest greater than 2 years is more suspicious for a
signs of physiologic puberty is the nocturnal, progressive disorder [43]. Given the higher
pulsatile secretion of GnRH with a subsequent prevalence of CNS abnormalities, especially in
increase in serum LH. There is a corresponding girls who present with particularly early onset
rise in LH for each pulse of GnRH secreted. or who have a known history of childhood
3 These same events occur with early onset, seizures, neuroimaging is always indicated to
and an LH:FSH ratio > 1 would be expected. rule out space-occupying lesions, malignant
Serum estradiol levels would be detected in the neoplasms, and other CNS anomalies, even in
pubertal range as well. In order to maintain the the absence of neurological complaints. Pelvic
diagnosis of CPP, androgen (DHEA, DHEA-S, ultrasound, however, is typically one of the
testosterone) and 17-hydroxyprogesterone (17- easiest and most useful studies since it provides
OHP) levels should be drawn. a good picture of ovarian function (develop-
ing follicles capable of producing estradiol,
3.9.3.1 Physical Exam increased cortical volume suggestive of excess
Physical findings suggestive of central pre- androgen production) or neoplastic processes.
cocious puberty (CPP) include Tanner Stage Ultrasound may also demonstrate subsequent
II breast development with darkening of steroid hormone influence on other reproduc-
the areola, labial fullness with a dullness of tive organs. A diagnostic approach to preco-
the vaginal mucosa, and leukorrhea. Coarse cious puberty is given in . Fig. 3.4.
pubic hair, acne, oily skin, clitoromegaly, and
deepening of the voice are signs of androgen
production, which may occur in the setting of 3.9.4 Treatment
heterosexual development and should like-
wise be investigated. Tall stature and adult- The ultimate therapeutic goal with central
type body odor are other indications for the precocious puberty is to suppress the HPO
evaluation of precocious puberty. A complete axis and return the hormonal environment to
neurological exam, psychological evaluation, that of the prepubertal state (serum estradiol
and skin assessment should be performed <10 pg/mL). The most important is the nor-
initially and with subsequent visits as well. malization of linear growth velocity and bone
Simple findings such as elevated blood pres- maturation. The outcome for patients with
sure, suggestive of nonclassic congenital CPP can vary significantly, which further lim-
adrenal hyperplasia (CAH), or skin changes its our ability to predict who will benefit most
consistent with café au lait spots are most from therapy.
helpful and easy to notice.
3.9.3.2 Imaging Studies 3.9.5 Hypothalamic Suppression

Imaging studies play a key role in the evalu-
ation of children with precocious puberty, Initial attempts to achieve such a degree of
because a rapid increase in growth and bone hypothalamic suppression included the use of
age are typically seen in children with rapidly progestins; however, these were unsuccessful
increasing levels of sex steroid hormones. at limiting progressive changes and their use
Linear growth and skeletal maturation are has since been abandoned [44]. The most com-
often a more accurate assessment of pubertal monly used GnRH agonists to treat CPP in the
development than progression of secondary USA are leuprolide, nafarelin, and histrelin.
sexual characteristics. Children with precocious puberty generally
Bone age is typically evaluated by radio- require higher doses to achieve suppression,
graphic plain films of the left hand and wrist. which can be monitored with serum estradiol
This is a simple and noninvasive test that is levels and GnRH stimulation tests. In order
well tolerated by most children. Bone age to improve compliance, subcutaneous formu-
advance over chronological age is diagnostic lations can be used. Early treatment protocols
65 3
Breast Development
(<7 years)
Normal Bone Age Advanced Bone Age

Prepubertal LH and FSH (GnRH Stimulation Test)
(-)Virilization (+)Virilization
High FSH High LH Prepubertal LH and FSH

DHEAS Response Response Levels
Premature Thelarche
Premature Adrenarche Thelarche

-Elevated DHEAS Elevated Normal Hypothyroidism MRI Pelvic/Renal
Sonogram
Adrenal Tumor Cushing’s Syndrome
Ovarian Tumor
CAH
GnRH Dependent GnRH Independent
Constitutional MeCune-Albright
CNS Tumor Ovarian Tumor
CNS Malformation Adrenal Tumor
.. Fig. 3.4 Evaluation of central, peripheral, and incomplete precocious puberty [41]
using long-acting GnRH agonists reported patients presenting beyond the window of
significant regression of secondary sexual opportunity, that limits final height.
characteristics and overall improvement in Significant consideration should be given
final height compared to non- randomized to promptly initiating therapy in girls pre-
controls [46]. A few randomized series have, senting early with advanced bone age, as they
however, been published that addressed the will likely benefit most from GnRH agonist
effect of GnRH agonists on final height in therapy [50–53]. Adan et al. suggested the
girls who presented with early or slowly pro- following as risk factors for decreased stat-
gressive puberty [47, 48]. They confirmed ure and appropriate indications for therapy,
results from previous observational and non- especially at an earlier age of onset: (1)
randomized reports that documented very predicted adult height below 155 cm (may
little effect of hypothalamic suppression on include those with a predicted height over
improving final height in patients presenting 155 cm if the LH/FSH ratio is consistent
at a later age. Children presenting with either with CPP) and (2) bone age advance over
“early puberty” or advanced “slowly progres- chronological age greater than 2 years [53].
sive puberty” were likely to achieve reasonable Hormonal monitoring of therapy can be per-
adult height without hypothalamic suppres- formed with the GnRH stimulation test at 3,
sion. If therapy is initiated, GnRH agonists 6, and 12 months after initiation, with annual
remain the historical and current primary follow-up thereafter.
treatment option. Although the optimal time of discontinu-
ing therapy remains unclear, many recom-
zz Treatment Expectations mend that suppression stop at a bone age of
One theory that may help explain impaired 12–12.5 years. Other elements to consider
growth during GnRH analog therapy in this include the total duration of therapy and
group is early growth plate senescence related growth velocity over the months preced-
to estrogen exposure prior to onset of treating. Routine evaluation of secondary sexual
ment [49]. So it may be this rate-limiting step, characteristics, weight, and sonographic mea-
66 S. Mathur et al.
surements of pelvic structures should be per-

formed on an ongoing basis as well. Bone (a) Granulosa cell
mineral density may be affected by prolonged (b) Functional cyst
use of GnRH agonists, so attention to bone 3. Adrenal tumors
health should not be omitted. 4. McCune–Albright syndrome
3
3.9.6 Recombinant Growth
Hormone Heterosexual precocious puberty
1. Exogenous steroid hormone exposure
Some children with precocious puberty (androgens)
will have early closure of their epiphyseal 2. Adrenal and ovarian androgen-producing
plates despite the use of GnRH analogs. As tumors
a result, these girls will grow up to be short
adults without further intervention. The use
of growth hormone as an adjunct to GnRH When precocious puberty occurs indepen-
agonists in girls with precocious puberty has dent of pituitary gonadotropins, the source
been evaluated by several observational and of estrogen production must be established.
randomized series and has been found to One common source is surreptitious ingestion
improve final height prognosis [54]. Although of exogenous hormones, such as those found
the use of growth hormone in certain patients in oral contraceptive pills or anabolic steroids.
is frequently prescribed among pediatric Other less common sources include primary
endocrinologists, the studies evaluating effi- hypothyroidism. However, the most common
cacy are troubled by obstacles quite similar origin of GnRH-independent estrogen pro-
to those seen with the analysis of GnRH ago- duction is frequently the ovary itself.
nists on final height. A meta-analysis from
2018 that analyzed data from either random-
ized or quasi-randomized trials did not show 3.9.8 Autonomous Ovarian
any benefit in combined GnRH and recom-
Estrogen Production
binant growth hormone administration spe-
cific to final adult height in girls with central
Ovarian tumors are uncommon but impor-
precocious puberty [55]. It is important to
tant childhood neoplasms that present with
be aware that growth hormone has not yet
precocious puberty in approximately 10%
been approved by the US Food and Drug
of cases [56]. Granulosa cell tumors are the
Administration for treatment of girls with
most common estrogen-producing neoplasms
short stature as a result of precocious puberty.
detected. However, other tumors, such as the-
cal cell tumors, gonadoblastomas, teratomas,
cystadenomas, and ovarian cancers, may be
3.9.7 GnRH-Independent responsible. Intra-abdominal masses are often
Precocious Puberty palpable, but imaging with sonography or
(See GnRH-Independent magnetic resonance imaging may help char-
Precocious Puberty) acterize the tumor, and surgical exploration is
generally warranted.
Laboratory criteria that help distin-
guish these processes from a central source
Peripheral precocious puberty (GnRH inde-
include low baseline gonadotropin levels
pendent)
and a prepubertal response to the GnRH
1. Exogenous steroid hormone exposure
stimulation test. Similar to CPP, estradiol
(estrogens)
levels will be high and bone age advanced
2. Ovarian tumors
(see . Fig. 3.2). Treatment is based on sur-
67 3
gical extirpation of the source, which results [61]. These findings help to explain the lack of
in regression of pubertal changes. therapeutic benefit of aromatase inhibitors in
certain patients with McCune–Albright syn-
drome. Evaluation and management of these
3.9.9 McCune–Albright Syndrome complicated patients should then be based on
algorithms used for CPP. The SERM, tamoxi-
McCune–Albright syndrome, also known as fen, was studied in a prospective, multicenter
polyostotic fibrous dysplasia, is a genetic dis- trial, for the 12-month treatment of 25 girls with
ease affecting the bones and pigmentation of McCune–Albright syndrome. This treatment
the skin. The hallmark of McCune–Albright decreased the incidence of vaginal bleeding and
syndrome in girls is precocious puberty, and also decreased bone velocity and bone matura-
this condition accounts for approximately 5% tion [62]. Other causes of precocious puberty
of all girls with precocious puberty. These can be found in 7 Box 3.1.
patients have estrogen-producing ovarian
follicular cysts that develop independent of
gonadal hormone stimulation, a condition 3.9.11 Premature Thelarche
termed autonomous follicle development.
Children with this rare disorder also have Early breast development in the absence of
fibrous dysplasia in their bones, which leads other signs of sexual maturity is typically a
to fractures, deformities, and X-ray abnor- benign, self-limited event. Initial laboratory
malities. Facial bone deformities may result evaluation will reveal prepubertal gonado-
in appropriate concerns for cosmesis. In addi- tropin levels and normal bone age. GnRH
tion, these children have cafe au lait spots, stimulation will result in a predominant FSH
which are light tan birthmarks. McCune– response. Continued observation is nonethe-
Albright syndrome is often associated with less mandatory, and breast development, which
several other endocrinopathies, including may be unilateral or bilateral, will likely regress,
hyperthyroidism, acromegaly, pituitary ade- but may persist until normal onset of puberty.
nomas, and adrenal hyperplasia [57].
3.9.12 Premature Adrenarche

3.9.10 Treatment
Adult pubic hair growth before the age of 6
In contrast to girls with CPP, girls with may result from an abnormal adrenal secre-
McCune–Albright syndrome exhibit a lack tory response, which promotes androgen pro-
of GnRH pulsatility, gonadotropin levels are duction (17-hydroxypregnenolone, DHEA,
low, and estradiol is produced from autono- and DHEA-S). Like premature thelarche, the
mous follicle development. Treatment pro- diagnosis can only be made after longitudinal
tocols for McCune–Albright syndrome are evaluation, in the absence of other signs of
aimed at inhibiting peripheral estradiol pro- sexual development. Although mild increases
duction with aromatase inhibitors or blocking in bone age may occur, no treatment is neces-
the effects at the receptor level with selective sary, as these children will likely achieve nor-
estrogen receptor modulators (SERMs). mal adult height [63].
Aromatase inhibitors offer several theoretical A fasting 17-OHP level is generally suffi-
benefits for the treatment of McCune–Albright cient to rule out nonclassic CAH unless there
syndrome. Unfortunately, results from studies is significant bone age advance. Only patients
evaluating testolactone have been inconclusive with conclusively high levels of 17-OHP war-
[58–60]. It has been suggested that continuous rant treatment. There is evidence to suggest
estrogen exposure from a peripheral source may that girls with premature adrenarche may be
secondarily induce the HPO axis, such that a at risk for developing polycystic ovarian syn-
central component may occur simultaneously drome (PCOS).
68 S. Mathur et al.
3.10 elayed Puberty and Primary

D Most girls with delayed puberty have normal
Amenorrhea ovaries (eugonadal) and their sexual develop-
ment is constitutionally delayed. Hypogonadism,
Delayed puberty in girls is fairly common, which can occur, can be the result of ovarian fail-
affecting up to 2% of adolescents, and is ure, termed hypergonadotropic hypogonadism,
or because normal ovaries are not stimulated to
3 defined as lack of thelarche by 13 years of age
or when more than 4 years pass between thelar- secrete hormones, referred to as hypogonado-
che (SMR Stage Tanner 2) and menarche [64]. tropic hypogonadism.
Primary amenorrhea is diagnosed when girls
who have developed secondary sexual char-
acteristics do not reach menarche by 16 years 3.10.1 Hypergonadotropic
of age. Constitutional delay of growth and Hypogonadism
puberty (CDGP) is the most common etiology
accounting for 53% of all cases [65]. Please see Hypergonadotropic hypogonadism is the
. Fig. 3.5 outlining a flow chart for evaluat- single most common etiology of pubertal
ing girls with delayed puberty [45]. delay, accounting for approximately 20% of
Delay in onset of secondary sexual Normal secondary sexual

development after 13 years in girls development with primary amenorrhea
Serum gonadotropins
Elevated Low Growth pattern Karyotype
Karyotype Normal Consistently short Late-onset growth Normal without Normal 46,XY
46,XX for chronologic failure especially growth spurt
age but appropriate with concurrent
for bone age diabetes insipidus
Absence or abnormality Signs of increased

of one X chromosome or intracranial
mosaicism with 45,X pressure or visual
cell line Bone age delayed abnormalities Sense of smell
Anosmia or
hyposmia
MRI Normal
Mass Absence of Normal

offactory bulb
and/or sulcus
Primary ovarian Isolated

CNS Kalimann’s
failure-autoimmune gonadotropin
tumor syndrome
or other etiology deficiency
Turner’s syndrome (may Anatomic

or may not have somatic Syndrome
defect or
stigmata of Turner’s Constitutional of
abnormality
syndrome but short stature delay in growth androgen
in LH
is extremely common) and puberty resistance
pulsatility
.. Fig. 3.5 Flowchart for the evaluation of delayed puberty in girls. (From Melmed et al. [45])
69 3
cases [64]. The essential condition required to Permanent hypogonadotropic hypogonad-
make this diagnosis is elevated gonadotropins, ism is characterized as elevated FSH and LH
both FSH and LH. Recent advances have due to interrupted negative feedback at the
enhanced our understanding of neuroendo- level of the ovary, such as congenital hypogo-
crine mechanisms affecting puberty, genetics, nadotropic hypogonadism (Kallmann’s syn-
and environmental roles have contributed to drome if associated with anosmia), whereas
this understanding. These have led to novel transient hypogonadotropic hypogonadism
therapies [66]. represents more of a functional disorder due
Turner’s syndrome is the most commonly to a delay in the activation of the central axis.
diagnosed condition within this subset (1:2000 Many of the underlying etiologies of func-
to 1:2500 live born females) [67]. Karyotype tional delay are associated with malnutrition
may reveal 45,X or a mosaic, which may occur or chronic illness (eating disorders, Crohn’s
in up to 40–50% of patients with gonadal disease) [68]. The most common cause of
dysgenesis. DNA analysis is crucial, because this is constitutional delay, which should
the presence of the Y chromosome places always be considered a diagnosis of exclu-
patients at risk for gonadal neoplasias such as sion. However, more than 50% of teens with
gonadoblastoma and dysgerminoma. Mixed constitutional delay have a common theme
gonadal dysgenesis, 45,X/46,XY (the most within their family tree [69]. Further, the tim-
common karyotype), is also representative of ing of the onset of puberty is highly variable
the abnormal sex chromosome group. with a similarly high correlation with genetic
Several forms of primary and second- factors [70]. Bone age and height age are
ary ovarian failure with normal sex chromo- delayed, unlike that seen in hypothyroidism
somes also exist. Pure gonadal dysgenesis, where bone age is delayed more than height
Swyer’s syndrome, typically presents with age. Unfortunately, the only way to discern
delayed puberty. Chemotherapy and/or radia- constitutional delay from idiopathic hypogo-
tion therapy may result in gonadal dysfunc- nadotropic hypogonadism is by longitudinal
tion and delayed development in an otherwise observation.
genetically and phenotypically normal female.
Other causes of ovarian failure include auto-
immune oophoritis, galactosemia, gonadotro- 3.10.3 Primary Amenorrhea
pin-resistant ovary syndrome, steroidogenesis with Otherwise Normal
enzyme deficiency, infection, or gonadotropin Sexual Development
receptor gene mutation. Autoimmune disor-
ders associated with hypergonadotropic hypo- Patients with 46XX with a normally function-
gonadism include Hashimoto’s thyroiditis and ing HPO axis who present with primary amen-
Addison’s disease. Patients with 17α(alpha)- orrhea typically have anomalies of the genital
hydroxylase deficiency present with adrenal outflow tract, such as imperforate hymen or
insufficiency, hypertension, and lack of sex vaginal septum (7 Box 3.2). One of the most
steroids, including androgens. common causes of primary amenorrhea in
these patients is Mayer–Rokitansky–Kuster–
Hauser (MRKH) syndrome. This condition is
3.10.2 Hypogonadotropic characterized by a blind vaginal pouch in an
Hypogonadism otherwise normally sexually developed ado-
lescent and results from the failure of devel-
This condition results from a failure of opment of the Müllerian (paramesonephric)
the HPO axis and deficiency of GnRH. duct system in genotypic females.
70 S. Mathur et al.
Box 3.2 Causes of Primary Amenorrhea

Hypergonadotropic hypogonadism (i) GnRH deficiencies
1. Abnormal sex chromosomes (ii) Gene mutations
(a) Turner’s syndrome (b) Constitutional delay
2. Normal sex chromosomes (c) Acquired abnormalities
3 (a) 46,XX gonadal dysgenesis (i) Endocrine disorders
(b) 46,XY gonadal dysgenesis (ii) Pituitary tumors
(c) Pseudo-ovarian failure (d) Systemic disorders
3. Eugonadism
Hypogonadism (a) Anatomic abnormalities
1. Hypergonadotropic hypogonadism (i) Congenital absence of uterus and
(a) Abnormal sex chromosomes vagina (CAUV)
(i) Turner’s syndrome (ii) Imperforate hymen
(b) Normal sex chromosomes (iii) Transverse vaginal septum
(i) 46,XX gonadal dysgenesis 4. Intersex disorders
(ii) 46,XY gonadal dysgenesis (a) Androgen insensitivity
(iii) Pseudo-ovarian failure (i) Polycystic ovarian syndrome
2. Hypogonadotropic hypogonadism
(a) Congenital abnormalities
Androgen insensitivity syndrome (AIS) is Syndromic hypergonadotropic hypogo-

another common cause of primary amenor- nadism is an autosomal recessive ovarian
rhea. Androgen insensitivity syndrome, pre- dysgenesis and has been termed “Perrault syn-
viously termed testicular feminization, is the drome” when associated with deafness [72].
result of an abnormal androgen receptor. This Congenital galactosemia has been asso-
maternal X-linked recessive disease occurs in ciated with primary ovarian insufficiency.
individuals with XY genotypes and normal but This appears to reflect a metabolic toxic-
partially or completely undescended testicles ity state affecting ovarian function [73].
that produce testosterone. Defects in andro- Inactivation of FSH and LH receptors also
gen action, manifesting as complete androgen can result in primary amenorrhea and pre-
insensitivity syndrome, appear to be associated mature ovarian failure resulting in delayed
with mutations of the androgen receptor (AR) puberty [74].
gene [71]. Because of the abnormal androgen
receptors, high levels of circulating testoster-
one result in appropriately timed puberty in 3.10.4 Evaluation
females who appear phenotypically normal. A
harbinger is sparse or absent pubic hair. A complete evaluation should be undertaken
Primary amenorrhea or delayed menarche for any adolescent who meets the standard
is frequently associated with hyperandrogen- criteria for delayed puberty or primary amen-
ism, secondary to either PCOS or adult-onset orrhea, defined by lack of any pubertal devel-
CAH. These patients have otherwise normal opment by 13 years of age, when more than
puberty, but will also present with signs of 4 years have passed between thelarche and
androgen excess ranging from hirsutism and menarche or no menses by 16 years of age
acne to virilization. with secondary sex characteristics.
71 3
Extensive neonatal and family history, deficiency). A prolactinoma may present with
including ages of pubertal development and hyperprolactinemia and galactorrhea.
attainment of final height extending to mem- Adolescents with primary amenorrhea who
bers beyond the nuclear family, is helpful. have normal development of other secondary
History pertinent to information of prior expo- sexual characteristics are usually of normal
sure to exogenous steroid hormones or chemo- stature. Pelvic or recto-abdominal examination
therapy must also be elicited. Review of systems is performed in these patients to exclude ana-
to evaluate for chronic illnesses and pattern of tomic abnormalities of the reproductive tract.
exercise and diet may uncover the diagnosis. Examples include vaginal septum and the
Physical examination and height and blind vaginal pouch associated with MRKH
weight plotted on a growth chart should be and androgen insensitivity syndrome.
completed as well as blood pressure, thyroid
exam, Tanner staging, and abdominal exam. 3.10.4.1 Lab Investigations
A complete neurological evaluation, includ- In patients with hypergonadotropic hypogo-
ing assessing the ability to smell, should also nadism, testing would be consistent with ovar-
be performed. Hypergonadotropic hypogo- ian failure, i.e., high serum gonadotropins and
nadism patients often present with short stat- low estradiol. In those presenting with hypo-
ure. Patients with Turner’s syndrome (45,XO), gonadotropic hypogonadism, serum levels of
the most common presentation of hyper- both gonadotropins and estradiol would be
gonadotropic hypogonadism, may present low. Patients with Müllerian anomalies would
during infancy with lymphedema or during have normal postpubertal gonadotropin and
childhood with typical features such as short estradiol levels.
stature, webbed neck, and shortened fourth
metacarpals. Cardiovascular anomalies and
renal abnormalities such as aortic coarctation, 3.10.5 Imaging
bicuspid aortic valves, and horseshoe kidney
can be determined with imaging studies. Bone age can be assessed similarly to ado-
Patients with mixed gonadal dysgenesis lescents presenting with precocious puberty.
(mosaic XY/XO) may present phenotypi- Stature, consequently, will be decreased in
cally similar to those with Turner’s syndrome; patients with hypergonadotropic hypogonad-
however, virilization or ambiguous genitalia ism, with the exception of pure gonadal dys-
may also be evident in the presence of the genesis (46,XX).
Y chromosome. Patients with 46,XX com- If gonadotropin levels are low with delayed
plete gonadal dysgenesis are normal to tall in puberty, then a central cause must be deter-
stature and are most commonly phenotypi- mined. Likewise, an elevated prolactin sug-
cally female. Sexual infantilism with lack of gests a pituitary or hypothalamic problem. In
Müllerian structures and 46,XY karyotype is these cases, MRI scan of the brain and pitu-
consistent with Swyer’s syndrome. itary gland is indicated to exclude abnormal-
Hypogonadotropic hypogonadism can ity of the hypothalamic–pituitary axis such as
be seen in adolescents who are extremely pituitary or hypothalamic tumors.
athletic or malnourished. Minimal body fat Adolescents with primary amenorrhea but
from either cause is associated with reversible otherwise normal sexual development require
hypothalamic dysfunction. Patients with CNS pelvic ultrasound to evaluate the internal
tumors may present with persistent headaches reproductive organs and detect the presence of
or visual field defects. Marked centripetal obe- a fluid collection consistent with hematocol-
sity and moon facies are typical of Cushing’s pos related to a vaginal septum. Abdominal
syndrome. Anosmia along with hypothalamic and pelvic MRI is helpful in evaluating renal
hypogonadism is consistent with the diagno- or skeletal anomalies in patients with vaginal
sis of Kallmann’s syndrome (isolated GnRH agenesis.
72 S. Mathur et al.
3.10.6 Treatment of Delayed age years. However, some Turner’s syndrome

Puberty patients will be referred for evaluation during
childhood. If these patients begin estrogen
zz Specific Therapy therapy too early, their potential growth may
Therapy for hypogonadotropic disorders be limited by epiphyseal closure.
Hormone replacement for treatment of
3 is focused on treating the primary etiology
whenever possible. If an intracranial lesion delayed puberty is begun with low-dose estro-
compresses the pituitary stalk, then surgical gens, typically 0.3 mg conjugated estrogens
therapy is indicated. If prolactinoma is the for 6–12 months. The main goal is to induce
cause, then bromocriptine becomes the first normal breast development, as too high of
line of therapy. Medical therapy generally an estrogen dose can result in the develop-
restores menses and fertility, and although ment of tuberous breasts [75]. Subsequent
surgical treatment may portend good results goals include regulation of menses and main-
initially, there is a high incidence of recurring tenance of bone mass. This can be achieved
hyperprolactinemia. Surgery may therefore be by increasing the dosage of estrogen slowly
postponed unless the condition is refractory after the first year until menstruation occurs.
to medical management. Progestin therapy (e.g., medroxyprogesterone
Treatment for competitive athletes and acetate [5–10 mg] at end of estrogen cycle)
patients with anorexia nervosa becomes some- is initiated approximately 3 months after the
what more challenging. Since body weight increase in dosage of estrogen, typically when
with total body fat of at least 12–14% has breakthrough bleeding occurs. The most com-
been associated with return of menses, many mon formulation includes continuous estrogen
clinicians feel that patients should be encour- therapy with sequential progestins given orally
aged to change their lifestyle and improve in the latter part of the cycle to create regular
their diet before introducing pharmaceutical menses. Alternative forms include transdermal
management. Whereas patients with idio- estrogen replacement and micronized proges-
pathic or irreversible gonadal failure who have tins that have less negative impact on lipid
not demonstrated sexual development begin profiles. Gonadotropins have also been used to
therapy at 14–15 years of age, therapy may be induce ovulation, but are costly and more diffi-
initiated later for these patients. cult to administer, especially in the adolescent
patient population [67].
zz Estrogen Therapy
If the cause of delayed puberty is determined to zz Novel Therapies
be irreversible or idiopathic (i.e., constitutional Kisspeptin-10 in men has been described. This
delayed), sex steroid hormone replacement is may have application in the future for females;
indicated. The goal of therapy involves induction it appears to stimulate the hypothalamic–pitu-
of breast development, bone growth, and menses. itary–ovarian axis and has been advocated
Hormone replacement for patients with ovarian as one selective option for treatment of idio-
failure is important not only to induce pubertal pathic hypothalamic hypogonadism [76].
development but also to decrease the risk of sub-
sequent osteoporosis and cardiovascular disease zz Gender Identity and Puberty (SM)
due to prolonged hypoestrogenic state. Children, teens, and young adults may expe-
Timing is quite important when starting rience incongruence between their gender
hormone replacement. In most instances, at birth and their gender identity, meeting
therapy is initiated when patients present certain Diagnostic and Statistical Manual of
with delayed puberty during their early teen- Mental Health Disorders, Fifth Edition, crite-
73 3
ria for gender dysphoria. There has been an Vries et al. where adolescents followed by
increase in the number of referrals for gen- a multidisciplinary gender team with phy-
der dysphoria and intervention is occurring sicians, mental health provides reported
at younger ages [77]. Children may present improved psychological function [78]. The
as early as 3 years of age as nonconform- Endocrine Society Clinical Practice Guide-
ing or transgender [77]. Transgender indi- lines for Gender Dysphoric individuals rec-
viduals experience significant bias, and have ommend inducing pubertal delay with the use
high rates of mental health disorders and of GnRH agonists. Annelou et al. also report
self-harm behaviors [77]. The World Profes- that pubertal suppression among transgender
sional Association for Transgender Health youth along with cross sex hormone therapy
(WPATH) and Endocrine Society recom- and gender reassignment surgery results in
mend a comprehensive approach to improve resolution of gender dysphoria and improved
mental health outcomes as described by De psychological well-being [79].
Box 3.3 Constitutional Delay

A 12-year-old, otherwise healthy, female, menarche at age 15 years and both par-
presents with Tanner Stage I breast develop- ents achieved normal final adult height.
ment, but no other pubertal advancement (b) No significant neonatal or pediatric his-
including menarche. She has reached the fifth tory to suggest infectious or traumatic
percentile for height and weight. She enjoys etiology.
school and lives with her parents. She is pri- 3. What investigations would you order?
marily concerned about being shorter than A bone age is a noninvasive test to eas-
her friends. ily differentiate between constitutional and
1. Does she meet criteria for delayed puberty? nonconstitutional delay. A hormone panel
(a) Yes: She does not have secondary sex testing LH and FSH levels would be rea-
characteristics by the age of 12 years. sonable as part of initial assessment.
2. What are some key presenting features to (a) Bone age demonstrates 2 years younger
suggest delay? than expected, consistent with 10 years
(a) Family history: There is no history of of age.
chromosomal anomalies, Müllerian (b) Gonadotropins and estradiol levels are
anomalies. Her mother experienced in the prepubertal range.
Conclusion
This case describes a classic presentation of
constitutional delay. The Tanner staging,
along with delay in growth and a bone age
of 10 point to a “hypothalamic age” of 10.
The FSH and LH being in the prepubertal
range confirm this finding. No intervention
at this time is needed, but close follow-up is
recommended.
74 S. Mathur et al.
Box 3.4 Primary Amenorrhea

A 16-year-old female presents with primary characteristics, along with a normal height.
amenorrhea and Tanner Stage IV breast and Given the physical exam findings, the diag-
axillary hair development. She is currently nosis for this patient is MRKH.
178 cm and 60 kg. She is otherwise healthy. (a) MRKH: normal endocrine panel,
3 Her parents are of normal height. Her mother blind vaginal pouch, pursue urinary
experienced menarche at the age of 13. On tract imaging to evaluate for anoma-
physical exam, this patient presents with a lies.
blind vagina. Laboratory findings show a nor- (b) AIS: high total testosterone (if com-
mal post-pubertal range gonadotropins and plete), sparse hair development, i.e.,
estrogen. non-androgenic appearance despite
1. What are the differential diagnoses? high serum levels; partial AIS will
The most common causes of primary manifest with androgenic features at
amenorrhea include Turner’s syndrome, onset of puberty.
Mayer–Rokitansky–Kuster–Hauser (MRKH) (c) Turners: hypergonadotropic hypogo-
syndrome and androgen insensitivity syn- nadism, but much less likely given
drome (AIS). This patient presents with normal final adult height and Tanner
normal development of secondary sex Stage IV breast development.
Box 3.5 Precocious Puberty

A 5-year-old girl of Southeast Asian descent the absence of other signs of sexual
presents with Tanner Stage II breast develop- development. Although mild increases
ment. No evidence of androgenic development in bone age may occur, no treatment is
and she denies vaginal bleeding. She is in the necessary, as these children will likely
50th percentile for her age-specific height. achieve normal final adult height.
1. Does she meet criteria for precocious puberty? 2. What investigations would you pursue?
(a) Premature thelarche is isolated breast (a) Bone age demonstrates no advance-
development and is considered a nor- ment.
mal variant. The diagnosis can only be (b) Gonadotropins and estradiol levels are
made after longitudinal evaluation, in in the prepubertal range.
3.11 Review Questions ??2. A mother is worried about her 3-year-

old child that seems to have breast
??1. A 16-year-old adolescent presents with development. She has no vaginal bleed-
amenorrhea and no breast developing. She has no medical problems. Phys-
ment. However, she has Tanner IV ical exam shows normal growth curves,
pubic hair. She has no medical prob- normal weight, and Tanner II breasts
lems. Her FSH is 80 mIU/mL and estra- and Tanner I pubic hair. FSH, LH and
diol less than lower limit of the assay. estradiol are all pre-pubertal. Your ten-
Imaging shows a pre-pubescent uterus. tative diagnosis is
What is your next step? A. Central precious puberty
A. Start her on hormone replacement B. Premature thelarche
therapy C. McCune Albright syndrome
B. Order a karyotype D. Premature adrenarche
C. Measure serum testosterone
D. Order a bone density scan
75 3
??3. A mother brings in her 5-year-old girl nadotropic and hypergonadotropic hypogonadism.
with an observation of pubertal devel- J Clin Endocrinol Metab. 1973;37:680.
8. Juul A, Hagen C, Aksglaede L, et al. Endocrine
opment. On exam she has Tanner III
evaluation of reproductive function in girls during
breast and Tanner 1 pubic hair. She infancy, childhood and adolescence. Endocr Dev.
noticed that she has grown 3 cm in 2012;22:24–39.
the past 5 months. Her LH, FSH, and 9. Biro F, Huang B, Daniels S, et al. Pubarche as
estradiol are all in the puberty range. well as thelarche may be a marker for the onset of
puberty. J Pediatr Adolesc Gynecol. 2008;21:323–8.
Her most likely diagnosis is
10. Boyar R, Finkelstein J, Roffwarg H, Kapen S,
A. Central precious puberty Weitzman E, Hellman L. Synchronization of aug-
B. Peripheral precious puberty mented luteinizing hormone secretion with sleep
C. Pituitary tumor during puberty. N Engl J Med. 1972;287:582.
D. Primary ovarian activation 11. Landy H, Boepple PA, Mansfield MJ, Charpie P,
Schoenfeld DI, Link K, et al. Sleep modulation of
neuroendocrine function: developmental changes in
gonadotropin-releasing hormone secretion during
3.12 Answers sexual maturation. Pediatr Res. 1990;28:213–7.
12. Yen SS, Apter D, Butzow T, Laughlin GA. Gonad-
vv1. B otropin releasing hormone pulse generator activity
before and during sexual maturation in girls: new
insights. Hum Reprod. 1993;8(Suppl 2):66–71.
vv2. B 13. Frisch RE, Revelle R. Height and weight at men-
arche and a hypothesis of critical body weights and
vv3. A adolescent events. Science. 1970;169:397.
14. Warren MP. The effects of exercise on pubertal pro-
gression and reproductive function in girls. J Clin
Endocrinol Metab. 1980;50:1150.
References 15. Penny R, Goldstein IP, Frasier SD. Gonadotro-
pin secretion and body composition. Pediatrics.
1. Knobil E, Plant T, Wildt L, et al. Control of the 1978;61:294.
Rhesus monkey menstrual cycle permissive role of 16. Apter D. Leptin and puberty. Curr Opin Endocrinol
hypothalamic gonadotropin-releasing hormone. Diabet. 2000;7:57–64.
Science. 1980;207:1371. 17. Farooqi IS, Jebb SA, Langmack G, Lawrence E,
2. Emans SJ, Laufer MR, Goldstein DP, editors. Pedi- Cheetham CH, Prentice AM, et al. Effects of recom-
atric and adolescent gynecology: the physiology of binant leptin therapy in a child with congenital
puberty. Baltimore: Lippincott Williams & Wilkins; leptin deficiency. N Engl J Med. 1999;341:879–84.
1998. p. 109–40. 18. Ibanez L, de Zegher F. Puberty and prenatal growth.
3. Kaplan SL, Grumbach MM, Aubert ML. The Mol Cell Endocrinol. 2006;25:22–5.
ontogenesis of pituitary hormones and hypotha- 19. Paul A, Deans R, Viner R, Creighton SM. Puber-
lamic factors in the human fetus: maturation of cental development and sexuality in female adolescents
tral nervous system regulation of anterior pituitary born preterm: a review of the literature. Int J Ado-
function. Recent Prog Horm Res. 1976;32:161. lesc Med Health. 2011;23(3):175–9.
4. Grumbach MM, Kaplan SL. The neuroendocri- 20. Barker DJ, Winter PD, Osmond C, Margetts B,
nology of human puberty: an ontogenetic perspec- Simmonds SJ, Barker DJ, et al. Weight in infancy
tive. In: Grumbach MM, Kaplan SL, Sizoneko PC, and death from ischaemic heart disease. Lancet.
Aubert ML, editors. Control of the onset of puberty. 1989;2(8663):577–80.
Baltimore: Williams & Wilkins; 1990. p. 1–68. 21. Sahu A, Phelps CP, White JD, Crowley WR, Kalra
5. Mitsushima D, Hei DL, Terasawa E. SP, Kalra PS. Steroidal regulation of hypothalamic
γ-Aminobutyric acid is an inhibitory neurotrans- neuropeptide Y release and gene expression. Endo-
mitter restricting release of luteinizing hormone- crinology. 1992;130:3331.
releasing hormone before the onset of puberty. 22. Kaye WH, Berrettini W, Gwirtsman H, George
Proc Natl Acad Sci U S A. 1994;91:395–9. DT. Altered cerebrospinal fluid of neuropeptide Y
6. Tapanainen J, Koivisto M, Vijko R, Huhtaniemi and peptide YY immunoreactivity in anorexia and
I. Enhanced activity of the pituitary-gonadal axis in bulimia nervosa. Arch Gen Psychiatry. 1990;47:548.
premature human infants. J Clin Endocrinol Metab. 23. Sonigo C, Binart N. Overview of the impact of kis-
1981;52:235–8. speptin on reproductive function. Ann Endocrinol
7. Roth JC, Kelch RP, Kaplan SL, Grumbach (Paris). 2012;73:448–58.
MM. FSH and LH response to luteinizing 24. Veldhuis J, Metzger D, Martha P, Mauras N, Ker-
hormone-releasing factor in prepubertal and puber- rigan J, Keenen B, Rogol A, Pincus S. Estrogen and
tal children, adult males and patients with hypogo- testosterone, but not a non-aromatizing androgen,
76 S. Mathur et al.
direct network integration of the hypothalamo- 40. Cutler GB. Precocious puberty. In: Hurst JW, edi-
somatotrope (growth hormone) insulin like growth tor. Medicine for the practicing physician. 2nd ed.
factor I axis in the human: evidence from pubertal Woburn: Butterworth; 1988. p. 526–30.
pathophysiology and sex-steroid hormone replace- 41. Cisternimo M, Arrigo T, Pasquino AM, Tinelli C,
ment. J Clin Endocrinol Metab. 1997;82:3414–20. Antoniazzi F, Beduschi L, et al. Etiology and age
25. Kerrigan J, Rogol A. The impact of gonadal ste- incidence of precocious puberty in girls: a multi-
roid hormone action on growth hormone secretion centric study. J Pediatr Endocrinol. 2000;13(Suppl
3 during childhood and adolescence. Endocrine Rev. 1):695–701.
1992;13:281–98. 42. Chalumeau M, Chemaitilly W, Trivin C, Adan L,
26. Juul A. The effects of estrogens on linear bone Bréart G, Brauner R. Central precocious puberty
growth. Hum Reprod Uptake. 2001;7:303–13. in girls: an evidence-based diagnosis tree to predict
27. Chulani V, Gordon L. Adolescent growth and devel- central nervous system abnormalities. Pediatrics.
opment. Prim Care Clin Office Pract. 2014;41:465–87. 2002;109:61.
28. Marshall W, Tanner J. Variations in the pat- 43. Fontoura M, Brauner R, Prevot C, Rappaport
tern of pubertal changes in girls. Arch Dis Child. R. Precocious puberty in girls: early diagnosis
1969;44:291. of a slowly progressing variant. Arch Dis Child.
29. Solnik JM, Sanfilippo JS. In: Hurd WW, Falcone T, 1989;64:1170–6.
eds. Clinical reproductive medicine and surgery. St. 44. Sorgo W, Kiraly E, Homoki J, Heinze E, Teller
Louis: Mosby/Elsevier WM, Bierich JR, et al. The effects of cyproterone
30. Bayley N, Pinneau SR. Tables for predicting acetate on statural growth in children with preco-
adult height from skeletal age: revised for use cious puberty. Acta Endocrinol. 1987;115:44–56.
with the Greulich-Pyle hand standards. J Pediatr. 45. Melmed S, Polonsky K, Larsen PR, et al. Williams
1952;40:423–41. textbook of endocrinology. 12th ed. Philadelphia:
31. Wyshak G, Frisch RE. Evidence for a secular trend Saunders; 2011. p. 1137.
in age of menarche. N Engl J Med. 1982;306:1033. 46. Comite F, Cutler GB Jr, Rivier J, Vale WW, Loriaux
32. Herman-Giddens ME, Slora EJ, Wasserman RC, DL, Crowley WF Jr. Short-term treatment of idio-
Bourdony CJ, Bhapkar MV, Koch GG, et al. Sec- pathic precocious puberty with a long-acting ana-
ondary sexual characteristics and menses in young logue of luteinizing hormone-releasing hormone. N
girls seen in office practice: a study from the pedi- Engl J Med. 1981;305:1546–50.
atric research in office settings network. Pediatrics. 47. Bouvattier C, Coste J, Rodrigue D, Teinturier
1997;99:505–12. C, Carel JC, Chaussain JL, et al. Lack of effect
33. MacMahon B. National health examination survey: of GnRH agonists on final height in girls with
age at menarche. Rockville: National Center for advanced puberty: a randomized long-term pilot
Health Statistics; DHEW publication (HRA); 1973. study. J Clin Endocrinol Metab. 1999;84:3575–8.
p. 74–1615. 48. Cassio A, Cacciari E, Balsamo A, Bal M, Tassinari
34. Kelly Y, Zilanawala A, Sacker A, Hiatt R, Viner D. Randomised trial of LHRH analogue treatment
R. Early puberty in 11-year-old girls: millennium on final height in girls with onset of puberty aged
cohort study findings. Arch dis child. 2017;102:232– 7.7–8.5 years. Arch Dis Child. 1999;81:329–32.
7. https://doi.org/10.1136/archdischild-2016-310475. 49. Weise M, Armando F, Barnes KM, Cutler GB
35. Buck Louis GM, Gray LEJ, Marcus M, Ojeda SR, Jr, Baron J. Determinants of growth during
Pescovitz OH, Witchel SF, et al. Environmental gonadotropin- releasing hormone analog therapy
factors and puberty timing: expert panel research for precocious puberty. J Clin Endocrinol Metab.
needs. Pediatrics. 2008;121:S192–207. 2004;89:103–7.
36. Wolff MS, Teitelbaum SL, Pinney SM, Windham 50. Oerter KE, Manasco P, Barnes KM, Jones J, Hill S,
G, Liao L, Biro F, et al. Investigation of relation- Cutler GB Jr. Adult height in precocious puberty
ships between urinary biomarkers of phytoestro- after long-term treatment with deslorelin. J Clin
gens, phthalates, and phenols and pubertal stages in Endocrinol Metab. 1991;73:1235–40.
girls. Environ Health Perspect. 2010;118:1039–46. 51. Kauli R, Galatzer A, Kornreich L, Lazar L, Pertz-
37. Mouritsen A, Aksglaede L, Sørensen K, Mogensen elan A, Laron Z. Final height of girls with cen-
SS, Leffers H, Main KM, et al. Hypothesis: expo- tral precocious puberty, untreated versus treated
sure to endocrine-disrupting chemicals may inter- with cyproterone acetate or GnRH analogue. A
fere with timing of puberty. Int J Androl. 2010;33: comparative study with re-evaluation of predic-
346–59. tions by Bayley-Pinneau method. Horm Res. 1997;
38. Lucaccione L, et al. Int J Mol Sci. 2020;21(6):2078. 47:54–61.
https://doi.org/10.3390/ijms21062078. 52. Brauner R, Adan L, Malandry F, Zantleifer D. Adult
39. Corbett BA, Vandekar S, Muscatello RA, Tang- height in girls with idiopathic true precocious
uturi Y. Pubertal timing during early adolescence: puberty. J Clin Endocrinol Metab. 1994;79:415–20.
advanced pubertal onset in females with autism 53. Adan L, Chemaitilly W, Trivin C, Brauner R. Fac-
spectrum disorder. Autism Res. 2020;13(12):2202– tors predicting adult height in girls with idiopathic
15. https://doi.org/10.1002/aur.2406. Epub 2020 Oct central precocious puberty: implications for treat-
12. PMID: 33043629; PMCID: PMC8021204. ment. Clin Endocrinol. 2002;56:297–302.
77 3
54. Khadilkar VV, Khadilkar VV, Maskati GB. Growth van Alfen-van derVelden JA, Woelfle J, Backeljauw
hormone and gnrha combination therapy in the PF; International Turner Syndrome Consensus
management of precocious puberty. Indian Pediatr. Group. Clinical practice guidelines for the care
2005;42(1):57–60. of girls and women with Turner syndrome: pro-
55. Song W, Zhao F, Liang S, Li G, Xue J. Is a Com- ceedings from the 2016 Cincinnati International
bination of a GnRH Agonist and Recombinant Turner Syndrome Meeting. Eur J Endocrinol.
Growth Hormone an Effective Treatment to 2017;177(3):G1-70. https://doi.org/10.1530/EJE-
Increase the Final Adult Height of Girls with 17-0430. PMID: 28705803.
Precocious or Early Puberty? Int J Endocrinol. 68. Palmert MR, Dunkel L. Clinical practice. Delayed
2018;2018:1708650. PMID: 30693027. puberty. N Engl J Med. 2012;366(5):443–53.
56. Schultz KA, Sencer SF, Messinger Y, Neglia JP, https://doi.org/10.1056/NEJMcp1109290. PMID:
Steiner ME. Pediatric ovarian tumors: a review of 22296078.
67 cases. Pediatr Blood Cancer. 2005;44(2):167–73. 69. Wehkalampi K, Widen E, Laine T, Palotie A, Dun-
57. Lumbroso S, Paris F, Sultan C. McCune-Albright kel L. Patterns of inheritance of constitutional
syndrome: molecular genetics. J Pediatr Endocrinol delay of growth and puberty in families of ado-
Metab. 2002;15(Suppl 3):875–82. lescent girls and boys referred to specialist pediat-
58. Roth C, Freiberg C, Zappel H, Albers N. Effective ric care. J Clin Endocrinol Metab. 2008;93:723–8.
aromatase inhibition by anastrozole in a patient PMID: 18160460
with gonadotropin-independent precocious puberty 70. Morris DH, Jones ME, Schoemaker MJ, et al. Famil-
in McCune-Albright syndrome. J Pediatr Endocri- ial concordance for age at menarche: analyses from
nol Metab. 2002;3(Suppl 15):945–8. the Breakthrough Generations Study. Paediatr Peri-
59. Nunez SB, Calis K, Cutler GB Jr, Jones J, Feuillan nat Epidemiol. 2011;25:306–11. PMID: 21470270
PP. Lack of efficacy of fadrozole in treating preco- 71. Brinkman A. Molecular basis of androgen insensi-
cious puberty in girls with the McCune-Albright tivity. Mol Cell Endocrinol. 2001;179:105–9.
syndrome. J Clin Endocrinol Metab. 2003;88: 72. Pallister P, Opitz J. The Perrault syndrome autoso-
5730–3. mal recessive ovarian dysgenesis with facultative,
60. Feuillan PP, Jones J, Cutler GB Jr. Long-term testo- non sex limited sensorineural deafness. Am J Med
lactone therapy for precocious puberty in girls with Genet. 1979;4:239–46.
the McCune-Albright syndrome. J Clin Endocrinol 73. Dessart Y, Odievre M, Evian D, Chaussain J. Insuf-
Metab. 1993;77:647–51. fisance ovarienne et galactosemie congenitale. Arch
61. Speroff L, Glass RH, Kase NG, editors. Clinical Fr Pediatr. 1982;39:321–2.
gynecologic endocrinology and infertility, abnormal 74. Huhtaniemi I, Aittomaki K. Mutations of fol-
puberty and growth problems. 6th ed. Philadelphia: licle stimulation hormone and its receptor: effects
Lippincott Williams & Wilkins; 1999. p. 381–420. on gonadal function. Eur J Endocrinol. 1998;138:
62. Eugster EA, Rubin SD, Reiter EO, Plourde P, Jou 473–81.
HC, Pescovitz OH, McCune-Albright Study Group. 75. Griffin JE. Hormonal replacement therapy at the
Tamoxifen treatment for precocious puberty in time of expected puberty in patients with gonadal
McCune-Albright syndrome: a multicenter trial. J failure. Endocrinologist. 2003;13(3):211–3.
Pediatr. 2003;143:9–10. 76. George J, Veldhuis J, Tena-Sempere M, et al.
63. Ibáñez L, Virdis R, Potau N, Zampolli M, Ghizzoni Exploring the pathophysiology of hypogonadism in
L, Albisu MA, et al. Natural history of premature men with type 2 diabetes: kisspeptin-10 stimulates
pubarche: an auxological study. J Clin Endocrinol serum testosterone and LH secretion in men with
Metab. 1992;74:254. type 2 diabetes and mild biochemical hypogonad-
64. Raivio T, Miettinen PJ. Constitutional delay of ism. Clin Endocrinol. 2013;79:100–4.
puberty versus congenital hypogonadotropic 77. Shumer DE, Nokoff NJ, Spack NP. Advances in
hypogonadism: Genetics, management and the Care of Transgender Children and Adoles-
updates. Best Pract Res Clin Endocrinol Metab. cents. Adv Pediatr. 2016;63(1):79–102. https://doi.
2019;33(3):101316. https://doi.org/10.1016/j. org/10.1016/j.yapd.2016.04.018. Epub 2016 Jun 3.
beem.2019.101316. PMID: 31522908. PMID: 27426896; PMCID: PMC4955762.
65. Sedlmyer I, Palmert M, Hospital C. Delayed puberty: 78. de Vries AL, Steensma TD, Doreleijers TA, Cohen-
analysis of a large case series from an academic cen- Kettenis PT. Puberty suppression in adolescents
ter. J Clin Endocrinol Metab. 2002;87:1613–20. with gender identity disorder: a prospective follow-
66. Wei C, Crowne E. Recent advances in the under- up study. J Sex Med. 2011;8(8):2276–83. https://
standing and management of delayed puberty. doi.org/10.1111/j.1743-6109.2010.01943.x. Epub
Arch Dis Child. 2016; https://doi.org/10.1136/ 2010 Jul 14. PMID: 20646177.
archdischild-2014-307963. 79. Steensma TD, Kreukels BP, de Vries AL, Cohen-
67. Gravholt CH, Andersen NH, Conway GS, Dekkers Kettenis PT. Gender identity development in ado-
OM, Geffner ME, Klein KO, Lin AE, Mauras N, lescence. Horm Behav. 2013;64(2):288–97. https://
Quigley CA, Rubin K, Sandberg DE, Sas TCJ, Sil- doi.org/10.1016/j.yhbeh.2013.02.020. PMID:
berbach M, Söderström-Anttila V, Stochholm K, 23998673.
79 4
Fertilization
and Implantation
Christopher K. Arkfeld and Hugh S. Taylor
Contents
4.2 perm Transport in the Male

S
Reproductive Tract – 81
4.3 perm Transport in the Female Reproductive

S
Tract – 83
4.4 Sperm Capacitation – 84
4.5 Oocyte Development – 85

4.5.1 Early Follicular Development – 85
4.6 umulus Cells and Oocyte Interactions During

C
Ovulation – 86
4.7 L ate Follicular Development

and Oocyte Pickup – 86
4.8 Fertilization – 87
4.8.1 S perm Penetration Through the Cumulus
Oophorus – 87
4.9 tructure of Zona Pellucida and Sperm

S
Penetration – 88
4.10 Cortical Reaction to Block Polyspermy – 89
4.11 Sperm–Oocyte Membrane Fusion – 89
4.12 Oocyte Activation – 90

https://doi.org/10.1007/978-3-030-99596-6_4
4.13 ale Pronucleus Formation
M
and Genomic Union – 91
4.14 Early Embryonic Development – 91
4.15 Trophoblastic Development and Invasion – 92
4.16 Implantation – 94
4.17 Endometrial Receptivity – 95

4.17.1 indow of Receptivity – 95
W
4.17.2 Anatomic Changes – 95
4.17.3 Stem Cells – 96
4.18 Pinopodes – 96
4.19 Selectins – 96
4.20 Integrins – 97
4.21 Mucins – 97
4.22 Cytokines – 98
4.23 Leukemia Inhibitory Factor – 98
4.24 Interleukins – 98
4.25 Prostaglandins – 99
4.26 HOX Genes – 99
4.27 I mmune Response to Trophoblast Invasion:

Trophoblast–Leukocyte Interactions – 100
4.28 Clinical Relevance – 101

4.30 Answers – 102
References – 102
Fertilization and Implantation
81 4
ful fertilization and implantation and their
Key Points relevance to current clinical reproductive
55 Prerequisites for fertilization are the medicine.
proper production, maturation, and
transport of sperm through the male
and female reproductive tracts as well Case Vignette
as capacitation.
55 Similarly proper development, ovula- A 27-year-old woman is undergoing in vitro
tion, and transport of the oocyte are fertilization (IVF) for idiopathic infertility.
necessary for fertilization. Her investigation revealed no abnormality.
55 Fertilization is controlled to allow a Her partner has normal sperm parameters.
single sperm to deliver DNA to the She undergoes in vitro fertilization (IVF).
oocyte and begin the process of early Eleven oocytes are obtained with fertiliza-
development. tion resulting in nine embryos. Seven
55 Implantation occurs during a limited embryos develop to the blastocyst stage.
period of endometrial receptivity con- One is transferred but no pregnancy
trolled progesterone and timed to coin- occurred. She has two subsequent frozen–
cide with the arrival of the blastocyst in thawed cycles with no pregnancy. She has
the uterus. two remaining embryos. She consults you
for an explanation and plan.
4.1 Introduction 4.2 Sperm Transport in the Male

Reproductive Tract
Infertility is a common problem with sig-
nificant psychological, economic, and medi- A mature and healthy spermatozoon is essen-
cal implications. It is estimated to affect one tial for reproductive success. The male gonads,
in eight women [1]. There are approximately commonly referred to as testes, have two
70 million infertile couples worldwide, most important functions for reproduction. The
of whom reside in developing countries [2]. first is to produce a constant supply of sper-
In the USA, the CDC estimated that of mar- matogenic stem cells and mature them through
ried women ages 15–44, 1.5 million (6%) are meiosis into spermatozoa, a process called
infertile, and of all women ages 15–44 years spermatogenesis. The second is to produce sex
old, 7.4 million have used infertility services hormones, which have diverse metabolic and
[3]. Two of the most common mechanisms of reproductive functions essential for spermato-
infertility are failure of fertilization and fail- genesis and male endocrinology. Even though
ure of implantation. Fertilization is the union these functions are accomplished in two dis-
of a sperm and an oocyte, while implantation tinct anatomical compartments of the testes,
is the attachment of a developed blastocyst the interstitial compartment and seminiferous
to the uterine endometrium. Although the tubules, respectively, they are very reliant on
majority of our knowledge on this subject each other.
relies on other mammalian fertilization mod- Seminiferous tubules are the most abun-
els, with advancing technology and a deeper dant anatomical component of the testicle.
understanding of gamete biology, transport, Each testicle contains approximately 360 m of
and implantation, our knowledge and avail- seminiferous tubules. This convoluted tubular
able treatment options and medical care for structure is lined by Sertoli cells, which act
infertile couples have significantly improved. to nourish and aid the process of spermato-
In this chapter, we will summarize the genesis. In between the Sertoli cells, germline
current evidence on molecular and cellular stem cells undergo differentiation into sper-
interactions that are essential for success- matogonia and ultimately mature into sper-
82 C. K. Arkfeld and H. S. Taylor
matozoa. In order to protect spermatogenesis, to become motile in the epididymis, but their
Sertoli cells form tight junctions between each motility is suppressed by acidification of the
other called the blood–testis barrier. This bar- epididymal lumen [7]. During the transport
rier helps regulate the entry of hormones and in epididymis, the sperm interacts with the
nutrients, and most importantly, prevents an seminal fluid and enriched with cholesterol,
immune response to the developing sperma- glycophospholipids. This process decreases
tozoon. the sperm membranes’ fluidity to prevent pre-
The interstitial compartment of the testes mature acrosomal reaction [8]. Activation of
4 contains Leydig cells, blood vessels, myofibro- cannabinoid receptors on the sperm surface
blastic cells, and nerves, which all contribute also helps to keep spermatozoa in an immotile
to spermatogenesis via hormone production state [9]. Additionally, various secretory pro-
and control of the local environment. Leydig teins in the epididymal lumen may contrib-
cells produce the majority of the androgens ute to sperm maturation [10]. Extracellular
needed for spermatogenesis and male repro- vesicular proteins containing MIF and aldose
ductive function. reductase can be transported from the apical
It is well known that ultimate control of surface of the epididymal cells to spermato-
spermatogenesis and production of gonad- zoa, thereby allowing spermatozoa to acquire
derived steroid hormones comes from the new surface proteins that are controlled by
anterior pituitary gonadotropins LH and androgen involved in further maturation of
FSH. Luteinizing hormone (LH), secreted by the spermatozoa [11].
the anterior pituitary gland, stimulates Leydig Human spermatozoa seem to rely on gly-
cells to produce androgens. Intratesticular colysis for ATP production, and the activity
testosterone exerts its effect through bind- of glycolytic enzymes is modified during epi-
ing to testosterone receptors found in Sertoli, didymal maturation [6, 12].
Leydig, and peritubular cells. With ejaculation, the spermatozoa are rap-
The other gonadotropin, follicle-stimulat- idly transported from the epididymis through
ing hormone (FSH), stimulates Sertoli cells the ductus deferens where they are mixed
to produce androgen-binding protein, which with seminal vesicle and prostatic secretions.
binds androgen and optimizes local androgen In fact, only 5% of the ejaculate volume is
levels that are essential for spermatogenesis. composed of spermatozoa. The bulk of the
Other secretory functions of the Sertoli cell ejaculate is composed of secretions from the
include, but are not limited to, production of seminal vesicle (70%) and prostatic secretions
aromatase, which converts androgens to estro- (25%). Less than 1% of the ejaculate volume
gens, and release of inhibin/activin, which comes from the bulbourethral glands.
regulates the release of FSH. Seminal vesicle secretions have an alka-
Spermatogenesis takes approximately line nature and contain rich nutritional sub-
72 days. After production in the seminiferous stances, which serve as an initial energy source
tubules, spermatozoa are transported to the for spermatozoa, and proteins responsible for
rete testis, efferent ducts, caput epididymis, the “coagulum” formation, which is impor-
corpus epididymis, and finally to the cauda tant to stabilize the deposited sperm in the
epididymis, where they are stored until ejac- female reproductive tract. An important com-
ulation [4]. The epididymis is not merely a ponent of prostatic secretions is a prostate-
storage site for spermatozoa; in fact, it is the derived serine protease, prostate-specific
site where spermatozoa undergo physiologi- antigen (PSA), responsible for liquefaction
cal modifications that result in the acquisi- of the coagulum so that the sperm can swim
tion of progressive motility and the ability freely once in the vaginal vault.
to undergo capacitation [5]. Spermatozoa in Components of ejaculate differ among
the epididymis contain free sulfhydryl groups individuals, as well as within a single indi-
rather than disulfide bonds, and the oxida- vidual. Initially, prostatic, non-coagulable
tion of those free groups helps stabilize the secretions are followed by the sperm-rich non-
sperm structures [6]. Spermatozoa are able coagulable component. Subsequently, seminal
83 4
vesicle secretions predominate, which results amount of sperm that transverse the cervix
in coagulation of the ejaculate. The initial depends on multiple factors, including sperm
non-coagulable spermatozoa have the advan- concentration, morphology, motility, molecu-
tage of entering the female reproductive tract lar characteristics of the sperm surface, as well
earlier than the spermatozoa that are trapped as genetic factors of the spermatozoa. Only
in the coagulum. An average ejaculate con- the highest quality spermatozoa can breach
tains 200–500 million spermatozoa, most of these barriers, which is an evolutionary pro-
which are mature and motile [13]. tective mechanism against polyspermy [18].
In addition to spermatogenesis, penile anat- Majority of the remaining spermatozoa that
omy is also important for reproductive success. do not enter the female reproductive tract are
Various anatomical abnormalities including either inactivated by the acidic environment
uncorrected urethral openings (hypospadias) or phagocytized.
can cause male factor infertility. As the spermatozoa enter the cervical
canal, they encounter the cervical mucus. At
the time of ovulation, under the influence of
4.3 Sperm Transport estrogen, the cervical mucus is highly hydrated
in the Female Reproductive and the cervical pH becomes alkaline, which
Tract are optimal for spermatozoa transport and
activation [19]. Failure of these physiologi-
After ejaculation, mature spermatozoa are cal changes is of clinical importance since
deposited near the external cervical os, or hyperandrogenic women have acidic cervi-
in the anterior vaginal fornix. The ejaculate cal pH likely contributing to infertility [20].
coagulates within a minute and forms a loose Additionally, coitus on the day of maximal
gel in humans rather than a compact gel that mucus hydration is more closely related with
is observed in rodents. The principal proteins pregnancy success than using other indica-
involved in coagulation are semenogelin I and tors such as basal body temperature [21]. If
semenogelin II, which are secreted from semi- the conception does not occur during this
nal vesicles [14]. The gel formation minimizes period, then, under the effect of progesterone,
the backflow of deposited sperm into the the cervical mucus gets thicker and creates an
vagina and protects spermatozoa against the unfavorable environment for passage of sper-
harsh vaginal environment, yet a median of matozoa.
35% of spermatozoa are still lost through ret- Cervical mucus acts as a selective gate for
rograde flow down and out of the vagina [15]. sperm transport. Cervical mucus also acts as
The coagulate is then enzymatically digested a barrier to abnormal sperm transport, select-
in about 30–60 min. PSA is the main enzyme ing for the more vigorous and motile sperm
that is involved in this digestion. Although [19, 22]. Additionally, due to flow of uterine
the alkaline nature of the seminal plasma pro- secretions, cervical mucus is aligned to form a
tects the spermatozoa from the acidic vaginal microarchitecture in cervical mucosal grooves.
environment, this protection is only transient The microarchitecture is thought to guide
and sperm is protected for 2 hours. Alkaline spermatozoa to the uterus [23]. Spermatozoa
environment of the ejaculate increases the pH carrying fragmented DNA are filtered in the
of the sperm cytoplasm and sperm become cervical mucus, likely as a result of their inad-
mobile [16]. Spermatozoa have to leave the equate membrane surface characteristics and
coagulant quickly to escape from inactiva- motility. This selection helps to prevent sperm
tion or immune attack; they are only able to with poor DNA quality to reach to oocyte
remain motile in the vagina for a few hours. that would otherwise result in poor quality
Within a few minutes of vaginal deposition, embryos [24].
human sperm begins to leave the seminal pool Like the vagina, the cervix also contains
and enter the cervical canal [17]. Cervix and immunologic barriers such as immunoglobu-
the uterotubal junction are two mechanical lins, the complement system, and neutrophils
barriers that spermatozoa need to breach. The that together act to combat entry of microor-
ganisms. However, with the aid of the semi- by incubation of sperm in a defined medium
nal plasma proteins which coat spermatozoa containing bicarbonate, a cholesterol acceptor
against immune attack, highly motile sper- like albumin, calcium, and an energy source
matozoa can escape this barrier without dif- such as pyruvate, glucose, or lactate [24].
ficulty. Spermatozoa have two principal structural
As sperm enter the uterus, they are able to compartments, the head and the tail, which
quickly transverse the cavity. Uterine smooth behave relatively independent from each other
muscle contractions, which are directed cra- during capacitation. However, some studies
4 nially, increase in intensity during the late suggested that they are functionally related,
follicular phase [25]. The smooth muscle con- and as capacitation starts in the tail (hyperac-
tractions appear to be limited to the layer of tivation), it subsequently triggers capacitation
myometrium directly beneath the endometrial in the other compartment, the sperm head
layer [26]. Thus, it appears that both active (acrosomal reaction) [24].
flagellar beating and uterine contractions aid Hyperactivation, which occurs in the tail
in transportation through the uterine cav- (or flagellum), increases the speed, velocity,
ity. It was also suggested that these contrac- and rate of flagellum beating when compared
tions could draw watery cervical mucus into to spermatozoa prior to capacitation. The
the uterus. As the uterine lumen is small in spermatozoa exhibit asymmetrical flagellar
volume and cervical mucus is plentiful dur- beats with increased amplitude of princi-
ing the peri-ovulatory phase, this would eas- pal flagellar bend and a typical high velocity
ily drag the spermatozoa through the uterine figure-eight pattern of movement. This pattern
lumen [27]. generates enough propulsive power to allow
The final part of the sperm transport is the spermatozoa to navigate through the viscous
passage through the uterotubal junction. In oviduct fluid and penetrate the outer layers
most mammals, it is narrow and may be filled of the oocyte, namely, the cumulus oopho-
with mucus. Although mucus has been shown rus and corona radiata [30]. Hyperactivation
in the uterotubal junction in humans, this is triggered by an alkaline environment and
does not appear to be a rate-limiting factor for subsequently increased intracytoplasmic cal-
sperm transport [17]. Only a few spermatozoa cium levels. Calcium enters into the sperma-
traverse the oviduct at any given time and tozoa from both the external milieu via sperm
move toward the ampulla, the most common ion channels and release from intracellular
site of fertilization. Movement is facilitated by stores [16, 31]. In addition to calcium altera-
oviduct contractions and fluid flow. tions, changes in membrane permeability to
potassium, sodium, protons, bicarbonate, and
chloride contribute to sperm capacitation [6].
4.4 Sperm Capacitation Mutations of these ion channels were found
to be associated with male subfertility [32].
Mature spermatozoa are not able to fertilize The spermatozoon head, where the “acro-
an oocyte immediately after spermatogenesis. somal reaction” occurs, is further divided into
A series of molecular and physiological events two parts: the acrosomal region and nucleus.
that begin in the cervix and occur in the female The acrosomal region contains various
reproductive tract give the spermatozoa the enzymes that play a critical role in penetrat-
ability to fertilize the oocyte; this process ing the zona pellucida and fusion with the
is known as capacitation [28]. Capacitation oocyte, whereas the nucleus carries the pater-
encompasses plasma membrane reorgani- nal genetic code. The acrosomal reaction is
zation, ion permeability regulation, mem- the last step of capacitation and occurs when
brane hyperpolarization, cholesterol loss, and the spermatozoon approaches the oocyte,
changes in the phosphorylation state of many normally in the ampulla of the oviduct. It is
proteins [29]. Capacitation normally takes described as acrosomal exocytosis and is a pre-
place within the female reproductive tract; requisite for fertilization because it allows the
however, it can be mimicked in the laboratory sperm to penetrate the oocyte zona pellucida.
85 4
The acrosome contains various hydrolytic follicles. The process of forming oogonium
enzymes including proteases, arylsulfatases, from primordial germ cells continues until
phosphatases, phospholipases, hyaluronidase, around the third trimester. Concomitantly,
and acrosin. Calcium is obligatory for acro- around the 11th week of gestation, oogonia
somal exocytosis. There are various theories begin to enter their first meiotic division to
on the source of calcium increase needed for become primary oocytes, but this division
acrosomal exocytosis. One theory is that the gets arrested at the dictyotene stage. Primary
depletion of calcium from the acrosome acti- oocytes will stay arrested at the dictyate stage
vates Ca++ channels, which allows the entry of prophase I until postnatal life when the
of Ca++ from the surrounding medium [33]. female enters menarche. With each menses/
Other theories suggest that the exposure of ovulation, only a few primary oocytes will
the sperm head to the zona pellucida proteins continue to develop while the others remain
or progesterone releases calcium stores, which arrested. The number of primary oocytes
are found in the redundant nuclear envelope is highest in the 20th gestational week [34],
at the posterior end of the sperm head. The estimated to be around seven million, and
increase in calcium starts from the head–tail steadily decreases thereafter. It was previously
junction and the calcium wave propagates believed that no oocytes were produced in
toward the head [31]. An increase in calcium reproductive-age women; however, recent data
levels leads to a concomitant increase in suggest the possibility of oogonial stem cells,
cAMP levels, with the release of the vesicu- which can give rise to new oocyte-like struc-
lar fusion proteins; the acrosome completely tures in the adult [35–38]. Further studies are
discharges its enzymatic contents to penetrate needed to understand their biology and con-
the zona pellucida and fuses with the oocyte tribution to the “oocyte pool.” This pool of
plasma membrane. The fertilization process available oocytes is the ultimate determinant
will be discussed further, after a discussion of of menopausal age under physiologic condi-
the oocyte. tions. Depletion of the oocyte reserve starts in
An understanding of the capacitation pro- utero and continues thereafter [39, 40]. At the
cess has useful clinical applications in some time of puberty, there are on average 200,000
couples with infertility. Since the fertilizable primary oocytes remaining in the ovary [41].
life of a sperm is decreased once it has been Follicles provide support for the oocyte,
capacitated, with evaluation of acrosomal and folliculogenesis occurs concomitantly
status and in vitro capacitation, the timing of with oocyte development. Initially, primor-
conception can be precisely controlled and aid dial follicles (immature oocytes surrounded
in the treatment infertility. by flat granulosa cells) develop and reach
their maximal numbers around the same
time as the peak in primary oocytes, around
4.5 Oocyte Development 20 weeks’ gestational age. These follicles will
either continue to develop or spontaneously
4.5.1 Early Follicular Development regress or undergo apoptosis, with only a frac-
tion remaining by puberty [39]. Primordial
During early embryonic development, at the follicles, also known as pre-antral follicles,
seventh week of gestation, gonadal stem cells are not responsive to gonadotropins and
derived from the yolk sac endoderm migrate therefore rely on other factors for their devel-
to the gonadal ridges. After this migration, opment. The factors that initiate follicular
primordial germ cells undergo mitosis and development prior to attainment of gonado-
substantially increase in number becoming tropin sensitivity have not been fully deter-
“oogonium.” During embryonic development, mined; however, kit ligand, LIF, EGF, KGF,
oogonium forms nests and is not initially sur- BMP-4, AMH, and bFGF have been shown
rounded with somatic cells. These oogonial to contribute to this process [42–47]. AMH is
cells are then individually surrounded with expressed in granulosa cells of small growing
flat pre-granulosa cells, forming primordial follicles and inhibits transition of primordial
follicles to primary follicles. It also reduces 1. OSF increases DNA synthesis in both CC
follicle sensitivity to FSH, thereby inhibiting and GC and increases cell proliferation.
FSH-induced pre-antral follicle growth. In 2. Inhibition of CC luteinization.
animal models, it also inhibits kit ligand and 3. Inhibition of CC apoptosis.
bFGF, which are known stimulatory factors 4. Regulation of CC metabolism.
for primordial follicle recruitment [48, 49]. 5. Promotion of CC mucification and expan-
Therefore, AMH seems to play a pivotal role sion.
in preventing follicle exhaustion and recruit-
4 ment at a younger age by suppressing primor- In conclusion, the oocyte tightly controls the
dial follicles [49, 50]. adjacent microenvironment for its optimal
As early follicular development is inde- development. Under the effect of OSF, CC/
pendent of gonadotropin stimulation, this GC are transformed into supportive cells
stage of follicular development can occur for oocyte development. CC/GC have dif-
before puberty, as well as during reproductive ferent physiological properties than mural
ages. However, they spontaneously regress granulosa cells, which are not affected by
or undergo apoptosis [51]. Only after the the OSF. Mural granulosa cells express FSH
development of antrum, the follicle becomes receptors, and later in follicular development,
responsive to the gonadotropins [44]. With they are involved in steroid hormone secre-
puberty, maturation of the hypothalamic– tion, follicular expansion, and finally, ovula-
pituitary axis, and pulsatile release of FSH tion.
and LH, antral follicles continue their devel-
opment until either ovulation or atresia [52,
53]. With puberty, maturation of the hypo- 4.7 ate Follicular Development
L
thalamic–pituitary axis and pulsatile release and Oocyte Pickup
of FSH and LH allow antral follicle devel-
opment to progress until either ovulation or In the follicular phase, under the influence
atresia [53]. of hypothalamic GnRH pulse frequency,
anterior pituitary gonadotrophs release
FSH. FSH binds to its receptors on the pri-
4.6 umulus Cells and Oocyte
C mary follicular granulosa cells and induces
Interactions During Ovulation proliferation. Under continuous FSH stimu-
lus, pre-antral follicles escape from follicular
Follicles contain both an oocyte and a num- atresia and continue to develop. A dominant
ber of cells surrounding it, including an inner follicle is then selected and continues to
layer of cumulus and outer layer of granulosa grow and develop under continued FSH and
cells. The oocyte actively regulates adjacent eventually LH stimulus, while other follicles
cumulus cell (CC)/granulosa cell (GC) metab- begin to undergo atresia. After the LH surge
olism and creates the optimal environment for in midcycle, the oocyte of the dominant fol-
its own development. The oocyte–CC inter- licle completes its first meiotic division (it
action is achieved by direct contact via gap had been arrested in meiosis prophase I since
junctions and by a paracrine effect of oocyte- initial development in gestation) and shortly
secreted factors (OSF). Because cumulus cells thereafter is expelled from the ovary. At this
lie closer to the oocyte than granulosa cells, stage, the oocyte is surrounded by a thick
the oocyte regulates the adjacent cumulus glycoprotein layer, the zona pellucida, and
cells more than the distant granulosa cells. overlying granulosa cells, which altogether
Two distinct factors that have been deter- form the cumulus oophorus complex. The
mined as OSF are growth differentiation fac- oocyte and granulosa cells are functionally
tor 9 (GDF9) and BMP-15 [54]. connected through gap junctions, which are
The effect of OSF on granulosa and cumu- thought to play an important role in local
lus cells can be summarized as follows: regulation of the oocyte. Shortly after ovula-
87 4
tion, the cumulus oophorus complex is taken 4.8 Fertilization
up by the infundibular part of the fallopian
tubes. The infundibula contain fimbriae that 4.8.1 Sperm Penetration Through
are fingerlike projections that constantly the Cumulus Oophorus
sweep the ovarian surface. The fimbriae guide
the ovulated COC into the fallopian tube.
To fertilize the oocyte, the capacitated sperm
Myometrial contractions together with beat-
has to pass through the cumulus oophorus, a
ing tubal epithelial cilia are thought to con-
specialized layer of cuboidal granulosa cells
tribute to this process. Within minutes, the
that surround the oocyte (. Fig. 4.1). These
cumulus oophorus oocyte complex can be
cells are formed by follicular cells, which are
found in the ampulla of the fallopian tube.
adherent to the oocyte prior to ovulation
During oocyte transport, the spermatozoa
and originate from the squamous granulosa
are moving up the fallopian tubes to meet the
cells present at the primordial stage of fol-
cumulus oophorus oocyte complex. Unlike
licular development. These cumulus cells are
spermatozoa which maintain fertilizing capa-
attached to each other with an extracellular
bility for days, the oocyte loses its capabil-
matrix that is mainly composed of hyal-
ity to become fertilized after 12 hours in the
uronic acid, heparin sulfate, and chondroitin
female reproductive tract. The differential
sulfate [55]. Although cumulus-free oocytes
timing of oocyte and sperm viability demon-
surrounded only by a zona pellucida are able
strates the clinical importance of proper tim-
to induce an acrosomal reaction, cumulus
ing intercourse to assure sperm availability at
cells seem to foster the reaction before the
ovulation.
sperm reach the zona pellucida [56]. Sperm
.. Fig. 4.1 Fertilization

process. 1 Sperm
penetration of cumulus
cells, 2 attachment to
zona, 3 exocytosis of
1
acrosomal contents, 4
penetration to the zona NUCLEUS Tail
pellucida, 5 entry into
2
perivitelline space, 6
binding and fusion with ACROSOME
3
the egg plasma membrane,

7 cortical reaction, and 8
block to polyspermy.
Corona radiata
(Reproduced with
permission from
Esfandiari [150]) Zona pellucida
4
Perivitelline space
Polar body
Cytoplasm
8
7
5
6
hyperactivated motility also helps penetra- standing of the zonal structure has increased.
tion through this initial barrier. There are three major glycoproteins that com-
pose the zona pellucida and have distinct roles
in this structure: ZP1, ZP2, and ZP3 [59]. The
4.9 tructure of Zona Pellucida
S ZP2 and ZP3 proteins form a filamentous
and Sperm Penetration structure that is then cross-linked with ZP1
proteins [60, 61].
Once spermatozoa pass through the cumulus In a classical model, ZP3 binds sperm and
4 oophorus, they bind zona pellucida, which initiates the acrosomal reaction (. Fig. 4.1).
is the thick extracellular coat of the egg Mutagenesis of O-glycosylation sites of ZP3
(. Fig. 4.2) [57]. The sperm to zona pellucida has been shown to decrease sperm recep-
binding is a species-specific process. This con- tor activity, suggesting that ZP3 serves as
cept is the basis of the “hamster zona binding the sperm receptor in zona pellucida [62].
test.” Human sperm cannot bind to hamster As sperm binds to ZP3, the outer acroso-
eggs with an intact zona pellucida, which led mal membrane fuses with the sperm plasma
to the thought that the zona pellucida contains membrane that subsequently causes mem-
species-specific receptors. Human sperm can brane blebs and results in the releasing of
only bind to hamster eggs after this glycopro- acrosomal enzymes that lyse the zona pel-
tein layer is removed. Although there are some lucida. This reaction exposes the inner
species–species exceptions, the zona pellucida acrosomal membrane that can bind to ZP2
is an important barrier between interspecies (. Fig. 4.3) [63]. Eventually, sperm pen-
fertilization. In the clinical setting, the sperm etrate the zona pellucida and enter into the
penetration assay, the sperm–zona pellucida perivitelline space. Various other models
binding, the acrosome reaction, and the hyal- have shown that this acrosomal reaction
uronan binding can be utilized in workup of could occur when sperm encounter cumu-
subfertile men [58]. lus cells [64]. However, as mentioned above,
With the aid of electron microscopy and some oocytes do not have cumulus cells and
advanced molecular techniques, our under- can still be fertilized.
.. Fig. 4.2 Light

microscopy of mouse
sperm binding the zona
pellucida of an unfertil-
ized egg. (Source:
Wassarman et al. [57].
Used with permission
from Nature Publishing
Group)
89 4
a b
Acrosome
reaction
(slow)
Penetration
N-glycan
ZP3 ZP3 ZP3 ZP3f ZP3f
ZP2 ZP2 ZP2 ZP2c ZP2c
Zona pellucida
.. Fig. 4.3 Sperm and ZP3 binding. Acrosome intact oocyte. b Immediately after fertilization, cortical granules
spermatozoon shown with red crescent on its head, release proteases to the perivitelline space that clip ZP2
whereas acrosome reacted spermatozoon does not. a ZP3 and convert it to cleaved ZP2 (ZP2c) that can no longer
binds spermatozoon and induces acrosome reaction, bind acrosome-reacted sperm. Cleaved ZP2 dissociates
thereby releasing of acrosomal enzymes that lyse the zona from ZP3, resulting in subtle modification of ZP3 to con-
pellucida. Acrosome-reacted spermatozoon binds ZP2 vert it to ZP3f that lacks sperm receptor and acrosome
via their exposed inner acrosomal membrane and pene- inducing capability. (Source: Clark [63]. Used with per-
trates the zona pellucida, ultimately fusing with the mission from Bioscientifica Ltd.)
4.10 ortical Reaction to Block

C tions that need to be answered, and further
Polyspermy research on the exact mechanism of sperm
binding is needed.
As the spermatozoa enter the perivitel-
line space, they initiate the cortical reaction
(. Fig. 4.1). Release of proteolytic enzymes 4.11 Sperm–Oocyte Membrane
from egg cortical granules causes cleavage Fusion
of ZP2, with subsequent dissociation of
ZP2 from ZP3 [65]. Thus, after the cortical After a spermatozoon penetrates the zona
reaction, sperm can no longer bind to ZP3 pellucida and enters the perivitelline space,
(. Fig. 4.3) [63]. Additionally, cleaved ZP2 the oocyte membrane and the spermatozoon
cannot bind a spermatozoon that had previ- membrane unite (. Fig. 4.1). At this stage,
ously undergone an acrosomal reaction. In the spermatozoon has already undergone
conclusion, neither a sperm with an intact an acrosomal reaction, which exposed the
acrosome nor a sperm that has undergone an inner acrosomal membrane and modified the
acrosomal reaction would be able to bind to membrane composition of both equatorial
the zona pellucida after the cortical reaction and post-acrosomal regions of the sperma-
[63]. This is the principal mechanism prevent- tozoon. The fertilizing spermatozoon binds
ing polyspermy. to the microvillar region of the oocyte mem-
Although through murine models we have brane with its equatorial segment [66]. Sperm
learned an impressive amount about the pro- tail movement decreases or stops within a
cess of fertilization, there are still many ques- few seconds of sperm–oocyte fusion [67].
.. Fig. 4.4 Model for

molecular interactions Sperm plasma
during sperm–egg membrane proteins
binding. GPI-anchored mSLLp1 Pdi3a
ADAMs
proteins, integrins,
CD151, CD9, CD81 on Izumo
the oocyte membrane and s
ADAM proteins, and s
Pdi3a chaperone refolding
Izumo on the sperm
4 membrane are involved in s
EWI-F
sperm–oocyte membrane GPI- s s s
anchored p s s
fusion. (Source: Nixon Protein
et al. [68]. Used with
permission from Springer) αβ
Egg plasma
membrane Integrins CD151 CD9 CD81
proteins
Tetraspanin Microdomain
Subsequently, the posterior region of the for gamete formation [70]. These morphologic
sperm head and the tail are incorporated into and biochemical changes that occur in the
the egg. Unfortunately, the details of molecu- oocyte are collectively called “oocyte activa-
lar interactions in sperm–egg fusion are not tion.” Another important hallmark of oocyte
fully known. Initially, ADAM family mem- activation is calcium oscillations. It has been
bers that are found on the sperm membrane, shown that injecting calcium into mice oocytes
specifically fertilin and cyritestin, gained is enough to trigger embryo development up
much attention. However, gene knockout to the blastocyst stage [71]. In a mammalian
studies questioned their fundamental roles in oocyte, the calcium oscillations are a direct
sperm–egg fusion. Currently, cyritestin, ferti- result of inositol triphosphate-mediated cal-
lin α, fertilin β, CRISP1, izumo proteins, α6β1 cium release. Sperm-derived phospholipase-
integrin, GPI- anchored proteins, CD151, zeta (PLC-ζ) is also responsible for oocyte
CD9, and CD81 on the plasma membrane are activation [72]. Another protein that has been
thought to be involved in sperm–oocyte mem- shown to activate oocytes is post-acrosomal
brane fusion and are the subjects of ongoing sheath WW domain-binding protein. Its exact
research [68, 69] (. Fig. 4.4). signaling mechanism is not clearly known, but
it presumably acts through calcium signaling
[73]. Regardless of the signaling pathway,
4.12 Oocyte Activation oocyte activation is essential for pronucleus
formation and subsequent embryo formation.
Mammalian oocytes become arrested at the Oocyte activation clearly has clinical
metaphase of the second meiotic division. importance. A deficiency in oocyte activa-
After sperm–oocyte fusion, the oocyte contin- tion was regarded as the principal cause of
ues meiotic division, releases cortical granules, fertilization failure or low fertilization rate
progresses cell cycle, forms its pronucleus, and after ICSI. Recently, it has been suggested
recruits maternal mRNA that are all essential that PLC-ζ could be used as an alternative
91 4
oocyte-activating agent, including male fac- [76]. Subsequently, the two nuclear envelopes
tor infertility, similar to other artificial oocyte disappear and the DNA undergoes replica-
activators [74, 75]. tion. Homologous chromosomes are paired
and aligned on the newly formed mitotic spin-
dle. Eventually, the zygote is ready to undergo
4.13 ale Pronucleus Formation
M its first mitotic division.
and Genomic Union
The final step of fertilization is the union 4.14 Early Embryonic Development
of sperm and egg pronuclei, producing a
diploid cell, the zygote. Dynactin, nucleo- In mammals, the zygote undergoes mitotic
porins, vimentin, dynein, and microtubules division (known as cleavage) as it travels
are involved in bringing the two pronuclei through the fallopian tube, and eventually
together. It was proposed that a nuclear pore develops into a blastocyst once in the uterus
complex is inserted into the nuclear envelopes (. Fig. 4.5). The symmetrical cell divisions
of the newly forming pronuclei. Dynactin and and cleavage create a ball of totipotent cells
vimentin filaments are then incorporated into (blastomeres) that are still enclosed in the
this nuclear pore complex. Formation of the zona pellucida. When the zygote is approxi-
complex probably starts after egg activation. mately 16 cells, blastomeres form a closely
The sperm aster then extends the microtubule packed group of cells with a smooth outer
“plus ends” away from the male pronucleus, surface. This early developmental event is
some of which reach the female pronuclear called compaction. The smooth surface is cre-
envelope. With the aid of the dynactin–dynein ated by the formation of adherens and tight
motor complex, the two pronuclei are apposed junctions between the blastomeres. At this
Blastocyst formations
Ovulation and Hatching and
Fertilization Cleavage and Compaction Implantation
Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
Gray
Infandibulum
Fimbria
Ampulla
Istmus
OVARY Gray
.. Fig. 4.5 Schematic drawing showing the major events from ovulation to the implantation of blastocyst during the
first week of human life. (Reproduced with permission from Esfandiari [150])
time, two types of polarity originate in the enzymes, strypsin and plasmin, are thought to
zygote. The first type of polarity is cellular lyse the zona pellucida, allowing the embryo
polarity. Cellular polarity occurs as the for- to hatch from the zona pellucida and begin to
mation of microvilli on the external surface of attach to the uterine endometrium [79, 80].
the outer blastomeres separate from the baso-
lateral surface [77]. The second type of polar-
ity is developmental polarity. Developmental 4.15 Trophoblastic Development
polarity is represented by the ability of the and Invasion
4 blastomeres in the internal compartment,
the inner cell mass, to remain pluripotent, The blastocyst is lined with a layer of tropho-
whereas the outer blastomeres begin to form ectoderm, which, as stated above, will give rise
trophoblast cells as they continue to divide to the placenta. Although the inner cell mass
[78]. This begins formation of the blastocyst is destined to produce embryonic and extra-
and typically occurs around day 5 of fertiliza- embryonic tissues, it stimulates trophoecto-
tion. As cleavage continues, outer blastomeres dermal growth. In vitro, the removal of the
express tight junction proteins, including ICM causes maturation of the trophoblastic
ZO-1 and uvomorulin, gap junction proteins cells, inducing them to turn into trophoblas-
such as Connexin-43, and differentially posi- tic giant cells that are unable to invade the
tion Na-K ATPase pumps selectively along endometrium. For proper endometrial attach-
the apical–basolateral axis. The outer blas- ment, the blastocyst should remain attached
tomeres have a highly restricted develop- to the trophoectoderm cells that are adjacent
mental fate, eventually becoming the cells of to the inner cell mass. Attachment of tropho-
trophoectoderm. The polarized expression blastic cells remote from the ICM has been
of Na-K- ATPase in trophoectoderm cre- associated with abnormal placental shape and
ates a trans-trophoectoderm sodium gradi- eccentric insertion of the umbilical cord [81].
ent, which drives the osmotic accumulation Prior to blastocyst attachment, for a suc-
of water into the nascent blastocoelic cavity. cessful pregnancy in the window of implan-
Growth factors like TGF-α and EGF increase tation, the uterine epithelium has to retract
expression of Na-K-ATPase, which subse- its cilia and express pinopodes. If all neces-
quently stimulate further expansion of the sary molecular events occur, the blastocyst
blastocoelic cavity (blastocoel). Meanwhile, is firmly attached to the uterine epithelium
the inner blastomeres continue to divide, and around 6–7 days postconception.
with the expansion of the blastocoel, they cre- The trophoblastic cells in contact with
ate a cluster of cells that impend into blasto- the inner cell mass start to proliferate and
coel. This totipotent cell cluster is commonly invade the uterine epithelium. As they invade,
called the inner cell mass. The inner cell mass they fuse with each other and form multi-
will eventually give rise to the embryo and nucleated giant trophoblastic cells, known
extraembryonic tissues. The outer layer of as syncytiotrophoblasts. An inner layer of
blastomeres, which has developed into tro- mononucleated trophoblastic cells also devel-
phoblasts/trophoectoderm, eventually gives ops called cytotrophoblasts. With fusion, the
rise to the placenta. It is at this point that the multinucleated syncytiotrophoblastic cells

developing embryo is called a “blastocyst.” cannot proliferate, so the cytotrophoblastic
Although difficult to completely exclude, cells function as a reservoir. Throughout the
this initial exponential division and formation pregnancy, cytotrophoblastic cells divide and
of the blastocyst seems to be relatively inde- replenish the mature syncytiotrophoblastic
pendent of maternal contribution. cells. In addition to replenishing syncytiotro-
Around day 6 after ovulation, the embryo/ phoblasts, cytotrophoblasts give rise to vari-
blastocyst reaches the uterine cavity and is ous other cell types of the placenta, which are
initially still covered with zona pellucida. For discussed below [82].
proper implantation, it must shed the zona The fusion kinetics of cytotrophoblasts
pellucida. Trophoblast-derived trypsin-like changes during pregnancy. In early pregnancy,
93 4
two mononuclear cytotrophoblasts fuse to Trophoblasts also secrete proangiogenic
become a syncytiotrophoblast. However, factors, which stimulate new vessel formation
later in the pregnancy, cytotrophoblasts fuse during invasion. Neovascularization is essen-
with already formed syncytiotrophoblasts tial for the growth and maintenance of the
[82]. Here we will discuss the process of early developing embryo. VEGF, PDGF, and PAF
embryo development; the process of implan- are the main angiogenic factors that have been
tation will be discussed in more detail below. shown to be secreted by trophoblasts. TGF-β
Around 14 days postconception, cytotro- and TNF-α, which are present in decidua, fur-
phoblastic cells invade beyond the syncytio- ther stimulate trophoblastic secretion of these
trophoblastic cell layer and come into contact angiogenic factors [91].
with maternal decidual cells. They form a Complex molecular interactions take place
column of cells with a proliferating core, and between the decidua and trophoblasts to reg-
as the cells proliferate, more mature cells are ulate trophoblastic invasion. In addition to
passively pushed toward the maternal decidua those factors mentioned above, cytokines like
[83]. More immature cells have α6β4 inte- EGF, HB-EGF, IGFBP-1, LIF, and IL-1 and
grin on their surface, which help bind basal hormones like hCG and progesterone have
membrane components like collagen IV and also been shown to regulate trophoblast inva-
laminin. However, as they move further in the sion [88].
column and become closer to maternal decid- A number of other important types of
ual cells, they change their expression of sur- trophoblast cells are involved in implanta-
face integrins (integrin α1/β1, α5/β1, or α-v/ tion—namely, extravillous, endovascular, and
β3/5), which helps them attach to the maternal endoglandular. Small extravillous tropho-
extracellular matrix [82, 84]. blasts invade maternal decidua up to the inner
In addition to adhesion molecules, tro- one-third of uterine myometrium and reach
phoblasts secrete a variety of enzymes that the maternal spiral arteries. EVTs replace the
regulate invasion. MMP-2 and MMP-9 spiral arteries’ tunica media, which contains
degrade collagen IV, which is the main colla- mainly the smooth muscle, and transform the
gen component of the basement membrane, spiral arteries into low resistance vessels that
and are therefore regarded as key enzymes are no longer reactive to maternal vasomotor
in the implantation process, enabling the substances. This transformation aims to allow
invasion of the trophoblast cells through the adequate maternal exchange with the devel-
decidua and into the maternal vasculature oping fetus, particularly in the second trimes-
[85, 86]. Tissue inhibitors of matrix metallo- ter when maternal blood flow increases to the
proteinases (TIMPs), particularly TIMP-1, uterus to support the developing fetus. Apart
TIMP-2, and TIMP-3, were also detected in from replacing the smooth muscle, endovas-
the trophoblastic cells and decidual tissues. cular trophoblasts, a subset of EVTs, replace
TIMPs are normally inhibitory metallopro- the intimal layer of the spiral arteries [92].
teinases and their regulation through tro- Disturbances in this remodeling can result
phoblastic and decidual cytokines control in fetal growth restriction (FGR) and pre-
MMP activity [87–89]. Other lytic enzymes eclampsia. Lastly, endoglandular t rophoblasts
involved in extracellular matrix degradation invade the uterine glands, orient them toward
are urokinase and tissue- type plasmino- the intervillous space, and replace the uterine
gen activator (uPA and tPA, respectively). epithelial cells (. Fig. 4.6) [81].
Both uPA and tPA are produced by tro- Despite all these early trophoblastic
phoblasts, and their activity is controlled changes, free transfer of maternal blood is
by plasminogen activator inhibitors (PAI) only established toward the end of the first
[88]. Another trophoblast protein, adreno- trimester. The large number of endovascular
medullin, decreases PAI levels and subse- trophoblasts plugs the distal segments of the
quently increases plasminogen activators. spiral arteries during initial invasion. Rather
Additionally, adrenomedullin increases tro- than maternal blood, the intervillous space
phoblastic proliferation [90]. ultimately contains glandular secretion prod-
Invasive Pathways
Syncytiotrophoblast
Cytotrophoblast 1 Interstitial trophoblast
Fetal blood vessel
2 Endovascular trophoblast
Floating villus
3 Endoglandular trophoblast
Anchoring villus
4 Cell column
2 1 Decidual
3 stroma
Uterine
gland
Spiral artery
Myometrium
Cell column Interstitial trophoblast Endovascular trophoblast

Proliferative EVT Spindle shaped EVT
Endoglandular trophoblast
Post-proliferative EVT
Large polygonal EVT
Multinucleated EVT
.. Fig. 4.6 Trophoblastic invasion of maternal decidua. trophoblasts replace the intimal layer of the blood vessels,
Small interstitial extravillous trophoblasts invade mater- while endoglandular trophoblasts invade the uterine
nal decidua up to the inner one-third of uterine myome- glands. (Source: Huppertz et al. [81]. Used with permis-
trium and replace the tunica media maternal spiral sion from John Wiley and Sons)
arteries to create low resistance blood flow. Endovascular
ucts and maternal plasma filtrate, which are main organ of nutrition, respiration, metabo-
responsible for intrauterine nutrition, up until lite excretion, and hormone production in the
approximately 10 weeks’ gestation [81]. The developing fetus.
reasoning behind the initial spiral artery plug-
ging is believed that it helps keep a low oxygen
environment and thus decreases free-radical 4.16 Implantation
formation during early embryogenesis.
After 10 weeks, the trophoblastic plugs Implantation can be divided into three
dissolve and maternal blood contributes to stages: apposition, adhesion, and invasion.
intervillous fluid, which provides the appro- Apposition is the initial adhesion of the blas-
priate amount of nutrients and oxygen for the tocyst to the endometrial surface. Apposition
developing fetus. These carefully regulated is unstable and with uterine flushing the blas-
interactions between the invading tropho- tocyst can be detached from the endometrial
blasts and the maternal decidua eventually surface. Apposition is followed by the adhe-
create a functional placenta, which is the sion stage, when a stronger connection is
95 4
established between the embryo and endome- have been multiple efforts aimed at develop-
trium. Finally, in the invasion stage, tropho- ing tests to assess and quantify endometrial
blastic cells invade the endometrium. receptivity. Three such commercial tests are
the endometrial receptivity array (ERA), the
endometrial function test (EFT), and the
4.17 Endometrial Receptivity ERPeak test. The ERA and ERPEAK test
utilize an endometrial biopsy to determine the
4.17.1 Window of Receptivity receptivity of the endometrium and the win-
dow of implantation based on gene expres-
Successful implantation requires a properly sion. The EFT test similarly samples the
developed blastocyst, a receptive endome- endometrium investigating the expression of
trium, and a series of molecular interactions. two genes and using histology to detect infec-
In humans, 75% of the failed pregnancies are tious or inflammatory processes that would
considered to be secondary to implantation limit the endometrial receptivity. At this time,
failure; therefore, it is essential to understand these tests are not validated for widespread
the basic molecular interactions involved in application given the limited external research
the process [93]. Under the influence of estra- on these tests, but rather offer an area of fur-
diol, the endometrium proliferates and reaches ther investigation.
a critical thickness to support implantation.
After ovulation, in response to progesterone,
the endometrium differentiates and becomes 4.17.2 Anatomic Changes
receptive to the newly hatched blastocyst.
Implantation occurs around 6 days after The endometrial environment is impacted by
ovulation, ranging between 6 and 12 days [94]. other pathophysiologic abnormalities including
The ideal time for implantation is thought to but not limited to hydrosalpinges, leiomyomas,
be around day 7 to day 9 after the LH surge adenomyosis, and uterine polyps. Hydrosal-
and is called the “window of implantation.” pinges have a direct effect on embryos but also
This period is characterized by structural and negatively impact the endometrial receptivity
secretory changes in endometrial cells, provid- and subsequently have decreased IVF live birth
ing the most favorable conditions for success- rates. The hydrosalpingeal fluid increases the
ful blastocyst implantation. The endometrium endometrial inflammatory response, increasing
increases in thickness and becomes more vas- IL-2, altering the uterine environment and con-
cularized, and glands become tortuous and tributing to decreased reproductive outcomes.
increase their secretions rich in cholesterol, Other anatomic changes like uterine isthmo-
fat-soluble vitamins, lipid, and protein. These celes (niches) have been discussed but have not
secretions will serve as an energy source for been studied enough to definitely state their
the embryo, which has no connection to uter- impact on implantation. The flushing effect of
ine vessels at this point in development. In these pro-inflammatory fluid collections further
addition, there is a decrease in uterine fluid decreases implantation.
content to allow greater contact between Adenomyosis, the ectopic presence of
the embryo and endometrium. These drastic endometrial glands and stroma within the
changes in the uterine environment are mostly myometrium of the uterus, is also com-
the result of progesterone stimulating the dif- monly discovered during infertility workup.
ferentiation of endometrial cells into decidual Theoretically, adenomyosis associated infer-
cells. Decidual cells contain more intracellular tility is secondary to altered uterine peristalsis
lipids and glycogen deposits than endometrial that inhibits normal sperm motility within the
cells, which cause them to get a polygonal uterine cavity. Adenomyosis likely also leads
shape as opposed to more rounded endome- to abnormal uterine decidualization impact-
trial cells. ing endometrial receptivity.
Given the importance of endometrial Leiomyomas, or fibroids, are benign
receptivity on successful implantation, there growths within the endometrium. Leiomy-
oma location and type may impact fertility have altered BMDC number and function in
to varying degrees. Currently, non-cavitary the endometrium. The functional implication
distorting fibroids have limited to no impact of these BMDC is not fully understood, but
on fertility, while submucosal fibroids clearly stem cell therapy offers a therapeutic oppor-
lead to decreased endometrial receptivity. tunity to overcome implantation defects. The
While anatomic explanations causing altered role of bone marrow transplant and stem cell
implantation were widely assumed in the therapies in increasing endometrial receptivity
past, molecular effects of fibroids on endo- needs to be further studied.
4 metrium are likely the cause of implantation
defects. Submucosal fibroids lead to a global
change of HOXA10 and HOXA11 mRNA 4.18 Pinopodes
expression throughout the endometrium.
The effect is not limited to the endometrium One characteristic feature of receptive endo-
overlying the fibroid; rather, it has an effect metrium is the presence of pinopodes on the
on the entire endometrium, suggesting regula- apical surface of endometrial cells. Pinopo-
tion by a diffusible molecule. Fibroids secrete des are bleb-like protrusions into the uter-
transforming growth factor (TGF)-β3 with a ine lumen and are found in large numbers
subsequent decrease in bone morphogenetic between days 19 and 21 in an idealized 28-day
protein (BMP). Blockage of TGF prevents menstrual cycle. Although they are expressed
repression of expression of HOXA10 and leu- throughout the mid- and late-secretory phase,
kemia inhibitory factor (LIF). This identifies they show different morphological features.
a signaling pathway that may be a target for This suggests that their morphology, rather
future fertility treatments. than their presence, is important for success-
Leiomyomas may also alter the endome- ful implantation [95]. Blastocyst attachment
trial cytokine production, vascular architec- has been shown to occur preferentially on the
ture, and contractility. Surgical management top of pinopodes, which suggests that recep-
remains the mainstay for treatment of leio- tors necessary for attachment are located on
myomas in the setting of infertility. As medi- the pinopode surface [96].
cal management of leiomyomas continues to Pinopode development has been associ-
develop, further studies are needed to under- ated with progesterone [95], HOXA10, LIF
stand the implications of medical and surgical [97], and aVβ3 integrin [98]. HOXA10, a
management of fibroids on fertility. homeobox gene, is necessary for blastocyst
Endometrial polyps have been associ- implantation, endometrial stromal cell pro-
ated with female infertility but remain a liferation, and epithelial cell morphogenesis
common finding in both fertile and infer- [95]. Blocking HOXA10 expression greatly
tile women. Large polyps are more likely to decreases the number of pinopodes.
impact fertility.
4.19 Selectins
4.17.3 Stem Cells
Selectins are glycoproteins that have a gly-
Bone marrow derivative cells (BMDC) have a cosylated extracellular domain, a single
role in developing the decidual stroma of the spanning transmembrane domain, and a cyto-
uterus and thus have impact on endometrial plasmic tail. There are three distinct selectins:
receptivity. Specifically, pregnancy recruits P selectin, L selectin, and E selectin. Selectins
increased number of BMDC to the decidua are commonly known for their role in initial
of the endometrium for further differentia- leukocyte attachment and subsequent rolling
tion. Pregnancy recruits approximately a four- on the endothelial surface. In addition to leu-
fold increase in BMDC to the endometrium kocytes, however, selectins are thought to be
compared to the nonpregnant endometrium. responsible for the initial blastocyst–endome-
Patients with recurrent pregnancy loss (RPL) trium attachment.
97 4
Strong L selectin expression has been also actively involved in the β3 subunit regu-
shown on the blastocyst surface, whereas on lation, probably with the embryonic IL-1 sys-
the maternal site, its ligands, namely, MECA- tem [96].
79 and HECA-452, are upregulated during Additionally, HOXA10 increases the
the window of implantation [99]. Although L expression of the β3 subunit in endometrial
selectin is found on both luminal and glan- cells [105]. This subunit is the rate-limiting
dular epithelia, expression of L selectin is step in αvβ3 integrin production. Considering
higher on the luminal epithelium [100]. Initial the important role of αvβ3 integrin in the
trophoblast attachment to endometrium is implantation process, it’s not surprising that
thought to occur with trophoblastic L selec- it is used as a clinical marker of endometrial
tin and endometrial oligosaccharide interac- receptivity [96, 106].
tions [101].
4.21 Mucins
4.20 Integrins
Mucins are heavily glycosylated proteins.
Integrins are transmembrane glycoproteins Carbohydrates constitute 50–90% of their
composed of noncovalently linked α- and molecular weight. To date, 18 mammalian
β-subunits. Each subunit has an extracellular, mucin genes have been identified [107]. Mainly
intracellular, and transmembrane domain. mucin-1 (MUC1) and to a lesser extent
The intracellular domains are linked to the mucin-6 (MUC6) are expressed in the human
cytoplasmic cytoskeleton and intracellular endometrium. They are found on the luminal
signaling pathways [96]. They are paired to surface of the epithelial cells in the reproduc-
compose integrin heterodimers; 24 function- tive tract. Their proposed physiological role in
ally distinct integrins have been identified the reproductive tract is to trap bacteria and
[102]. Among various other functions, they viruses and expel them. They are resistant to
are mainly involved in cell-to-cell and cell- digestive enzymes. Their extracellular portion
to-extracellular matrix interactions. Among can be cleaved, and those cleaved molecules
the many different types of integrins that can join via sulfide bonds to create a mucin
are expressed constitutively in the endome- gel. Altogether, mucins produce a formi-
trium, α1β1, α4β1, and αvβ3 are co-expressed dable barrier in microbial defense. Estrogens
between days 20 and 24 in the menstrual increase mucin production. Progesterone has
cycle. β3 integrin deserves special attention no independent effect on mucin production;
among other subunits, because its expression yet by counteracting the effects of estrogens,
starts at cycle day 19 and increases thereaf- the net effect of progesterone is to decrease
ter [103]. Moreover, it is mainly expressed on mucin levels. Cytokines, particularly TNF-α,
the endometrial luminal surface, which sug- have also been shown to be involved in mucin
gests that αvβ3 integrin, and its endometrial regulation.
ligand osteopontin, might serve as a receptor Although they provide an important bar-
for embryonic attachment [103, 104]. Various rier in microbial defense, mucins also consti-
studies showed that the αvβ3 integrin is reg- tute a barrier against blastocyst implantation.
ulated in both a hormonal and paracrine Mucins extend their projections well beyond
manner. For example, estrogens downregu- endometrial surface receptors, thereby hinder-
late integrin expression, but increasing levels ing blastocyst access to them [108]. At the site
of progesterone in the luteal phase counter- of implantation, mucins’ extracellular domain
act the estrogen effect. Rather than a direct needs to be cleaved. The sheddase family of
effect, progesterone increases epidermal enzymes, particularly TACE/ADAM17 and
growth factor and heparin binding growth MT1-MMP, has been suggested to play a role
factor in the uterine stroma, which results in this cleavage process [109]. The blastocyst,
in increased αvβ3 levels [103]. The embryo is through the action of secreted cytokines,
upregulates sheddases that cleave mucins in and PI3 kinase pathways [96]. Other mem-
endometrium [108]. bers of the gp130 cytokine family, including
Interestingly, during the implantation oncostatin M, ciliary neurotrophic factor, car-
period, mucin production is increased [110]. diotrophin-1, IL-6, and IL-11, can also bind
It seems to be a paradoxical phenomenon; to the LIFR [112].
however, two possible explanations have been LIF was the first cytokine shown to be
suggested. First, after sexual intercourse, the critical for implantation in mice [113]. Wild-
ejaculate may introduce microbial pathogens type mice embryos failed to implant in the
4 into the endometrium, and the increased endometrium of homozygous LIF mutant
mucin levels may act as an additional protec- female mice, and the implantation failure was
tive barrier. Second, as the blastocyst is actively reversed after LIF supplementation.
involved in sheddase induction, it has to be LIF mRNA is expressed between men-
competent to do so. Mucins may be a pro- strual cycle days 18 and 28 in fertile women,
tective mechanism against the attachment of and it is expressed by both glandular and
unhealthy embryos that would otherwise have luminal epithelia [114]. Among many LIF
resulted in pregnancy failure [110]. Consistent regulators, progesterone is probably respon-
with this view, women with recurrent preg- sible for endometrial LIF induction. When
nancy failure have decreased mucin levels com- treated with a selective progesterone receptor
pared to a fertile control group [111]. modulator, mifepristone, decreased levels of
To summarize, mucins prevent embryo LIF are observed in endometrium [115]. In
attachment and need to be cleaved at the addition to progesterone, IL-1α, TNF, PDGF,
site of embryonic attachment. This process TGF-β1, and HB-EGF stimulate LIF expres-
involves a series of interactions that requires sion in cultured endometrial stromal cells.
a healthy embryo as well as a functional endo- The embryo secretes hCG, IGF-1, and IGF-2
metrium. that also increases LIF levels [116].
LIF protein expression is maximal in uter-
ine flushings in the midlate secretory phase of
4.22 Cytokines the menstrual cycle at the time of expected
implantation. Considering the ease of per-
Cytokines are soluble proteins that have a forming uterine flushings, LIF has been sug-
variety of functions in inflammation, the gested as a marker of uterine receptivity [117,
menstrual cycle, ovulation, and implantation. 118]. In women with recurrent implantation
A disturbance in the normal expression or failure, LIF levels are lower than in controls,
action of several cytokines results in implan- emphasizing the importance of LIF in suc-
tation failure and abnormal placental devel- cessful implantation [118, 119]. rhLIF has
opment in humans. Of known importance are also been suggested to improve endometrial
members of the gp130 family, such as LIF, receptivity in recurrent implantation failure
IL-1, IL-11, and IL-15 system [112]. patients; however, the efficacy has not been
demonstrated in clinical trials [120].
4.23 Leukemia Inhibitory Factor

4.24 Interleukins
A member of the gp130 cytokines, LIF acts
through its surface receptor complex, LIF IL-1 is one of the key regulatory mediators
receptor (LIFR), and the gp130 receptor of the inflammatory response. IL-1α, IL-1β,
chain. Binding of LIF to LIFR results in het- and the IL-1 receptor antagonist are members
erodimerization with gp130 and subsequent of the IL-1 cytokine family. Stromal cells,
activation of downstream signaling pathways glandular cells, and macrophages are the res-
that include the JAK/STAT, MAP kinase, ervoir of IL-1 in the endometrium. In vitro,
99 4
treating endometrial cells with IL-1 increases 4.25 Prostaglandins
integrin β3 expression in the epithelial cells
[121]. IL-1α knockout mice are, however, fer- Prostaglandins (PGs) are lipid mediators
tile, suggesting redundancy in the effects these of inflammation, and they have a variety of
interleukins have in implantation. IL-1 recep- functions in inflammation, menstrual cycle
tor antagonist expression is decreased during regulation, ovulation, embryo attachment,
the implantation window. It is possible that trophoblastic invasion, and labor. Prosta-
downregulation of IL-1 antagonist works glandins, leukotrienes, and thromboxanes are
synergistically with IL-1 to affect implanta- members of the eicosanoid family. They are
tion [122]. Exogenous IL-1 receptor antago- produced from membrane lipids by phospho-
nist treatment during implantation can block lipase A2 (PLA2) and cyclooxygenase (COX)
blastocyst implantation [121]. Overall, the enzymes. To date, three isoforms of COX
IL-1 system is clearly involved in implanta- enzymes have been discovered: COX-1, COX-
tion; however, its exact role in implantation 2, and COX-3. COX-1 is constitutive and
remains unclear. expressed under normal physiological func-
IL-6 is involved in many immune interactions, whereas COX-2 is involved mainly in
tions, and it has been also suggested to play inflammatory responses. COX-3 is expressed
a role in implantation. Endometrial IL-6 in the human brain and is responsible for fever
mRNA expression increases during the mid- and response to pain.
to late secretory phase and decreases in the Murine studies have shown the impor-
late secretory phase. Strong immunoreactiv- tance of prostaglandins (PGs) in implanta-
ity has been observed in uterine glandular tion. Lack of either PLA2 or COX2 in mice
and luminal epithelium during the window leads to defective PG synthesis; PLA2 knock-
of implantation [123]. While controversial, out mice show pregnancy failure [127]. COX
IL-6-deficient mice appear to have reduced expression is maximal in the menstrual and
fertility and decreased implantation rate proliferative phases. Among many regula-
[124]. The IL-6 receptor is found on the sur- tors, IL-1 deserves further consideration. IL-1
face of the blastocyst, and IL-6 is probably increases COX enzymes and PG production,
involved in paracrine/autocrine interactions resulting in increased endometrial integrin
in the window of implantation. Decreased levels that are essential for blastocyst implan-
levels of mid-secretory IL-6 mRNA are tation [96].
found in patients with recurrent spontaneous Although prostaglandins’ role in the men-
abortions, also supporting this hypothesis strual cycle and pathophysiology in endo-
[125]. metriosis is well known, their role in human
Another cytokine that has gained atten- blastocyst attachment and subsequent inva-
tion is IL-11. IL-11 has anti-inflammatory sion needs to be explored further.
activities, and it is expressed in endometrial
glandular and luminal epithelium. Estrogen,
progesterone, and local factors increase IL-11 4.26 HOX Genes
levels. IL-11 advances progesterone-induced
decidualization of human endometrial stro- Homeobox (HOX) genes are highly conserved
mal cells. IL-11 and its receptor IL-11R were genes that are involved in embryonic develop-
immunolocalized to decidualized stromal cells ment as well as endometrial growth, differen-
in the mid–late secretory phase epithelium. tiation, and receptivity [128]. Both estrogen
They were also shown on the trophoblastic and progesterone increase HOXA10 and
cells, suggesting a role in normal placentation HOXA11 expression. Additionally, HOXA10
[112]. Additionally, inadequate IL-11 signal- and HOXA11 expressions reach the high-
ing was found to result in dysregulation in tro- est levels during the window of implanta-
phoblastic invasion [126]. tion [129]. Wild-type mice embryos cannot
implant to the uteri of HOXA10 or HOXA11 form the main interface for gas and nutrient
knockout mice. These findings suggest that exchange between the fetus and mother, and
HOXA10 and HOXA11 play an essential as discussed above, extravillous trophoblasts
role in endometrial receptivity [130]. In par- invade and remodel the spiral arteries.
allel with these findings, pinopodes, β3 inte- Maternal and fetal cells are in direct con-
grin, and insulin-like growth factor binding tact during this invasion process, and the
protein were shown to be regulated by HOX immune response deserves a detailed explana-
genes [131]. As discussed above, these genes tion. Maternal leukocytes reside in the uter-
4 are among the few proven to be essential for ine endometrium, and it has been estimated
endometrial receptivity. In humans, there that approximately 40% of the decidua is
are no documented HOXA10 or HOXA11 leukocytes. Fortunately, trophoblasts have
mutations. However, in various gynecologic a distinct MHC expression profile. They do
disorders such as endometriosis, PCOS, not express the most common HLA antigens
hydrosalpinx, and uterine fibroids, endome- such as HLA-A and HLA-B, and even with
trial HOXA10 and HOXA11 mRNA levels potent stimulators like IFN-α, they do not
are reduced [132–134]. These findings demon- express MHC class II antigens recognized by
strate that HOX genes contribute to the defec- certain leukocytes. The dominant MHC types
tive endometrial receptivity that is observed in expressed on trophoblasts are HLA-C, HLA-
those disorders. G, and HLA-E.
Villous syncytiotrophoblasts line blood-
filled lacunae and are in direct contact with
maternal blood. They do not express MHC-I
4.27 Immune Response antigens and are therefore protected from
to Trophoblast Invasion: T-cell-mediated responses. Interstitial tropho-
Trophoblast–Leukocyte blasts invade the decidua and express HLA-C,
Interactions HLA-G, and HLA-E. Endovascular tropho-
blasts that line the maternal spiral arteries
As mentioned above, to achieve a success- express HLA-C, HLA-G, and HLA-E. The
ful pregnancy, the blastocyst must be able to expression of HLA-G and HLA-E on this cell
attach to the endometrial decidua without population confers protection from maternal
complication. The blastocyst has to invade immune rejection.
the endometrium and maternal blood vessels Leukocytes are normally found in endo-
in order to ensure adequate blood supply for metrium and actually 40% of the decidua con-
nutrients and gas exchange. However, because sists of leukocytes. In endometrial infection,
a blastocyst receives half of its genome from there are multiple types of leukocytes that
the father and the other half from the mother, are found in the endometrial lining, and they
it is treated as a semiallogenic by the mater- all act through different mechanisms. B cells
nal immune system. Therefore, alterations in respond to antigenic stimulation and produce
the reactivity of the maternal immune system antibody secreting plasma cells.
must occur at the maternal–fetal interface. Additionally, macrophages can be found
As the blastocyst attaches to the uterine and represent approximately 20% of the
epithelium, the trophoectoderm differentiates endometrial leukocytes; they can recognize
into two layers, as previously mentioned, an and respond to HLA-G antigens [135].
outer syncytiotrophoblast and an inner cyto- T cells represent 10% of the leukocytes
trophoblast layer. Two weeks after implan- found in the endometrium. They require an
tation, the cytotrophoblast layer protrudes MHC-II antigen presentation for immune
through the syncytiotrophoblasts and forms response, and, as trophoblasts do not express
cytotrophoblastic buds. The buds then dif- MHC-II antigens, they cannot directly stimu-
ferentiate into both villous trophoblasts late T cell responses. This is how villous syn-
and extravillous trophoblasts. Villous tro- cytiotrophoblasts, which line the maternal
phoblasts cover the chorionic villi which blood-filled lacunae, are protected from the
101 4
maternal T cells. However, maternal endo- their origin is recruitment from CD56+ cells
metrial dendritic cells and macrophages can in the blood into the endometrium. Regardless
process paternally derived antigens by migrat- of their origin, their quantity correlates with
ing to lymph nodes where they can initiate an maternal progesterone levels. Additionally,
immune response. they are found to accumulate in large num-
Interestingly, antibodies against paternal bers at the site of implantation. Their close
HLA antigens can be found during preg- proximity to trophoblasts suggests that they
nancy; however, they are likely formed during may be involved in regulating trophoblastic
birth due to fetal cells crossing the placenta. invasion [92]. In addition, lower uNK counts
Fortunately, these antibodies are mainly in the endometrium have been correlated with
against HLA-A and HLA-B. As these HLA decreased IVF–ET success [137]. In summary,
types are not expressed by the trophoblasts, although dysregulation of uNK cells and
the presence of these antibodies is not corre- their cytokine production profile was shown
lated with pregnancy success [92]. to be related with recurrent pregnancy loss,
Natural killer T (NKT) cells are a subset preeclampsia, and implantation failure, their
of T cells that have an immunomodulatory exact role in implantation is not known [138].
role in infection through cytokine production.
Invading trophoblasts are protected from
blood NK cells through multiple different 4.28 Clinical Relevance
mechanisms. Villous syncytiotrophoblasts
are likely protected by the absence of NK- Infertility is classically defined as the failure
activating ligands on the syncytiotropho- of a couple to conceive after 12 months of fre-
blastic surface. Similarly, endovascular and quent intercourse in women under 35 years,
interstitial trophoblasts, which line mater- and after 6 months in women over the age of
nal spiral arteries and decidua, respectively, 35 [139]. Infertility can be due to male fac-
express HLA-C, HLA-G, and HLA-E. The tors, female factors, or both. The availability
expression of HLA-G and HLA-E on these of ICSI/IVF has resulted in pregnancy rates
cell populations confers protection from in couples with male factor infertility that
blood NK cells. are comparable to those without male factor
Uterine NK cells (uNK) are among the infertility [140].
most studied endometrial leukocyte type Key steps for successful fertilization are
and are known to be involved in endometrial the oocyte quality and appropriate oocyte
renewal, differentiation, and breakdown in maturation. As our understanding of oocyte
menstrual cycle. Although their exact role in biology has increased, we are able to mimic
implantation is unknown, their dysregulation endogenous oocyte developmental steps
has been shown to be associated with recurrent in vitro. One such success in reproductive med-
pregnancy loss, preeclampsia, and implanta- icine is improving in vitro maturation (IVM),
tion failure. uNK cells are CD56brightCD16dim in which immature oocytes are collected and
and functionally distinct compared to their cir- then maturated for in vitro fertilization. This
culating counterparts. They are spatially and technique provides an invaluable opportunity
temporally correlated with the implantation for many infertile patients. Additionally, IVM
site of the embryo and modulate the cytokine, and IVF provide an opportunity for fertility
chemokine microenvironment, thereby con- preservation, including use in patients under-
tributing to physiological changes within the going gonadotoxic chemotherapy for various
uterine stroma during pregnancy [136]. Their cancers [141]. As will be discussed further in
origin is still unknown, yet they are thought to the book, morphokinetics of the develop-
arise from in utero proliferation and differen- ing embryo have been used to select viable
tiation of CD34+ stem cells. They are found embryos that are more likely to implant the
in deeper layers of decidua and are not shed endometrium and result in successful preg-
during menstruation. Another alternative to nancy [142].
Defective endometrial receptivity is a sig- 4.30 Answers

nificant cause of ART failure [143]. Therefore,
it is essential to correctly assess the endome- vv1. A
trial receptivity state for successful implan-
tation. Among many others, pinopodes and vv2. D
αvβ3 integrin have been suggested as candi-
date biomarkers that reflect the window of vv3. D
implantation [144]. Endometrial scratching
4 and G-CSF have been used to improve endo-
metrial receptivity and implantation; how- References
ever, strong evidence favoring these methods
is lacking [145–147]. Endometrial receptiv- 1. Chandra A, Copen CE, Stephen EH. Infertility
and impaired fecundity in the United States, 1982–
ity arrays based on the transcriptomic data
2010: data from the National Survey of Family
have been developed to predict the window Growth. Natl Health Stat Report. 2013;67:1–18.
implantation in efforts to increase implanta- 2. Ombelet W, Cooke I, Dyer S, Serour G, Devroey
tion success [148, 149]. However, there is cur- P. Infertility and the provision of infertility medi-
rently insufficient evidence from adequately cal services in developing countries. Hum Reprod
Update. 2008;14(6):605–21.
powered prospective clinical trials to validate
3. Rocha AL, Reis FM, Petraglia F. New trends for
these markers. Patients with endometriosis, the medical treatment of endometriosis. Expert
fibroids, PCOS, and hydrosalpinx frequently Opin Investig Drugs. 2012;21(7):905–19.
present with infertility due at least in part to 4. Cornwall GA. New insights into epididymal
defective endometrial receptivity. Recognizing biology and function. Hum Reprod Update.
2009;15(2):213–27.
and treating the underlying etiology can at
5. Sullivan R, Frenette G, Girouard J. Epididy-
least partly improve endometrial receptivity mosomes are involved in the acquisition of new
in these patients. sperm proteins during epididymal transit. Asian J
Androl. 2007;9(4):483–91.
6. Buffone MG, Ijiri TW, Cao W, Merdiushev T,
Aghajanian HK, Gerton GL. Heads or tails?
4.29 Review Questions Structural events and molecular mechanisms that
promote mammalian sperm acrosomal exocytosis
??1. The block to polyspermy is regulated and motility. Mol Reprod Dev. 2012;79(1):4–18.
by: 7. Shum WW, Da Silva N, Brown D, Breton S. Regu-
A. Cortical reaction lation of luminal acidification in the male repro-
ductive tract via cell-cell crosstalk. J Exp Biol.
B. Capacitation
2009;212(Pt 11):1753–61.
C. Cervical mucus 8. Arienti G, Carlini E, Polci A, Cosmi EV, Palmerini
D. Limited sperm transport to the ovi- CA. Fatty acid pattern of human prostasome lipid.
duct Arch Biochem Biophys. 1998;358(2):391–5.
9. Cobellis G, Ricci G, Cacciola G, Orlando P, Petro-
sino S, Cascio MG, et al. A gradient of 2-arachi-
??2. Regulation of the window of endome-
donoylglycerol regulates mouse epididymal sperm
trial receptivity includes: cell start-up. Biol Reprod. 2010;82(2):451–8.
A. HOX genes 10. Dacheux JL, Belghazi M, Lanson Y, Dacheux
B. Integrins F. Human epididymal secretome and proteome.
C. Pinopodes Mol Cell Endocrinol. 2006;250(1–2):36–42.
11. Frenette G, Lessard C, Madore E, Fortier MA,
D. All of the above
Sullivan R. Aldose reductase and macrophage
migration inhibitory factor are associated with
??3. Barrier to obtaining a receptive endo- epididymosomes and spermatozoa in the bovine
metrium includes: epididymis. Biol Reprod. 2003;69(5):1586–92.
A. Fibroids 12. Hereng TH, Elgstoen KB, Cederkvist FH, Eide L,
Jahnsen T, Skalhegg BS, et al. Exogenous pyru-
B. Hydrosalpinges
vate accelerates glycolysis and promotes capaci-
C. Adenomyosis tation in human spermatozoa. Hum Reprod.
D. All of the above 2011;26(12):3249–63.
103 4
13. Rodriguez-Martinez H, Kvist U, Ernerudh J, ular basis of sperm capacitation. J Androl.
Sanz L, Calvete JJ. Seminal plasma proteins: 1998;19(2):242–8.
what role do they play? Am J Reprod Immunol. 29. Visconti PE, Krapf D, de la Vega-Beltran JL, Ace-
2011;66(Suppl 1):11–22. vedo JJ, Darszon A. Ion channels, phosphoryla-
14. Lilja H. A kallikrein-like serine protease in pros- tion and mammalian sperm capacitation. Asian J
tatic fluid cleaves the predominant seminal vesicle Androl. 2011;13(3):395–405.
protein. J Clin Invest. 1985;76(5):1899–903. 30. Suarez SS. Control of hyperactivation in sperm.
15. Bellis MA, Baker RR, Matson P, Chew J. A guide Hum Reprod Update. 2008;14(6):647–57.
to upwardly mobile spermatozoa. Andrologia. 31. Ho HC, Suarez SS. Characterization of the intra-
1990;22(5):397–9. cellular calcium store at the base of the sperm fla-
16. Hamamah S, Gatti JL. Role of the ionic environ- gellum that regulates hyperactivated motility. Biol
ment and internal pH on sperm activity. Hum Reprod. 2003;68(5):1590–6.
Reprod. 1998;13(Suppl 4):20–30. 32. Brown SG, Publicover SJ, Mansell SA, Lishko PV,
17. Suarez SS, Pacey AA. Sperm transport in the Williams HL, Ramalingam M, et al. Depolariza-
female reproductive tract. Hum Reprod Update. tion of sperm membrane potential is a common
2006;12(1):23–37. feature of men with subfertility and is associated
18. Holt WV, Fazeli A. Do sperm possess a molecular with low fertilization rate at IVF. Hum Reprod.
passport? Mechanistic insights into sperm selec- 2016;31(6):1147–57.
tion in the female reproductive tract. Mol Hum 33. Herrick SB, Schweissinger DL, Kim SW, Bayan
Reprod. 2015;21(6):491–501. KR, Mann S, Cardullo RA. The acrosomal vesicle
19. Katz DF, Slade DA, Nakajima ST. Analysis of of mouse sperm is a calcium store. J Cell Physiol.
pre-ovulatory changes in cervical mucus hydra- 2005;202(3):663–71.
tion and sperm penetrability. Adv Contracept. 34. Baker TG. A quantitative and cytological study of
1997;13(2–3):143–51. germ cells in human ovaries. Proc R Soc Lond B
20. Eggert-Kruse W, Kohler A, Rohr G, Runnebaum Biol Sci. 1963;158:417–33.
B. The pH as an important determinant of sperm- 35. Johnson J, Canning J, Kaneko T, Pru JK, Tilly
mucus interaction. Fertil Steril. 1993;59(3):617–28. JL. Germline stem cells and follicular renewal
21. Bigelow JL, Dunson DB, Stanford JB, Ecochard in the postnatal mammalian ovary. Nature.
R, Gnoth C, Colombo B. Mucus observations in 2004;428(6979):145–50.
the fertile window: a better predictor of concep- 36. Oatley J, Hunt PA. Of mice and (wo)men: purified
tion than timing of intercourse. Hum Reprod. oogonial stem cells from mouse and human ova-
2004;19(4):889–92. ries. Biol Reprod. 2012;86(6):196.
22. Barros C, Vigil P, Herrera E, Arguello B, Walker 37. Woods DC, Tilly JL. The next (re)generation of
R. Selection of morphologically abnormal ovarian biology and fertility in women: is cur-
sperm by human cervical mucus. Arch Androl. rent science tomorrow’s practice? Fertil Steril.
1984;12(Suppl):95–107. 2012;98(1):3–10.
23. Sheehan JK, Oates K, Carlstedt I. Electron micros- 38. Woods DC, White YA, Tilly JL. Purification of
copy of cervical, gastric and bronchial mucus gly- oogonial stem cells from adult mouse and human
coproteins. Biochem J. 1986;239(1):147–53. ovaries: an assessment of the literature and a view
24. Bianchi PG, De Agostini A, Fournier J, Guidetti toward the future. Reprod Sci. 2013;20(1):7–15.
C, Tarozzi N, Bizzaro D, et al. Human cervical 39. Gougeon A, Ecochard R, Thalabard JC. Age-
mucus can act in vitro as a selective barrier against related changes of the population of human ovar-
spermatozoa carrying fragmented DNA and chro- ian follicles: increase in the disappearance rate of
matin structural abnormalities. J Assist Reprod non-growing and early-growing follicles in aging
Genet. 2004;21(4):97–102. women. Biol Reprod. 1994;50(3):653–63.
25. Kunz G, Beil D, Deininger H, Wildt L, Leyen- 40. Hansen KR, Knowlton NS, Thyer AC, Charleston
decker G. The dynamics of rapid sperm trans- JS, Soules MR, Klein NA. A new model of repro-
port through the female genital tract: evidence ductive aging: the decline in ovarian non-growing
from vaginal sonography of uterine peristalsis follicle number from birth to menopause. Hum
and hysterosalpingoscintigraphy. Hum Reprod. Reprod. 2008;23(3):699–708.
1996;11(3):627–32. 41. Block E. Quantitative morphological investiga-
26. Lyons EA, Taylor PJ, Zheng XH, Ballard G, Levi tions of the follicular system in women; variations
CS, Kredentser JV. Characterization of subendo- at different ages. Acta Anat (Basel). 1952;14(1–
metrial myometrial contractions throughout the 2):108–23.
menstrual cycle in normal fertile women. Fertil 42. Bedell MA, Brannan CI, Evans EP, Copeland NG,
Steril. 1991;55(4):771–4. Jenkins NA, Donovan PJ. DNA rearrangements
27. Fukuda M, Fukuda K. Uterine endometrial cav- located over 100 kb 5′ of the Steel (Sl)-coding
ity movement and cervical mucus. Hum Reprod. region in Steel-panda and Steel-contrasted mice
1994;9(6):1013–6. deregulate Sl expression and cause female sterility
28. Visconti PE, Galantino-Homer H, Moore GD, by disrupting ovarian follicle development. Genes
Bailey JL, Ning X, Fornes M, et al. The molec- Dev. 1995;9(4):455–70.
43. Dean J. Oocyte-specific genes regulate follicle for- 58. Oehninger S, Franken DR, Ombelet W. Sperm
mation, fertility and early mouse development. J functional tests. Fertil Steril. 2014;102(6):1528–33.
Reprod Immunol. 2002;53(1–2):171–80. 59. Bleil JD, Wassarman PM. Sperm-egg interactions
44. Morita Y, Manganaro TF, Tao XJ, Martim- in the mouse: sequence of events and induction of
beau S, Donahoe PK, Tilly JL. Requirement the acrosome reaction by a zona pellucida glyco-
for phosphatidylinositol-3′-kinase in cytokine- protein. Dev Biol. 1983;95(2):317–24.
mediated germ cell survival during fetal oogenesis 60. Monne M, Jovine L. A structural view of egg coat
in the mouse. Endocrinology. 1999;140(2):941–9. architecture and function in fertilization. Biol
45. Muraji M, Sudo T, Iwasaki S, Ueno S, Wakahashi Reprod. 2011;85(4):661–9.
S, Yamaguchi S, et al. The effect of abdominal 61. Tremellen K. Oxidative stress and male infertil-
4 radical trachelectomy on ovarian reserve: serial ity–a clinical perspective. Hum Reprod Update.
changes in serum anti-mullerian hormone levels. J 2008;14(3):243–58.
Cancer. 2012;3:191–5. 62. Chen J, Litscher ES, Wassarman PM. Inactiva-
46. Quennell JH, Stanton JA, Hurst PR. Basic fibro- tion of the mouse sperm receptor, mZP3, by site-
blast growth factor expression in isolated small directed mutagenesis of individual serine residues
human ovarian follicles. Mol Hum Reprod. located at the combining site for sperm. Proc Natl
2004;10(9):623–8. Acad Sci U S A. 1998;95(11):6193–7.
47. Nilsson EE, Skinner MK. Kit ligand and basic 63. Clark GF. The molecular basis of mouse sperm-
fibroblast growth factor interactions in the induc- zona pellucida binding: a still unresolved
tion of ovarian primordial to primary follicle tran- issue in developmental biology. Reproduction.
sition. Mol Cell Endocrinol. 2004;214(1–2):19–25. 2011;142(3):377–81.
48. Nilsson E, Rogers N, Skinner MK. Actions of 64. Jin M, Fujiwara E, Kakiuchi Y, Okabe M, Satouh
anti-Mullerian hormone on the ovarian transcrip- Y, Baba SA, et al. Most fertilizing mouse sperma-
tome to inhibit primordial to primary follicle tran- tozoa begin their acrosome reaction before contact
sition. Reproduction. 2007;134(2):209–21. with the zona pellucida during in vitro fertilization.
49. Visser JA, Durlinger AL, Peters IJ, van den Heuvel Proc Natl Acad Sci U S A. 2011;108(12):4892–6.
ER, Rose UM, Kramer P, et al. Increased oocyte 65. Gahlay G, Gauthier L, Baibakov B, Epifano O,
degeneration and follicular atresia during the Dean J. Gamete recognition in mice depends on
estrous cycle in anti-Mullerian hormone null mice. the cleavage status of an egg’s zona pellucida pro-
Endocrinology. 2007;148(5):2301–8. tein. Science. 2010;329(5988):216–9.
50. Durlinger AL, Gruijters MJ, Kramer P, Karels B, 66. Rubinstein E, Ziyyat A, Wolf JP, Le Naour F,
Kumar TR, Matzuk MM, et al. Anti-Mullerian Boucheix C. The molecular players of sperm-
hormone attenuates the effects of FSH on follicle egg fusion in mammals. Semin Cell Dev Biol.
development in the mouse ovary. Endocrinology. 2006;17(2):254–63.
2001;142(11):4891–9. 67. Evans JP. The molecular basis of sperm-oocyte
51. Gougeon A. Regulation of ovarian follicular membrane interactions during mammalian fer-
development in primates: facts and hypotheses. tilization. Hum Reprod Update. 2002;8(4):
Endocr Rev. 1996;17(2):121–55. 297–311.
52. Craig J, Orisaka M, Wang H, Orisaka S, Thomp- 68. Nixon B, Aitken RJ, McLaughlin EA. New insights
son W, Zhu C, et al. Gonadotropin and intra- into the molecular mechanisms of sperm-egg inter-
ovarian signals regulating follicle development and action. Cell Mol Life Sci. 2007;64(14):1805–23.
atresia: the delicate balance between life and death. 69. Ohto U, Ishida H, Krayukhina E, Uchiyama S,
Front Biosci. 2007;12:3628–39. Inoue N, Shimizu T. Structure of IZUMO1-JUNO
53. Messinis IE. From menarche to regular menstrua- reveals sperm-oocyte recognition during mamma-
tion: endocrinological background. Ann N Y lian fertilization. Nature. 2016;534(7608):566–9.
Acad Sci. 2006;1092:49–56. 70. Publicover S, Harper CV, Barratt C. [Ca2+]i sig-
54. Gilchrist RB, Lane M, Thompson JG. Oocyte- nalling in sperm–making the most of what you’ve
secreted factors: regulators of cumulus cell func- got. Nat Cell Biol. 2007;9(3):235–42.
tion and oocyte quality. Hum Reprod Update. 71. Swann K, Yu Y. The dynamics of calcium oscilla-
2008;14(2):159–77. tions that activate mammalian eggs. Int J Dev Biol.
55. Drahorad J, Tesarik J, Cechova D, Vilim V. Pro- 2008;52(5–6):585–94.
teins and glycosaminoglycans in the intercellular 72. Saunders CM, Larman MG, Parrington J, Cox
matrix of the human cumulus-oophorus and their LJ, Royse J, Blayney LM, et al. PLC zeta: a
effect on conversion of proacrosin to acrosin. J sperm-specific trigger of Ca(2+) oscillations in
Reprod Fertil. 1991;93(2):253–62. eggs and embryo development. Development.
56. Bedford JM. Site of the mammalian sperm physi- 2002;129(15):3533–44.
ological acrosome reaction. Proc Natl Acad Sci U 73. Wu AT, Sutovsky P, Xu W, van der Spoel AC, Platt
S A. 2011;108(12):4703–4. FM, Oko R. The postacrosomal assembly of sperm
57. Wassarman PM, Jovine L, Litscher ES. A pro- head protein, PAWP, is independent of acrosome
file of fertilization in mammals. Nat Cell Biol. formation and dependent on microtubular manch-
2001;3(2):E59–64. ette transport. Dev Biol. 2007;312(2):471–83.
105 4
74. Kashir J, Heindryckx B, Jones C, De Sutter P, Par- 88. Staun-Ram E, Shalev E. Human trophoblast
rington J, Coward K. Oocyte activation, phospho- function during the implantation process. Reprod
lipase C zeta and human infertility. Hum Reprod Biol Endocrinol. 2005;3:56.
Update. 2010;16(6):690–703. 89. Stetler-Stevenson WG, Krutzsch HC, Liotta
75. Nomikos M, Yu Y, Elgmati K, Theodoridou M, LA. Tissue inhibitor of metalloproteinase (TIMP-
Campbell K, Vassilakopoulou V, et al. Phospho- 2). A new member of the metalloproteinase inhib-
lipase Czeta rescues failed oocyte activation in a itor family. J Biol Chem. 1989;264(29):17374–8.
prototype of male factor infertility. Fertil Steril. 90. Zhang X, Green KE, Yallampalli C, Dong
2013;99(1):76–85. YL. Adrenomedullin enhances invasion by tro-
76. Payne C, Rawe V, Ramalho-Santos J, Simerly C, phoblast cell lines. Biol Reprod. 2005;73(4):
Schatten G. Preferentially localized dynein and 619–26.
perinuclear dynactin associate with nuclear pore 91. Chung IB, Yelian FD, Zaher FM, Gonik B,
complex proteins to mediate genomic union during Evans MI, Diamond MP, et al. Expression and
mammalian fertilization. J Cell Sci. 2003;116(Pt regulation of vascular endothelial growth factor
23):4727–38. in a first trimester trophoblast cell line. Placenta.
77. Watson AJ. The cell biology of blastocyst develop- 2000;21(4):320–4.
ment. Mol Reprod Dev. 1992;33(4):492–504. 92. Trundley A, Moffett A. Human uterine leukocytes
78. Capco DG. Molecular and biochemical regulation and pregnancy. Tissue Antigens. 2004;63(1):1–12.
of early mammalian development. Int Rev Cytol. 93. Norwitz ER, Schust DJ, Fisher SJ. Implantation
2001;207:195–235. and the survival of early pregnancy. N Engl J
79. Perona RM, Wassarman PM. Mouse blastocysts Med. 2001;345(19):1400–8.
hatch in vitro by using a trypsin-like proteinase 94. Wilcox AJ, Baird DD, Weinberg CR. Time of
associated with cells of mural trophectoderm. Dev implantation of the conceptus and loss of preg-
Biol. 1986;114(1):42–52. nancy. N Engl J Med. 1999;340(23):1796–9.
80. Menino AR Jr, O’Claray JL. Enhancement of 95. Usadi RS, Murray MJ, Bagnell RC, Fritz MA,
hatching and trophoblastic outgrowth by mouse Kowalik AI, Meyer WR, et al. Temporal and
embryos cultured in Whitten’s medium contain- morphologic characteristics of pinopod expres-
ing plasmin and plasminogen. J Reprod Fertil. sion across the secretory phase of the endometrial
1986;77(1):159–67. cycle in normally cycling women with proven fer-
81. Huppertz B, Berghold VM, Kawaguchi R, Gauster tility. Fertil Steril. 2003;79(4):970–4.
M. A variety of opportunities for immune inter- 96. Achache H, Revel A. Endometrial receptivity
actions during trophoblast development and inva- markers, the journey to successful embryo implan-
sion. Am J Reprod Immunol. 2012;67(5):349–57. tation. Hum Reprod Update. 2006;12(6):731–46.
82. Huppertz B, Bartz C, Kokozidou M. Trophoblast 97. Aghajanova L, Stavreus-Evers A, Nikas Y, Hov-
fusion: fusogenic proteins, syncytins and ADAMs, atta O, Landgren BM. Coexpression of pinopo-
and other prerequisites for syncytial fusion. des and leukemia inhibitory factor, as well as its
Micron. 2006;37(6):509–17. receptor, in human endometrium. Fertil Steril.
83. Muhlhauser J, Crescimanno C, Kaufmann P, 2003;79(Suppl 1):808–14.
Hofler H, Zaccheo D, Castellucci M. Differen- 98. Lessey BA, Damjanovich L, Coutifaris C, Castel-
tiation and proliferation patterns in human tro- baum A, Albelda SM, Buck CA. Integrin adhe-
phoblast revealed by c-erbB-2 oncogene product sion molecules in the human endometrium.
and EGF-R. J Histochem Cytochem. 1993;41(2): Correlation with the normal and abnormal men-
165–73. strual cycle. J Clin Invest. 1992;90(1):188–95.
84. Irving JA, Lala PK. Functional role of cell surface 99. Genbacev OD, Prakobphol A, Foulk RA, Krtol-
integrins on human trophoblast cell m igration: ica AR, Ilic D, Singer MS, et al. Trophoblast
regulation by TGF-beta, IGF-II, and IGFBP-1. L-selectin-mediated adhesion at the maternal-
Exp Cell Res. 1995;217(2):419–27. fetal interface. Science. 2003;299(5605):405–8.
85. Isaka K, Usuda S, Ito H, Sagawa Y, Nakamura H, 100. Lai TH, Shih Ie M, Vlahos N, Ho CL, Wallach
Nishi H, et al. Expression and activity of matrix E, Zhao Y. Differential expression of L-selectin
metalloproteinase 2 and 9 in human trophoblasts. ligand in the endometrium during the menstrual
Placenta. 2003;24(1):53–64. cycle. Fertil Steril. 2005;83(Suppl 1):1297–302.
86. Librach CL, Werb Z, Fitzgerald ML, Chiu K, 101. Fazleabas AT, Kim JJ. Development. What makes
Corwin NM, Esteves RA, et al. 92-kD type IV col- an embryo stick? Science. 2003;299(5605):355–6.
lagenase mediates invasion of human cytotropho- 102. Hynes RO. Integrins: bidirectional, allosteric sig-
blasts. J Cell Biol. 1991;113(2):437–49. naling machines. Cell. 2002;110(6):673–87.
87. Hurskainen T, Hoyhtya M, Tuuttila A, Oikar- 103. Lessey BA. Two pathways of progesterone
inen A, Autio-Harmainen H. mRNA expressions action in the human endometrium: implications
of TIMP-1, −2, and −3 and 92-KD type IV col- for implantation and contraception. Steroids.
lagenase in early human placenta and decidual 2003;68(10–13):809–15.
membrane as studied by in situ hybridization. J 104. Apparao KB, Lovely LP, Gui Y, Lininger RA,
Histochem Cytochem. 1996;44(12):1379–88. Lessey BA. Elevated endometrial androgen recep-
tor expression in women with polycystic ovarian 118. Mikolajczyk M, Skrzypczak J, Szymanowski K,
syndrome. Biol Reprod. 2002;66(2):297–304. Wirstlein P. The assessment of LIF in uterine
105. Daftary GS, Troy PJ, Bagot CN, Young SL, Tay- flushing—a possible new diagnostic tool in states
lor HS. Direct regulation of beta3-integrin sub- of impaired fertility. Reprod Biol. 2003;3(3):
unit gene expression by HOXA10 in endometrial 259–70.
cells. Mol Endocrinol. 2002;16(3):571–9. 119. Laird SM, Tuckerman EM, Dalton CF, Dunphy
106. Thomas K, Thomson A, Wood S, Kingsland C, BC, Li TC, Zhang X. The production of leukae-
Vince G, Lewis-Jones I. Endometrial integrin mia inhibitory factor by human endometrium:
expression in women undergoing in vitro fertiliza- presence in uterine flushings and production by
tion and the association with subsequent treat- cells in culture. Hum Reprod. 1997;12(3):569–74.
4 ment outcome. Fertil Steril. 2003;80(3):502–7. 120. Brinsden PR, Alam V, de Moustier B, Engrand
107. Carson DD. The glycobiology of implantation. P. Recombinant human leukemia inhibitory fac-
Front Biosci. 2002;7:d1535–44. tor does not improve implantation and pregnancy
108. Aplin JD. MUC-1 glycosylation in endometrium: outcomes after assisted reproductive techniques
possible roles of the apical glycocalyx at implan- in women with recurrent unexplained implan-
tation. Hum Reprod. 1999;14(Suppl 2):17–25. tation failure. Fertil Steril. 2009;91(4 Suppl):
109. Thathiah A, Carson DD. MT1-MMP medi- 1445–7.
ates MUC1 shedding independent of TACE/ 121. Simon C, Frances A, Piquette GN, el Danasouri
ADAM17. Biochem J. 2004;382(Pt 1):363–73. I, Zurawski G, Dang W, et al. Embryonic implan-
110. Aplin JD, Hey NA, Graham RA. Human endo- tation in mice is blocked by interleukin-1 receptor
metrial MUC1 carries keratan sulfate: charac- antagonist. Endocrinology. 1994;134(2):521–8.
teristic glycoforms in the luminal epithelium at 122. Boucher A, Kharfi A, Al-Akoum M, Bossu P,
receptivity. Glycobiology. 1998;8(3):269–76. Akoum A. Cycle-dependent expression of inter-
111. Serle E, Aplin JD, Li TC, Warren MA, Gra- leukin-1 receptor type II in the human endome-
ham RA, Seif MW, et al. Endometrial differen- trium. Biol Reprod. 2001;65(3):890–8.
tiation in the peri-implantation phase of women 123. Tabibzadeh S, Kong QF, Babaknia A, May
with recurrent miscarriage: a morphological LT. Progressive rise in the expression of interleu-
and immunohistochemical study. Fertil Steril. kin-6 in human endometrium during menstrual
1994;62(5):989–96. cycle is initiated during the implantation window.
112. Dimitriadis E, White CA, Jones RL, Salamonsen Hum Reprod. 1995;10(10):2793–9.
LA. Cytokines, chemokines and growth factors 124. Salamonsen LA, Dimitriadis E, Robb L. Cyto-
in endometrium related to implantation. Hum kines in implantation. Semin Reprod Med. 2000;
Reprod Update. 2005;11(6):613–30. 18(3):299–310.
113. Stewart CL, Kaspar P, Brunet LJ, Bhatt H, Gadi 125. von Wolff M, Thaler CJ, Strowitzki T, Broome J,
I, Kontgen F, et al. Blastocyst implantation Stolz W, Tabibzadeh S. Regulated expression of
depends on maternal expression of leukaemia cytokines in human endometrium throughout the
inhibitory factor. Nature. 1992;359(6390):76–9. menstrual cycle: dysregulation in habitual abor-
114. Sharkey AM, King A, Clark DE, Burrows TD, tion. Mol Hum Reprod. 2000;6(7):627–34.
Jokhi PP, Charnock-Jones DS, et al. Localization 126. von Rango U, Alfer J, Kertschanska S, Kemp B,
of leukemia inhibitory factor and its receptor Muller-Newen G, Heinrich PC, et al. Interleukin-
in human placenta throughout pregnancy. Biol 11 expression: its significance in eutopic and

Reprod. 1999;60(2):355–64. ectopic human implantation. Mol Hum Reprod.
115. Gemzell-Danielsson K, Svalander P, Swahn 2004;10(11):783–92.
ML, Johannisson E, Bygdeman M. Effects of a 127. Song H, Lim H, Paria BC, Matsumoto H, Swift
single post-ovulatory dose of RU486 on endome- LL, Morrow J, et al. Cytosolic phospholipase
trial maturation in the implantation phase. Hum A2alpha is crucial [correction of A2alpha defi-
Reprod. 1994;9(12):2398–404. ciency is crucial] for ‘on-time’ embryo implan-
116. Perrier d’Hauterive S, Charlet-Renard C, Berndt tation that directs subsequent development.
S, Dubois M, Munaut C, Goffin F, et al. Human Development. 2002;129(12):2879–89.
chorionic gonadotropin and growth factors at the 128. Cakmak H, Taylor HS. Molecular mechanisms
embryonic-endometrial interface control leuke- of treatment resistance in endometriosis: the role
mia inhibitory factor (LIF) and interleukin 6 (IL- of progesterone-hox gene interactions. Semin
6) secretion by human endometrial epithelium. Reprod Med. 2010;28(1):69–74.
Hum Reprod. 2004;19(11):2633–43. 129. Taylor HS, Arici A, Olive D, Igarashi P. HOXA10
117. Ledee-Bataille N, Lapree-Delage G, Tau- is expressed in response to sex steroids at the time
pin JL, Dubanchet S, Frydman R, Chaouat of implantation in the human endometrium. J
G. Concentration of leukaemia inhibitory fac- Clin Invest. 1998;101(7):1379–84.
tor (LIF) in uterine flushing fluid is highly pre- 130. Benson GV, Lim H, Paria BC, Satokata I, Dey
dictive of embryo implantation. Hum Reprod. SK, Maas RL. Mechanisms of reduced fertility in
2002;17(1):213–8. Hoxa-10 mutant mice: uterine homeosis and loss
107 4
of maternal Hoxa-10 expression. Development. ductive technology in the United States: 2001
1996;122(9):2687–96. results generated from the American Society
131. Cakmak H, Taylor HS. Implantation failure: for Reproductive Medicine/Society for Assisted
molecular mechanisms and clinical treatment. Reproductive Technology registry. Fertil Steril.
Hum Reprod Update. 2011;17(2):242–53. 2007;87(6):1253–66.
132. Cermik D, Selam B, Taylor HS. Regulation of 141. Rodriguez-Wallberg KA, Oktay K. Options on
HOXA-10 expression by testosterone in vitro fertility preservation in female cancer patients.
and in the endometrium of patients with poly- Cancer Treat Rev. 2012;38(5):354–61.
cystic ovary syndrome. J Clin Endocrinol Metab. 142. Meseguer M, Herrero J, Tejera A, Hilligsoe KM,
2003;88(1):238–43. Ramsing NB, Remohi J. The use of morphokinet-
133. Daftary GS, Kayisli U, Seli E, Bukulmez O, ics as a predictor of embryo implantation. Hum
Arici A, Taylor HS. Salpingectomy increases Reprod. 2011;26(10):2658–71.
peri-implantation endometrial HOXA10 expres- 143. Donaghay M, Lessey BA. Uterine receptiv-
sion in women with hydrosalpinx. Fertil Steril. ity: alterations associated with benign gyneco-
2007;87(2):367–72. logical disease. Semin Reprod Med. 2007;25(6):
134. Taylor HS, Bagot C, Kardana A, Olive D, Arici 461–75.
A. HOX gene expression is altered in the endo- 144. Lessey BA. Assessment of endometrial receptiv-
metrium of women with endometriosis. Hum ity. Fertil Steril. 2011;96(3):522–9.
Reprod. 1999;14(5):1328–31. 145. Potdar N, Gelbaya T, Nardo LG. Endometrial
135. King A, Allan DS, Bowen M, Powis SJ, Joseph injury to overcome recurrent embryo implanta-
S, Verma S, et al. HLA-E is expressed on tro- tion failure: a systematic review and meta-analysis.
phoblast and interacts with CD94/NKG2 recep- Reprod Biomed Online. 2012;25(6):561–71.
tors on decidual NK cells. Eur J Immunol. 146. Barad DH, Yu Y, Kushnir VA, Shohat-Tal A,
2000;30(6):1623–31. Lazzaroni E, Lee HJ, et al. A randomized clinical
136. Zhang J, Chen Z, Smith GN, Croy BA. Natu- trial of endometrial perfusion with granulocyte
ral killer cell-triggered vascular transformation: colony-stimulating factor in in vitro fertiliza-
maternal care before birth? Cell Mol Immunol. tion cycles: impact on endometrial thickness and
2011;8(1):1–11. clinical pregnancy rates. Fertil Steril. 2014;101(3):
137. Fukui A, Fujii S, Yamaguchi E, Kimura H, Sato 710–5.
S, Saito Y. Natural killer cell subpopulations 147. Santamaria X, Katzorke N, Simon C. Endome-
and cytotoxicity for infertile patients undergo- trial ‘scratching’: what the data show. Curr Opin
ing in vitro fertilization. Am J Reprod Immunol. Obstet Gynecol. 2016;28(4):242–9.
1999;41(6):413–22. 148. Garrido-Gomez T, Ruiz-Alonso M, Blesa D,
138. Fukui A, Funamizu A, Yokota M, Yamada K, Diaz-Gimeno P, Vilella F, Simon C. Profiling the
Nakamua R, Fukuhara R, et al. Uterine and gene signature of endometrial receptivity: clinical
circulating natural killer cells and their roles in results. Fertil Steril. 2013;99(4):1078–85.
women with recurrent pregnancy loss, implanta- 149. Ruiz-Alonso M, Blesa D, Diaz-Gimeno P, Gomez
tion failure and preeclampsia. J Reprod Immu- E, Fernandez-Sanchez M, Carranza F, et al. The
nol. 2011;90(1):105–10. endometrial receptivity array for diagnosis and
139. Practice Committee of American Society for personalized embryo transfer as a treatment for
Reproductive M. Definitions of infertility and patients with repeated implantation failure. Fertil
recurrent pregnancy loss: a committee opinion. Steril. 2013;100(3):818–24.
Fertil Steril. 2013;99(1):63. 150. Esfandiari N. In: Falcone T, Hurd WW, eds. Clin-
140. Society for Assisted Reproductive T, American ical reproductive medicine and surgery. St. Louis:
Society for Reproductive M. Assisted repro- Mosby/Elsevier; 2007.
109 5
Reproductive Imaging
Laura Detti
Contents

5.2 Pelvic Ultrasonography – 110
5.2.1 asic Ultrasound Concepts – 111
B
5.2.2 Scanning Techniques – 113
5.2.3 Ultrasound Evaluation of Pelvic Structures – 114
5.3 Saline Infusion Sonohysterography (SIS) – 122
5.3.1 S IS Indications and Technical Considerations – 122
5.3.2 Limitations – 123
5.3.3 SIS Evaluation of the Uterine Cavity – 123
5.4 ystero-salpingo Contrast Sonography (HyCoSy)
H
and Hystero-salpingo Foam Sonography
(HyFoSy) – 123
5.4.1 yCoSy and HyFoSy Indications and Scanning Tech-
H
niques – 123
5.4.2 HyCoSy and HyFoSy Technical Considerations – 125
5.5 Hysterosalpingogram (HSG) – 126
5.5.1 I ndications – 126
5.5.2 HSG Technical Considerations – 127
5.6 Magnetic Resonance Imaging (MRI) – 129
5.6.1 I ndications – 129
5.6.2 MRI Technical Considerations – 132
5.8 Answers – 134

References – 134

https://doi.org/10.1007/978-3-030-99596-6_5
110 L. Detti
ence of peritubal adhesions, dynamic hydro-

Key Points salpinx, or blockage. However, all of these
55 Imaging of the female reproductive tract ultrasonography techniques are made difficult
is a mainstay of fertility evaluation. by obesity.
55 With its widespread availability and low HSG provides better definition of the
cost, transvaginal ultrasound (TVUS) tubal contour, but provides only limited and
is considered the first-line imaging tool. indirect information about the presence of
55 Saline infusion sonography is the best other pelvic pathology. MRI provides the best
tool to evaluate the uterine cavity and information on pelvic anatomy and the pres-
the endometrium, as it allows imaging ence of pathology, such as uterine fibroids,
complex Mullerian anomalies, and adeno-
5 the myometrium and endometrium at
the same time. myosis, but it is not ideal for the evaluation of
55 Tubal patency evaluation can be per- tubal patency and it is expensive. Both HSG
formed by hysterosalpingo-contrast and MRI have the disadvantage of not being
sonography (HyCoSy), hysterosalpingo- performed in the office and HSG exposes the
foam sonography (HyFoSy), or hystero- patient to radiation.
salpingogram (HSG), and the choice This chapter discusses the different repro-
among the different imaging methods ductive imaging techniques and emphasizes
should be dictated by the patient’s his- the appropriate use of each for the evaluation
tory and symptoms. of the nonpregnant uterus and adnexa. The
indications and limitations for each of these
techniques will be discussed. In addition,
techniques will be reviewed for the identifica-
5.1 Introduction tion and characterization of the most com-
mon pathologies associated with infertility.
Imaging techniques are important nonsurgical
methods for assessing the uterus, the uterine
cavity and endometrium, the ovaries, and the Case Vignette
tubes, in addition to the pelvic peritoneum.
Commonly available techniques include A 31-year-old, gravida 1, para 1001, female
transvaginal ultrasonography (TVUS), saline presents with secondary infertility for 16
infusion sonography (SIS), hysterosalpingo- months. She reports a history of a term
contrast sonography using saline (HyCoSy) vaginal delivery followed by postpartum
or foam (HyFoSy) as a contrast, hysterosal- endometritis. You suspect intrauterine
pingogram (HSG), and magnetic resonance synechiae as the cause of her infertility.
imaging (MRI).
TVUS and SIS are complementary first-
line techniques for evaluating the uterus and 5.2 Pelvic Ultrasonography
ovaries. Enhancement of these techniques
using three-dimensional (3D) image render- Transabdominal (TAUS) and transvaginal
ing, and Doppler flow interrogation allows ultrasound (TVUS) are the most readily avail-
better characterization of Mullerian anoma- able and optimal imaging modalities for the
lies, such as septate and bicornuate uterus, and evaluation of the uterus and adnexa, and
adnexal masses, such as dermoids and other should be used first in the evaluation of infer-
tumors. TVUS can also be used to evaluate tility, whether or not gynecological symptoms
the tubes in the office with the addition of are present [1]. In fact, many women will not
contrast materials such as saline (HyCoSy) or pay attention to long-standing symptoms and
foam (HyFoSy). In addition to tubal patency, will realize that a symptom was present when
these techniques can determine the pathway it is treated.
and inner contour of the fallopian tubes and The choice of imaging the uterus and
can identify the fimbrial portion for the pres- adnexa by TAUS, or TVUS, is typically deter-
111 5
mined by the type of pathology being evalu- 1 second. This is an important characteristic
ated. With the exception of large uterine or of ultrasound because the depth of penetra-
adnexal masses which extend outside of the tion and image resolution depend on it: lower
pelvis, TVUS, with its higher resolution and frequencies have more depth penetration, but
closer proximity to pelvic organs, is preferred. lower resolution, while higher frequencies
Additionally, the transvaginal transducer have lower penetration, but better resolution.
allows for direct contact with pelvic organs Typical frequencies used in gynecology are
and can be used as an extension of the digital between 3 and 10 Mega Hz.
pelvic exam by eliciting discomfort, or pain, Ultrasound waves are scattered back
and thus allows correlation of the patient’s from the interfaces between tissue structures
symptoms with the sonographic findings. encountered in its pathway. The echoes that
Expansions of the TVUS approach, tran- are reflected back to the transducer are trans-
srectal (TRUS) and translabial ultrasound formed into real-time dynamic images of
(TLUS), can be employed when the transvagi- these structures. In fact, strong reflectors of
nal approach is not feasible, such as in virginal the ultrasound waves, such as bone, fat, or air,
females, or if an obstruction is present (i.e., will result in a hyperechoic image, while weak
imperforate hymen). reflectors, such as fluid or muscle, will result in
hypoechoic, or anechoic, image on the moni-
tor (. Fig. 5.1).
5.2.1 Basic Ultrasound Concepts Several different ultrasound modes have
been used. The A-mode (amplitude mode) is
Sound is a mechanical wave which travels no longer in use but was the foundation for
through tissues in a direct-line fashion, as it all the other modes. The B-mode (brightness
is transmitted from one molecule to another. mode) is a two-dimensional (2D), real-time,
The human ear can hear sounds in the range gray-scale display of an ultrasound image.
of 20 cycles/second, or 20 Hertz (abbreviated The M-mode (motion mode) is infrequently
as Hz), to 20,000 Hz. Sounds with frequen- used in current ultrasound imaging but is spe-
cies less than 20 Hz cannot be heard by the cifically used to assess the cardiac motion in
human ear and are defined as infrasound. early pregnancy.
Likewise, sounds with frequencies greater than Doppler modes can be used to identify
20,000 Hz cannot be heard by the human ear blood flow within specific organs and tissues.
and are referred to as ultrasound. The gyne- These modes are dependent on the Doppler
cological ultrasound transducer emits pulses principle that describes the variation in fre-
of high-frequency waves (typically between quency of a sound wave as the source of the
3 and 10 Mega Hz) produced by piezoelec- wave approaches or moves away from the
tric crystals located in its curvilinear, or flat, transducer. Color Doppler converts sound
margin. The frequency of sound waves repre- waves into different colors, showing the direc-
sents the number of wave cycles that occur in tion and speed of blood flow. Color Doppler
a Uterus b c
E E E
.. Fig. 5.1 Examples of different weak reflectors, such phase, b peri-ovulatory, with sonolucent endometrium, c
as the uterus and the endometrium, which result in dif- mid-luteal phase, with homogeneously hyperechoic endo-
ferent tones of gray on the monitor. The images show metrium. (Images provided by Laura Detti, MD, Baylor
the same uterus at different phases of the menstrual cycle College of Medicine, Houston, TX)
and the respective endometrial changes: a early follicular
112 L. Detti
depicts blood flow moving toward the trans- 55 Further characterization of a pelvic abnor-
ducer in a red color, and the blood flow mov- mality noted on another imaging study
ing away from the transducer in a blue color 55 Evaluation of congenital uterine anoma-
(. Fig. 5.2). Power Doppler is a type of color lies
Doppler that provides more detail about blood 55 Excessive bleeding, pain, or signs of infec-
flow but does not show direction and typically tion after pelvic surgery, delivery, or abor-
depicts blood flow in an orange color. tion
Three-dimensional (3D) ultrasound entails 55 Localization of an intrauterine contracep-
a computation of multiple 2D images to pro- tive device
duce a 3D image that displays volume on 55 Screening for malignancy in patients at
the monitor. This technique allows to rotate increased risk
5 the rendered volumes and to obtain the best 55 Urinary incontinence or pelvic organ pro-
image segment to make a diagnosis (i.e., a cor- lapse
onal view of the uterus to diagnose a septate, 55 Guidance for interventional or surgical
versus a bicornuate, uterus). procedures (such as transvaginal oocyte
aspiration, [3] and ultrasound-guided
zz Indications and limitations of ultrasound embryo transfer [4])
Indications of pelvic sonography include, but
are not limited to, the following: Limitations of using ultrasound include:
Modified with permission from the Ameri- Technique-independent limited visualiza-
can Institute of Ultrasound in Medicine [2] tion. Pelvic imaging can be difficult with
55 Pelvic pain transabdominal approach on an obese indi-
55 Dysmenorrhea (painful menses) vidual. Similarly, enhanced bowel peristalsis
55 Amenorrhea (absence of menses) and overlying can impair visualization on
55 Menorrhagia (excessive menstrual bleeding) both TAUS and TVUS. Experience of the
55 Metrorrhagia (irregular uterine bleeding) sonologist can interfere with the acquisition
55 Menometrorrhagia (excessive irregular of adequate images. It is typically easier for
uterine bleeding) the physician to detect abnormalities while
55 Follow-up of a previously detected abnor- directly performing or observing a real-time
mality dynamic scan.
55 Evaluation, monitoring, and/or treatment Limited information on tubal, peritoneal,
of infertility in patients or endometrial pathology. These structures are
55 Delayed menses, precocious puberty, or so small and isoechoic with the surrounding
vaginal bleeding in a prepubertal child tissues that cannot be typically individually
55 Postmenopausal bleeding identified. However, they are easily identified
55 Abnormal or technically limited manual when affected by a pathologic process that
pelvic examination changes the size and shape (i.e., endometrial
55 Signs or symptoms of pelvic infection polyps, or hydrosalpinges), or makes them
a b c
Endometrioma
EP CL
Sagittal Transverse
.. Fig. 5.2 a Power Doppler identifies the single ves- ing the right ovary (utero-ovarian ligament and external
sel pedicle of an endometrial polyp at the fundus of the iliac vessels) appear bright orange/red, while the ovarian
endometrial cavity. b Color Doppler highlights the vascu- cyst does not show vascularity, typical of endometrio-
lar ring around a corpus luteum. c Power Doppler aids in mas. (Images provided by Laura Detti, MD, Baylor Col-
the diagnosis of an endometrioma: the vessels surround- lege of Medicine, Houston, TX)
113 5
adhere to nearby organs (i.e., peritoneal endo- 5.2.2 Scanning Techniques
metriotic foci). Timing TVUS during the fol-
licular phase of the menstrual cycle can help The sonographic examination of the pelvic
identify endometrial abnormalities against organs can be optimally performed during
the hypoechoic background that characterize the proliferative (or follicular) phase of the
normal endometrium during this phase of the menstrual cycle, when the endometrium is
cycle. Alternatively, when endometrial pathol- thin and hypoechoic and the ovaries have
ogy is suspected, or tubal patency is required, multiple follicles. Interpretation of the
SIS should be utilized. images should be adjusted when performed
Ultrasound bioeffects. Because ultrasound during the secretory (or luteal) phase, when
is a form of mechanical energy, it can have the endometrium is hyperechoic and a cor-
bioeffects on the traversed tissues which can pus luteum can be visualized in at least one
be measured using the thermal index (TI) and ovary.
the mechanical index (MI). The TI describes A pelvic ultrasound exam starts by intro-
the maximum temperature increase under ducing the transvaginal transducer into the
clinically relevant conditions and is defined vagina maintaining the reference notch on
as the ratio of the power used over the power the transducer at the 12 o’clock position
required to produce a temperature rise of 1 ° (. Fig. 5.3). The uterus is first visualized and
C. The TI has importance mostly for grow- measured at the midsagittal, or longitudinal,
ing tissues, such as during obstetrical ultra- plane. In this view, the uterine fundus and
sound, where it is strictly regulated. The MI cervix are simultaneously visualized and the
provides an assessment of the cavitation uterine length and anteroposterior dimension,
effects of ultrasound on the traversed tissues, or height, are measured. This midsagittal view
from the interaction of the ultrasound waves of the uterus also allows for assessment and
with microscopic gas bubbles in the tissue. measurement of the endometrium, record-
These two attributes of ultrasound are used ing its thickness, focal or diffuse abnormali-
therapeutically for the treatment of uterine ties, and the presence of fluid within its two
fibroids (referred to as magnetic resonance- layers (. Fig. 5.3: The thickest portion is
guided focused ultrasound therapy) [5]. Of measured on a magnified image). Accurate
the ultrasound modes used for obstetric and evaluation and measurement of the endome-
gynecologic indications, B-mode has the low- trium is important especially in the presence
est energy, with essentially no risk of adverse of abnormal, or dysfunctional, uterine bleed-
bioeffects on the pelvic organs. ing. . Uterine length, and the largest diameters
E
Width
Sagittal Transverse
.. Fig. 5.3 Measurement of the uterine dimensions in the uterus. The yellow dotted line indicates the endome-
the sagittal and transverse frozen images of an anteverted trial echo thickness (E endometrium). (Images provided
uterus. The magenta dashed lines indicate the length, by Laura Detti, MD, Baylor College of Medicine, Hous-
anteroposterior diameter (A-P, or height), and width of ton, TX)
114 L. Detti
5
Sagittal Transverse
.. Fig. 5.4 Measurement of the ovary dimensions in the est diameter from left to right of the organ. (Images pro-
sagittal and transverse frozen images. LO Left Ovary, V vided by Laura Detti, MD, Baylor College of Medicine,
Volume, L Length, W Width, H Height. Note that the Houston, TX)
width is measured on a transverse view, tracing the larg-
of the uterus at the fundus are reported in the metrium, irregular contour (wide
ultrasound report (. Fig. 5.4). junctional zone [6], or a hyperecho-
The same midsagittal orientation is uti- genic morphology, during the fol-
lized to take the ovarian measurements, length licular phase could be indicative of
and height. In order to measure the transverse endometrial pathology, such as pol-
diameters, the transducer is rotated 90 degrees yps, hyperplasia, endometritis, adeno-
counterclockwise (this maintains the correct myosis, or submucosal fibroids, which
left/right orientation on the monitor). The should be flagged and further charac-
largest diameters of the ovaries are reported terized using power, or color Doppler,
in the ultrasound report (. Fig. 5.4). The and 3D rendering (. Fig. 5.5a–d).
number of antral follicles and/or a corpus These techniques allow exact localiza-
luteum should be noted. tion and diagnosis of the endometrial
Finally, the posterior cul-de-sac behind abnormalities and foreign bodies, or
the cervix should be examined. The presence intrauterine device . Fig. 5.5d).
of any masses, adhesions with the bowel, and (b) The myometrium should be carefully
any free fluid should be noted. During the fol- studied for the presence of fibroids
licular phase of the menstrual cycle, minimal/ and adenomyosis. Fibroids may cause
no fluid should be seen in the cul-de-sac. A infertility (i.e., fibroids causing tubal
larger amount of free fluid during the luteal occlusion or impinging the endome-
phase is physiologic and is characteristic of an trial cavity; . Fig. 5.6a, b), or preg-
occurred ovulation. nancy loss. In fact, intramural fibroids
decrease implantation and clinical and
ongoing pregnancy in ART. Intramu-
5.2.3 Ultrasound Evaluation ral fibroids greater than 3 cm nega-
of Pelvic Structures tively affect assisted reproduction
outcomes (i.e., submucosal fibroids
1. Uterus: Any uterine abnormalities can impinging the endometrial cavity;
decrease fertility and increase the risk for . Fig. 5.6b) [7]. Submucosal fibroids
miscarriages. cause infertility and decrease implan-
(a) The presence of endometrial abnor- tation. Live birth rates are reduced
malities, such as a thicker endo- by up to 70% [8]. On TVUS, fibroids
115 5
a TVUS 3D US Hysteroscopy
b 3D US Hysteroscopy
TVUS
c 3D US Hysteroscopy
TVUS
d 3D US 3D US
TVUS
.. Fig. 5.5 TVUS of endometrial pathology: a Endome- lateral wall in the far-right picture. (Images provided by
trial polyp; b Endometrial hyperplasia; c Endometritis; Laura Detti, MD, Baylor College of Medicine, Houston,
d Intrauterine device; note the arm embedded in the left TX)
appear as rounded, hyperechoic ine walls can be asymmetrically thick-

masses within the myometrium with ened. On a 3D coronal view of the
prominent scattered vasculature and uterus, the junctional zone between
with the characteristic posterior shad- endometrium and myometrium
owing resembling “Venetian blinds”. appears enlarged, ill-defined, and het-
Adenomyosis can also cause erogenous, caused by dilated endome-
infertility, pregnancy loss, and other trial glands within the myometrium
adverse perinatal outcomes includ- [6]. . Figure 5.7 shows a graphical
ing preterm delivery, increased representation (. Fig. 5.7a), and
cesarean section rates, post-partum ultrasound appearance of adenomyo-
hemorrhage, and low birth weight [9]. sis (. Fig. 5.7b, c).
Adenomyosis is diagnosed when the (c) Mullerian anomalies such as septate,
uterus is enlarged in dimensions, it bicornuate, and unicornuate uterus
portrays the characteristic “Venetian are more frequent in women with
blinds” posterior shadowing, but no infertility [10]. While bicornuate, and
discrete fibroid is seen, and the uter- unicornuate uteri are associated with
116 L. Detti
a Hysteroscopy
3D US 3D Render
b 3D US 3D Render Hysteroscopy
5
c
TVUS SIS
EC
Transverse Sagittal Sagittal
.. Fig. 5.6 TVUS diagnosis of uterine fibroids: a Sub- the fibroid with the endometrial cavity (EC). (Images
mucosal type 1; b Submucosal type 2; c Intramural type provided by Laura Detti, MD, Baylor College of Medi-
3: SIS is determinant to understand the relationship of cine, Houston, TX)
a b c
.. Fig. 5.7 Adenomyosis. a Graphical representation myometrial adenomyotic cysts are noted in the posterior
with widening of the junctional zone on a coronal view uterine wall. (Images provided by Laura Detti, MD, Bay-
of the uterus; b Diffuse adenomyosis with typical myo- lor College of Medicine, Houston, TX)
metrial “Venetian blinds” shadowing; c Multiple, large,
increased rates of preterm delivery, [11, 12]. Indeed, the length of the uter-
malpresentation, and cesarean section ine septation is commensurate to the
rates, and do not need surgical correc- uterine cavity width and its area, and
tion [11], septate uteri are associated septate uteri regain normal uterine
with early pregnancy loss in which risk dimensions, after surgical correction
is decreased after surgical correction [13]. Uterine septa are measured on
117 5
a B-mode coronal view of the uterus, studies have found 3D ultrasound to
as depicted in . Fig. 5.8. It should be superior to HSG, as well as MRI
not be measured on the 3D rendering [15–17]. 3D ultrasound allows to
coronal view because it includes the rotate the coronal view of the uterus
endometrium and does not allow for and to visualize the internal and exter-
accurate septum measurement. Sev- nal contours of the uterine fundus at
eral classifications are available for the the same time, while MRI is not as
ultrasound diagnosis of uterine sub- ductile [18, 19]. A comparative study
septations, but they are not consistent found a higher concordance rate for
in indicating a cutoff length for surgi- 3D ultrasound (Kappa index = 0.896)
cal correction [14]. than MRI (Kappa index = 0.592) for
3D mode allows for precise charac- pre-operative diagnosis of uterine
terization of the endometrial cavity’s anomalies [20].
shape and contour and is determinant In contrast to 3d ultrasound, HSG
in diagnosing Mullerian anomalies is unable to evaluate soft tissues and
such as a septate, bicornuate, and uni- is thus limited in its ability to charac-
cornuate uterus (. Fig. 5.9). Several terize evaluate uterine anomalies. In
C
A
B
.. Fig. 5.8 Graphical representation of a partial uterine from the base to the tip of the septum; c uterine fundus
septum and measurement technique on a coronal view of thickness, measured from the base of the septum to the
the uterus, obtained with 3D ultrasound. a Line connect- outer contour of the uterus. (Images provided by Laura
ing the uppermost points of the uterine cavity, demarcat- Detti, MD, Baylor College of Medicine, Houston, TX)
ing the base of the septum; b septum length, measured
EC EC
EC EC
EC EC
X: 11.0mm
Normal Septate Bicornuate Unicornuate
.. Fig. 5.9 Mullerian abnormalities diagnosed on a trial Cavity. (Images provided by Laura Detti, MD, Bay-
coronal view of the uterus obtained with 3D ultrasound: lor College of Medicine, Houston, TX)
Normal; Septate; Bicornuate; Unicornuate. EC Endome-
118 L. Detti
a prospective blinded study with 101 echogenicity of the endometrium dur-

females who underwent HSG and 3D ing the luteal phase, uterine anomalies
ultrasound and compared to surgical are better studied during this time of
findings, Bocca et al. found that of the the cycle [22].
30 congenital anomalies diagnosed at 3D ultrasound is an inexpensive,
surgery (arcuate, unicornuate, bicor- accurate, and noninvasive imaging
nuate, septate uteri as well as uterus modality to diagnose congenital, or
didelphys), all were correctly identified acquired, uterine anomalies, and it
with 3D ultrasound, while HSG had should be the first-line test. In fact,
identified only 10 [16]. . Figure 5.10 when compared to other imaging and
shows an HSG image of a septate surgical modalities utilized with the
5 versus a bicornuate uterus. In another same purpose, it carries lower morbid-
study, 3D ultrasound diagnosis was ity, shorter examination time, and the
found to have a positive predictive advantage of being performed in the
value of 96.3% and a negative predic- office setting.
tive value of 100% of uterine anoma- (d) Infertility Treatments: TVUS is piv-
lies [21]. Because of the increased otal in monitoring of follicle devel-
3D US HSG
Partial septum
3D US MRI
septum
ovary
EC
EC
cervix
Complete septum Complete septum
.. Fig. 5.10 Partial and complete uterine septa visual- cannot be obtained. EC Endometrial Cavity. (Images pro-
ized with 3D US, HSG and MRI. Despite obtaining MRI vided by Laura Detti, MD, Baylor College of Medicine,
pelvic view, the cervix cannot be visualized as a contin- Houston, TX)
uum with the uterus, and the exact length of the septum
119 5
a b
Follicles
c d
Bladder
Speculum
Needle
Catheter
.. Fig. 5.11 Ultrasound imaging during in vitro fertiliza- aspiration; d Ultrasound-guided embryo transfer on
tion cycles: a Follicle development monitoring; b Assess- transabdominal ultrasound). (Images provided by Laura
ment of endometrial thickness; c Transvaginal oocyte Detti, MD, Baylor College of Medicine, Houston, TX)
opment, assessment of endometrial

.. Table 5.1 Most common benign ovarian and
thickness, transvaginal oocyte aspira-
adnexal masses
tion, and ultrasound-guided embryo
transfer [4], shown in . Fig. 5.11a–d. Ovarian masses Adnexal masses
2. Ovaries: In addition to measuring the
three orthogonal diameters and counting Simple cyst (follicular) Hydrosalpinx and
the number of antral follicles, the ovaries hematosalpinx
should be characterized for the presence Hemorrhagic cyst Peritoneal inclusion
of any ovarian cysts, or masses. Doppler (=corpus luteum) cyst
and 3D modes aid in better defining any Endometrioma Tubo-ovarian abscess
ovarian abnormalities and help in formu-
Dermoid cyst Pedunculated fibroid
lating a correct diagnosis. . Table 5.1 lists
the most common benign ovarian and Adenomas (serous,
adnexal masses encountered in reproduc- mucinous)
tive-age women.
A simple, or follicular, cyst is a func-
tional cyst described as a thin-walled, well- nant follicle is often incorrectly described
rounded cyst without internal echoes (the as a simple cyst and unnecessary follow-up
fluid appears black), avascular, and with ultrasounds are needed (. Fig. 5.12a).
dimensions greater than 30 mm. A domi- Correlation with the phase of the men-
strual cycle, and its dimensions less than
120 L. Detti
1 D 11.0 mm
2 D 19.6 mm
a d
b e
c f 43 x 27 x 35 mm 3D US
.. Fig. 5.12 Ovarian cyst identified with transvaginal trioma; e Mature teratoma, or dermoid; f Serous cystad-
ultrasound: a Dominant follicle, sonolucent; b Early enoma. (Images provided by Laura Detti, MD, Baylor
corpus luteum; c Organizing corpus luteum; d Endome- College of Medicine, Houston, TX)
30 mm, helps in allotting the correct diag- Doppler interrogation, suggesting exhaus-
nosis. Follicular cysts spontaneously tion of hormonal function.
resolve within two menstrual cycles. Endometriomas appear as avascular,
A corpus luteum is identified during thick-walled, well-rounded cysts with
the luteal phase of the menstrual cycle and ground- glass appearance of the fluid
it can be solid, but more frequently, it (. Fig. 5.12d). Sometimes avascular sep-
appears on ultrasound as a hemorrhagic tations and small hyperechoic structures
cyst with a highly vascular thick wall, can be seen within an endometrioma and
irregular contour, with internal echoes that typically represent fibrin deposition.
represent fibrin deposition (. Fig. 5.12b, Applying pressure with the transvaginal
c). Depending on the “age” of the corpus transducer can help in diagnosing endo-
luteum, the internal echoes can be fine metriomas, as they are typically painful.
(when ovulation just occurred), coarse, At times it becomes difficult to differenti-
weblike, or with a visible solid-fluid gradi- ate an endometrioma from an avascular,
ent (when a clot is organizing). When large, hemorrhagic corpus luteum persisting
a hemorrhagic corpus luteum can become over a few menstrual cycles. In these
painful to probe pressure. A collapsing instances, it is appropriate to follow-up
corpus luteum can be identified also at the this finding with serial ultrasounds, to
beginning of the follicular phase, but in avoid unnecessary surgery.
this instance the “cyst” is avascular at Mature teratomas, or dermoid cysts,
can have different ultrasound appearance
121 5
depending on the type, quantity, and dis- “complex, unilocular, or multilocular,
tribution of the primordial structures that mass with solid components, acoustic
they contain. Hair and unorganized fat are shadows, and avascular on Doppler inter-
the most common findings, and they rogation” by IOTA and as a “complex,
appear as hyperechoic striae and mounds unilocular, or multilocular, mass with
in the midst of coarsely corpuscular fluid hyperechoic component with shadowing,
(. Fig. 5.12e). hyperechoic lines and dots, and avascular
Benign serous adenomas share the on Doppler interrogation” by O-RADS.
same characteristics of follicular cysts, Both systems entail serial evaluation over
typically being thin-walled, well-rounded several months, when indicated.
cysts without internal echoes (the fluid 3. Fallopian tubes: Normal fallopian tubes
appears black), avascular, and with dimen- are typically not visible ultrasonographi-
sions greater than 30 mm. However, they cally. However, when a fallopian tube is
have a peculiar appearance of the inner blocked at the ampullary segment, it will
contour of the wall, with small, avascular accumulate as fluid and be visible as a
projections that are sometimes difficult to hydrosalpinx. Typical sonographic charac-
visualize. Benign serous adenomas persist teristics of a hydrosalpinx are incomplete
through more than two menstrual cycles septations (caused by the inner folds,
as they do not spontaneously resolve which give the “cogwheel” sign on a cross
(. Fig. 5.12f). section of the tube) in an avascular,
Two ultrasonography scoring systems tapered, hypoechoic, tubular structure,
have been used to aid in the ultrasound often very convoluted (. Fig. 5.13). The
diagnosis of adnexal masses and can be sensitivity of TVUS in diagnosing hydro-
utilized in the daily practice: the salpinx is 86% [25] and specificity 99.6%
International Ovarian Tumor Analysis [26]. Doppler and 3D modes help in char-
(IOTA) [23] and the Ovarian- Adnexal acterizing a hydrosalpinx from other
Reporting and Data System (O-RADS) adnexal masses, because the tube is typi-
[24]. Both scoring systems assign grades of cally avascular and its often tortuous path-
complexity and color Doppler of the way can be spatially visualized.
adnexal cyst/mass, which provide risk- 4. Posterior cul-de-sac: The presence of any
prediction models in the pre-operative adhesions in the posterior cul-de-sac is
identification of malignancy. For example, suggestive of endometriosis, or past pelvic
a mature teratoma will be identified as a inflammatory disease (. Fig. 5.14).
3D US
Sagittal Transverse
.. Fig. 5.13 Hydrosalpinx visualized on 2D and 3D ultrasound. (Images provided by Laura Detti, MD, Baylor Col-
lege of Medicine, Houston, TX)
122 L. Detti
the contrast fluid. SIS should be typically per-

formed during the proliferative, or follicular,
phase of the menstrual cycle, when the endo-
metrium is expected to be thin and hypoechoic,
and any deviation from this can be easily iden-
tified. Typically, it is performed between cycle
days 6–7, soon after cessation of menses and
before ovulation, to avoid artifacts from the
presence of menstrual blood and to avoid the
possibility of an early pregnancy. Most care-
givers perform a urine pregnancy test prior
5 .. Fig. 5.14 Adhesions identified in the adnexal space. to SIS, to further decrease the risk of a con-
(Images provided by Laura Detti, MD, Baylor College of
current pregnancy. If a patient is taking oral
Medicine, Houston, TX)
contraceptive pills, an SIS can be performed at
any time after cessation of menses.
5.3 Saline Infusion The uterus is scanned in the midsagittal
and transverse plane and 3D mode can also
Sonohysterography (SIS) be used. In order to study the whole uterine
cavity, multiple video clips of the midsagit-
5.3.1 IS Indications and Technical
S tal and transverse plane sweeps should be
Considerations obtained and saved for future reference. Any
abnormality should be measured in the three
SIS was first introduced by Nannini in 1981 orthogonal planes and its location accurately
to evaluate the endometrial cavity [27]. It is described. This will guide the provider dur-
performed by inserting a size 5- or 7-Fr, ster- ing hysteroscopy, if applicable. Even though
ile, plastic catheter (insemination catheter or in the two endometrial layers thickness can
a small feeding tube), connected to a plastic be obtained after instillation of fluid, it is not
syringe containing sterile saline, into the uter- necessary, as the presence of fluid pressure
ine cavity through the cervical canal. To mini- within the two layers can cause underestima-
mize the risk of infection, it is recommended tion of the total thickness (. Fig. 5.15).
using an aseptic solution to clean the external SIS portrays a high sensitivity and specific-
cervical os before inserting the catheter. If ity for detecting intracavitary abnormalities
catheter insertion is difficult, a tenaculum and compared to TVUS [29], and it is equivalent to
a cervical dilator can be utilized. hysteroscopy, even though it is not invasive [30,
Antibiotics are rarely indicated at time 31]. It should be the first choice to evaluate the
of SIS, but they should be administered in endometrial cavity. It is far superior to HSG
the presence of hydrosalpinx or other known and hysteroscopy, as it can detect subtle intra-
vaginal/cervical infections, similar to the rec- endometrial abnormalities and it can evaluate
ommendations of the American College of extra-endometrial structures, respectively.
Obstetricians and Gynecologists (ACOG) 3D imaging added to SIS has further
for HSG: doxycycline 100 mg orally BID × improved detection of intracavitary lesions
5 days [ACOG bulletin 2009]. Performing [32]. A Cochrane meta-analysis has shown
SIS has rare side effects, which include a 1% 3D-SIS to have a sensitivity of 94.5% (95%
risk for endometritis and a 1–5% risk for sig- confidence interval 90.6% to 96.9%) and spec-
nificant cramping or pain [28], which should ificity 99.4% (95% confidence interval 96.2%
be discussed prior to obtaining an informed to 99.9%). The metanalysis revealed no statis-
consent. Oral ibuprofen administered 1 hour tically significant differences between 2D-SIS
before the procedure typically helps minimiz- and 3D-SIS. Summary sensitivity and sum-
ing uterine cramping during the procedure. mary specificity were higher for 3D-SIS, but
Saline is slowly instilled into the cavity and margins of improvement are limited because
any filling defects can be visualized against 2D-SIS is already very accurate.
123 5
a b
+
+
+
*
+ *
+ 2.7 mm
+ 7.6 mm * 2.5 mm
.. Fig. 5.15 Endometrial echo thickness measured before a, and after instillation of fluid b. (Images provided by
Laura Detti, MD, Baylor College of Medicine, Houston, TX)
5.3.2 Limitations ship with the uterine cavity, according to the

Classification of Submucosal Fibroids by the
The limitations of SIS are the same as for International Federation of Gynecology and
TVUS, with the added caution of perform- Obstetrics (FIGO) [37]:
ing it during the follicular phase, as the con- 55 Type 0: Complete submucosal involve-
sequences of inadvertently performing SIS ment with no myometrial involvement
after conception could be devastating [33]. In (intracavitary).
addition, it should not be performed if pelvic 55 Type I: Submucosal component is greater
infection is suspected, or in a woman with than 50% of the fibroid.
unexplained pelvic tenderness [33]. If hydro- 55 Type II: Submucosal component is less
salpinx is noted while performing an SIS, anti- than 50% of the fibroid.
biotic prophylaxis should be considered, per 55 Type III: The fibroid is 100% within the
guidelines [34]. myometrium, but it is positioned adjacent
to the endometrium.
5.3.3 IS Evaluation of the Uterine

S 5.4 Hystero-salpingo Contrast
Cavity Sonography (HyCoSy)
and Hystero-salpingo Foam
SIS can detect focal or diffuse intrauterine
Sonography (HyFoSy)
lesions, such as polyps (. Fig. 5.16a), submu-
cosal uterine fibroids (. Fig. 5.16b), or endo-
metrial hyperplasia (. Fig. 5.16c) [35]. The
5.4.1 HyCoSy and HyFoSy
incidence of polyps and submucosal leiomyo- Indications and Scanning
mas in symptomatic premenopausal women is Techniques
33% and 21%, respectively [35]. Please, remove
. Fig. 5.16d SIS showed a higher sensitivity Methods for investigating tubal patency
(89.3%) and positive (65.8%) and negative include laparoscopy with dye chromopertu-
(91.4%) predictive values, but a lower speci- bation, X-ray hysterosalpingography (HSG),
ficity (71.1%), than TVUS in the identifica- and hystero-salpingo contrast sonogra-
tion of endometrial polyps (sensitivity 48.7%, phy using either saline (HyCoSy) or foam
specificity 81.8%, positive predictive value %, (HyFoSy) for contrast. The sonographic tech-
and negative predictive value %) [36]. niques are non-invasive procedures that assess
Submucosal uterine leiomyomas are tubal patency as well as evaluate the endome-
classified based on their location in relation- trium and uterus.
124 L. Detti
a Endometrial Polyps b Endometrial Polyp and Fibroid
Polyp
Fibroid
5
Polyp
Fibroid
c Endometrial Hyperplasia d Redundant Endometrium
Hysteroscopy Hysteroscopy
.. Fig. 5.16 Endometrial ad sub-endometrial pathol- lower cavity and fundal polyp; c. Localized endometrial
ogy identified with SIS and confirmed with hysteroscopy: hyperplasia; d. Redundant, uneven endometrium which
a. Endometrial polyps; b. Submucosal fibroid type 0 in harbored endometrial hyperplasia
125 5
It is well appreciated that all available sound visualization. The first contrast to be
methods for evaluation of tubal factors have utilized, and currently most often used, was
technical limitations that must be consid- normal saline mixed with air bubbles in the
ered, particularly in the presence of abnormal same syringe that would be vigorously shaken
results. Even laparoscopic chromopertuba- immediately prior to infusion [42], or can be
tion, considered the gold standard for evalu- intermittently angled to infuse increments of
ation of tubal patency, was found to have a saline to expand the cavity, followed by air that
3% false-positive rate, where patients with would escape the cavity through the tubal ostia
bilateral tubal occlusion spontaneously con- [43]. Different contrasts have been used; how-
ceive [38]. When compared to HSG for evalu- ever, only two are FDA-approved and are com-
ation of tubal patency, with HyCoSy there is mercially available in the United States. One
no exposure to radiation, and the procedure consists of evenly mixed normal saline and air,
can be performed in the office rather than in with air bubbles regularly spaced within the
the radiology suite. However, this technique instilling tube (FemVue,), and the other is an
is less accurate than HSG in identifying sal- air polymer-type A foam which is claimed to
pingitis isthmica nodosa (SIN), which is a allow a more accurate definition of the tubal
known complication of severe inflammatory pathway and inner profile, and is concordant
processes of the proximal portion of the tube, with HSG in 93.2% of the times [44, 45].
such as in chlamydia infections. Multiple
studies have compared the sensitivity of the
two techniques in regard to tubal patency with 5.4.2 HyCoSy and HyFoSy Technical
the HSG procedure and laparoscopy with Considerations
chromopertubation. HyCoSy’s sensitivity for
determination of tubal patency was estimated The HyCoSy and HyFoSy procedures are
between 76% and 96%, and specificity ranged normally conducted after performing a stan-
from 67% to 100% [39, 40]. dard SIS procedure. The air bubbles dispersed
HyCoSy allows evaluation of the fallopian within the saline can be followed exiting the
tubes’ patency, which is otherwise difficult to tubal ostia on a transverse view at the level of
visualize on regular ultrasound if they are ana- the fundus and can be identified throughout
tomically normal [41]. HyCoSy is performed the extension of the tubes. “Scintillations” of
at the time of SIS with instillation of con- the air bubbles around the ovary will diagnose
trast media through the same 5-, or 7-French, ipsilateral tubal patency [46] (. Fig. 5.17). If
SIS catheter, under direct transvaginal ultra- a blockage is present in any portions of the
a b
.. Fig. 5.17 HyCoSy for the diagnosis of tubal patency: ovary, denoting tubal patency. (Images provided by Laura
a Scintillation identified in the proximal and distal por- Detti, MD, Baylor College of Medicine, Houston, TX)
tion of the left fallopian tube; b Scintillation around the
126 L. Detti
tubes, it can typically be traced and identified. 5.4.3 Limitations

If the tubes appear to be blocked at the cornual
region, especially when bilateral, the assess- In addition to the limitations noted for TVUS
ment should be repeated after 1–2 minutes to and SIS, HyCoSy and HyFoSy present addi-
exclude a reactive cornual spasm. Using con- tional difficulties. Visualization of scintil-
trast media at body temperature can help in lation in the fallopian tubes may be more
preventing myometrial spasms and decreasing difficult in obese patients, as well as in case
discomfort [47]. When tubal patency is con- of retroverted uterus, or distorted pelvic anat-
firmed with HyCoSy, the patient should be omy. Pitfalls also include false interpretation
alerted of the possibility of transitory shoul- of tubal patency if scintillation is seen in the
der pain after the procedure, secondary to
5 peritoneal irritation by intra-abdominal air.
tube, but not in the adnexa (false positive), or
if no passage of fluid at the cornual region is
Concordance between HyCoSy and HSG due to spasm. In this instance, HyFoSy is con-
was found to be 89.6% [48]. When the 3D sidered superior to HyCoSy with any of the
mode is added to the HyCoSy procedure, fluids utilized, as passage of foam through the
accuracy and specificity are enhanced [49]. tubal ostia appears not to cause myometrial
Using the commercially available device spasm [53]. A therapeutic effect of HyCoSy
FemVue® (Femasys, Suwanee, GA, USA), has never been proven, as there is no differ-
tubal patency was confirmed in 32/39 (82%) ence in pregnancy rates after laparoscopic
fallopian tubes via HyCoSy and in 34/39 chromopertubation, HSG and HyCoSy [54].
(87%) fallopian tubes via HSG, with a 77%
concordance rate between the two techniques
[50] and concordance was higher in the pres- 5.5 Hysterosalpingogram (HSG)
ence of patent tubes [51].
HyFoSy was introduced in 2007 and 5.5.1 Indications
is performed with a non-embryotoxic gel
known as ExEm® Foam (GynaecologIQ, The HSG is the oldest noninvasive tool utilized
Netherlands, distributed by Cardinal Health, to evaluate tubal patency. . In the setting of
USA), containing hydroxyethylcellulose and infertility, women with a history of pelvic
glycerol. The gel is diluted in water just prior infection, pelvic surgery, or endometriosis are
to the procedure, and foam is mechanically at risk for tubal factor infertility.
created in the form of echogenic micro-air HSG is also used to examine uterine cavity
bubbles which maintains its echogenicity contour and defects, and the communication
for about 7 minutes, allowing for prolonged between uterine cavities in the presence of a
visualization and assessment [52]. In a study complete uterine septum. The utility of HSG
analyzing 132 women, HyFoSy was found to for any other tubal, endometrial, or uterine
be more accurate than HyCoSy, and it was abnormalities has progressively decreased
indicated as the best noninvasive option to over time, with other noninvasive diagnostic
confirm tubal patency when HyCoSy had not techniques having outperformed it, including
previously shown patency [53]. Other contrast ultrasound and magnetic resonance.
media have been used and evaluated, but are The HSG procedure images the uterine
either no longer available, or not currently cavity and fallopian tubes by injecting radio-
licensed for intrafallopian use in the United graphic contrast media through the cervix
States. These include Hyskon (Pharmacia and taking radiographs of the pelvis under
Laboratories, Piscataway, NJ, USA); Infoson® fluoroscopy (. Fig. 5.18). Previous studies
(MBI, San Diego, CA, USA), Echovist-200 showed that when tubal patency is identified
(Schering AG, Berlin, Germany), a galactose with HSG, tubal blockage is unlikely [55].
microparticle/air microbubble suspension; However, in 60% of patients in whom HSG
and SonoVue® (Bracco, Milan, Italy). showed proximal tubal blockage, repeat HSG
127 5
a b
.. Fig. 5.18 Features of technically adequate HSG spill is seen outlining loops of bowel. a Normal uterus
imaging of a normal uterus with patent tubes, bilaterally. without filling defects. b Normal uterus with small fill-
The speculum is not obscuring view of the uterus. The ing defect that could represent air bubbles, or endometrial
tenaculum on the cervix has straightened the uterus such polyps. (Images provided by Laura Detti, MD, Baylor
that it is perpendicular to the X-ray beam. The balloon College of Medicine, Houston, TX)
catheter in the cervical canal, below the internal os. Free
TVUS Laparoscopy Laparoscopy HSG
.. Fig. 5.19 Bilateral hydrosalpinges shown at TVUS, laparoscopy, and HSG. (Images provided by Laura Detti, MD,
Baylor College of Medicine, Houston, TX)
and/or subsequent laparoscopy showed tubal a nurse for field preparation, a physician to
patency [55, 56]. This was explained with insert the catheter inside the uterine cavity,
the frequent occurrence of cornual myome- a radiology technician performing fluoros-
trial spasm, but also to supposed therapeutic copy while the contrast medium is instilled,
effects of HSG when an oil-based contrast and, in some instances, a radiology physi-
was used [57]. In the presence of unilateral cian to interpret the images. The physician
tubal occlusion, asking the patient to roll so interpreting the images should be familiar
that the side of cornual occlusion is down will with normal female pelvic anatomy and
result in its resolution in greater than 50% of uterine anomalies. Similarly to HyCoSy and
the times [58]. . Figure 5.19 shows bilateral HyFoSy, the exam should be scheduled dur-
hydrosalpinges shown at TVUS, HSG, and ing the follicular phase (cycle days 6–11) to
laparoscopy. minimize the risk of an occult early preg-
nancy. A urine pregnancy test should also be
performed prior to the procedure, to mini-
5.5.2 HSG Technical Considerations mize patient’s misinterpretation of menstru-
ation with implantation bleeding.
HSG must be performed in a radiology Two different media can be utilized to
suite, as it requires taking radiograph pic- perform an HSG procedure. Water-based
tures under fluoroscopy. It requires having contrasts such as iothalamate meglumine
128 L. Detti
30% or 60% usually result in better imaging gography, MR-VHSG) to provide more com-
quality, as can highlight fine details, and they prehensive assessment of the pelvic organs,
dissipate quickly. Oil-soluble media, of which in addition to tubal patency [61]. These two
Ethiodol is an example, were associated with imaging modalities are available in select
an increased risk of intravasation of contrast radiology centers and both entail infusion
medium, embolism, and granuloma forma- of a dilute contrast solution into the uterus
tion, which greatly downplay the minor benefit at 0.3 ml per second over a 30 to 60-second
of increased post-procedure pregnancy rates intervals, using a power injector. For both
[55]. A recent study from the Netherlands, imaging modalities, the quantity of contrast
where 3289 HSGs performed with oil-based solution is approximately 10–20 mL. For
and 1876 with water-based contrast were CT- VHSG,1–5 mL of iodine contrast and
5 evaluated for complications, found an overall 9–15 mL of saline is used, while for MR-
complication rate of 5.1% in oil-based versus VHSG, a 100-mL mixture of 1 mL gadolin-
1.8% in water-based HSGs (relative risk 2.8, ium, 29 mL iodinated contrast, and 70 mL
95% confidence interval 1.9–4.0; p < 0.0001) saline solution is used. CT-VHSG provides
[59]. In addition, the study found a higher 2-D and 3D images of the contrast media
incidence of intravasation, but no embolic volume and volume filling defects, but does
episodes, in the with oil-based group (4.8% not provide information on the actual pelvic
versus 1.3% in water-soluble contrast group, organs. MR-VHSG provides 2-D images of
relative risk 3.6, 95% confidence interval 2.4– the contrast media volume and volume filling
5.4; p < 0.0001). Caution should be used in defects, in addition to 3D virtual rendering of
interpreting these results, as data was based the organ within which the contrast medium
on clinician recall in 50% of the clinics where is contained. For the CT-VHSG, a multide-
no formal event reporting was in place. tector computerized tomography machine is
A standard disposable 5-, or 7-Fr, double- required along with at least a 64-detector-row
lumen intrauterine HSG balloon catheter is CT scanner, to shorten the study time. This
inserted through the cervix and the balloon is helpful specifically for imaging of the fal-
inflated in the cervix (feasible in nulliparous lopian tubes since infused contrast is quickly
women, or parous women who delivered by dispersed from the tubes. For the MR-VHSG,
cesarean section), or the lower uterine cavity a high-field 3-T MR imaging scanner with
(preferable in parous women, in whom cervi- three-dimensional volumetric time-resolved
cal retention of the balloon is not feasible). MR sequences is required. Usually T1- and
Antibiotics are rarely indicated at time of T2-weighted images are combined with 3D
HSG, but they should be administered in the volume scan to obtain the best image qual-
presence of hydrosalpinx or other known vag- ity. Results are available shortly after comple-
inal/cervical infections: doxycycline 100 mg tion of the exam, and the pelvic structures
orally BID × 5 days [34]. Concerning the out- can be visualized from different angles after
come of cramping and pain at time of HSG reconstruction of the images. The total exam
and HyCoSy, no significant difference was time for CT-VHSG is approximately 20 min,
found between the two imaging modalities while an MR-VHSG is approximately 40 min
at different times, up to 28 days post proce- [61]. High-quality images of cervical stenosis,
dure [60]. Special precautions should be taken intracavitary synechiae, endometrial polyps,
in the presence of cervical stenosis, or other submucosal fibroids and the presence of com-
vaginal/cervical abnormalities. The catheter municating hydrosalpinges are obtained with
should be flushed prior to placement in the both imaging modalities, which can be useful
uterus, to avoid introducing air bubbles that to define communicating, complex Mullerian
could create artifacts. anomalies and communicating hydrosalpin-
HSG has recently been paired with either ges [61, 62]. However, the image obtained
CT (computerized tomographic virtual hys- is the contrast filling, as both imaging tech-
terosalpingography, CT-VHSG) or MRI niques have the limitation of not providing
(magnetic-resonance virtual hysterosalpin- a clear image of the surrounding soft tissue,
129 5
which limits their applicability in everyday uterine malformations [68]. When oil-soluble
practice. In addition, both require specific contrast is used and it intravasates into myo-
equipment, are costly, and can be performed metrial veins, there is a high risk for it to be
only in a radiology center. Complications transported to the lungs via the uterine and
are less than for traditional HSG, probably ovarian veins and cause pulmonary embo-
due to the automated dispensing of the con- lism [70], Granulomas also occurs more fre-
trast medium. The most frequent complica- quently with oil-soluble contrast. They occur
tion is the intravasation of contrast, which is as a foreign-body reaction and can affect the
observed in 3% of patients [61]. uterus or tubes, but rarely form in the normal
HSG has several contraindications. Some tube [68]. Because of these three major risks
are in common with SIS, such as active pel- related to using oil-based contrast, there has
vic infections, active uterine bleeding, or been a progressive undertaking to perform-
pregnancy. Other contraindications specifi- ing HSG with water-soluble media, which is
cally pertain to HSG, such as alleged iodine the predominant contrast media used in the
allergy. Other low osmolarity, nonionic, United States.
water-soluble, iodine-based contrast media
such as Isovue 370 (iopamidol) or Omnipaque
(iohexol) can be used instead of high osmolar- 5.5.3 Limitations
ity iodine media. The decreased incidence of
intravasation, and allergy, of the three non- False interpretation of tubal blockage at the
ionic media is probably related to the lower cornual region can be due to due to spasm
viscosity [63].Gadolinium-based contrast and it can happen in up to 60% of the cases
media (Magnevist) has also been successfully [55, 56]. HSG has a low sensitivity and speci-
used for HSG [64]. ficity for the diagnosis of uterine cavity filling
Patients with a history of allergy to con- defects, especially when small, and it should
trast media can be effectively premedicated not be utilized to evaluate the uterine cavity.
with prednisone, 50 mg orally 13 hours, HSG inability to visualize the soft tissue limits
7 hours, and 1 hour before the procedure and its ability to diagnose Mullerian duct anoma-
diphenhydramine, 50 mg orally 1 hour before, lies (. Fig. 5.10) [16]. Another possible limi-
which may be considered, as outlined in the tation of HSG is the effect of iodine-based
American College of Radiology (ACR) 2011 contrast on the thyroid function of patients
HSG practice guideline [65]. and their newborns, when conception occurs
In addition to the risks shared with SIS, close to HSG performance. A single-cen-
such as vasovagal reaction (less than 5% of ter, randomized, controlled, parallel-group,
patients) [66] and pelvic infection (1.4% of superiority trial on this outcome is currently
patients) [67], HSG carries the risks of radia- underway in China [59].
tion exposure, intravasation, contrast media
embolism, and granuloma formation.
Modern digitally enhanced fluoroscopy 5.6 agnetic Resonance Imaging
M
results in a much lower dose of radiation than (MRI)
old fashioned fluoroscopy, and it depends on
several factors, including the patient’s BMI, 5.6.1 Indications
the distance between the tubes and the fluo-
roscopy unit, the duration of fluoroscopy, and The MRI procedure is the gold standard non-
the degree of image magnification [68]. The invasive modality to evaluate the pelvic organs.
average gonadal radiation dose during one However, because of expense, it should be
completed HSG procedure is estimated to be considered as a second-line imaging modality
a maximum of 5 mGy [69]. when ultrasound, SIS, and HyCoSy cannot
Intravasation happens in the presence of provide adequate images or definitive diag-
tubal obstruction, excessive injection pressure, nosis, especially in the settings of Mullerian
recent uterine surgery, misplaced cannula, or anomalies, adenomyosis, pelvic endometrio-
130 L. Detti
sis, and uterine fibroids. In fact, the versatility rent early pregnancy loss. Arcuate uterus and
and ready availability of ultrasound is unsur- septate uterus, defined as a septum longer than
passed by any of the other imaging modali- 10 mm, were found in 3.9% and 2.3% of an
ties. MRI is especially useful in pre-pubertal unselected population, respectively. In women
girls, whenever transvaginal ultrasonography with recurrent early pregnancy loss, a septate
is not acceptable and transabdominal ultraso- uterus was present in 5.3%, and in women with
nography is inadequate. infertility in 15.4% [73]. Considering in vitro
MRI is utilized for characterizing con- fertilization treatment outcomes, the presence
genital and acquired uterine anomalies, of congenital uterine anomalies significantly
especially uterine agenesis and complex impacts pregnancy rates, which return to nor-
anomalies, such as didelphys uterus, or other mal when the anomalies are corrected [74, 75].
5 incomplete fusion defects. Congenital anom- In 2016, ASRM has revised the definitions
alies have been classified by two major sys- of arcuate (< 10-mm subseptation length)
tems, the American Fertility Society (AFS, and septate uterus (> 15-mm subseptation
today’s American Society for Reproductive length) and introduced a “gray” area for sub-
Medicine, or ASRM) in 1989 [71], and the septation lengths between 10 and 15 mm [76].
European Society of Human Reproduction This revision, however, has not been favor-
and Embryology- European Society of ably met because of the gray area between 10
Gynecological Endoscopy (ESHRE-ESGE), and 15 mm, which is left to personal inter-
in 2013 [72]. Although they encompass the pretation for indication of surgical correc-
same anomalies, the two classification systems tion. . Figure 5.20 shows a uterine septum
are slightly different. In the United States, diagnosed by MRI. Despite the high-quality
the AFS classification is still the most widely images, a challenge posed by this imaging tool
utilized. The prevalence of AFS-diagnosed is obtaining an exact septum length measure-
congenital uterine anomalies was found to ment, compromised by the inability to rotate
be about 5.5% in an unselected population, the image to obtain a perfect coronal view of
and 13.3% in women with history of recur- the uterus.
a b
EC fundus
EC
ovary
EC
EC
septum cervix
EC
Complete septum
.. Fig. 5.20 Septate uterus. This is best appreciated on (longitudinal) with a cervical septum. b Coronal view of
oblique coronal T2-weighted image demonstrating the the uterus, showing the two cavities, septum, and the fun-
septum. a Transverse view of the uterus showing the myo- dus. EC Endometrial Cavity. (Images provided by Laura
metrial septum separating the two cavities and the cervix Detti, MD, Baylor College of Medicine, Houston, TX)
131 5
With regard to acquired anomalies, MRI ability to diagnose this condition with MRI
can be helpful in the diagnosis of adenomyo- being superior in the presence of obesity or
sis and pelvic and extrapelvic endometriosis concomitant uterine leiomyomas [77, 79].
(. Fig. 5.21), and in establishing the exact The presence of small endometrial cysts
location, and number of fibroids prior to mini- within the myometrial thickness is the first
mally invasive surgical resection (. Figs. 5.22 noticeable sign of adenomyosis with both
and 5.23). imaging modalities. Measurement of the
Adenomyosis can be diagnosed with endometrium-myometrium junctional zone
TVUS (see 7 Sect. 5.2.3) and confirmed thickness is the most widely used param-
with MRI, when indicated. The two tech- eter to diagnose adenomyosis when using
niques were found to be similar in their 3D TVUS and MRI [78, 79]. A recent sys-
tematic review and meta-analysis of 32
studies showed the diagnostic performance
of TVUS In diagnosing adenomyosis to be
high and comparable to the performance of
Adenomyosis MRI [80].
DIE Pelvic deep infiltrating endometriosis can
be diagnosed with TVUS and confirmed with
Rectum MRI [77, 81], and a recent meta-analysis of
30 studies (n = 3374) found the sensitivity of
Bladder Cervix TVUS to be 89% (95% confidence interval
83–93%), while for MRI 86% (95% confi-
dence interval 79–91%), showing TVUS as for
slightly better for the detection of pelvic infil-
.. Fig. 5.21 Adenomyosis and deep infiltrating endome- trating endometriosis [82]. Transrectal endo-
triosis (DIE). T2-weighted sagittal image of adenomyo-
scopic ultrasound was found to have a higher
sis, which significantly increases the posterior wall of the
uterus. A DIE focus is noted between the posterior aspect sensitivity then TVUS: 92% (95% confidence
of the cervix and the rectum. (Images provided by Laura interval 87–95%). Extrapelvic deep infiltrating
Detti, MD, Baylor College of Medicine, Houston, TX) endometriosis, however, is better diagnosed
a b
Fibroids
Fibroid
.. Fig. 5.22 Uterine fibroids at MRI imaging for pre- b Enlarged uterus with multiple fibroids. (Images pro-
operative mapping. T2-weighted sagittal images of uter- vided by Laura Detti, MD, Baylor College of Medicine,
ine fibroids. a One small subserosal fibroid at the fundus. Houston, TX)
132 L. Detti
Which Reproductive Imaging Modality to Use and When?
Interest in Interest in Interest in tubal patency OR in Interest in

basic pelvic endometrial tubal patency and endometrial leiomyomas or
structures cavity cavity congenital uterine
anomalies
TVS SIS with & Non-obese obese TVS with 3D

without 3D imaging
imaging
5
HyCoSy HyCoSy not HSG
feasible in feasible in Unclear
office office
MRI
HyCoSy
.. Fig. 5.23 Algorithm depicting the optimal imaging methodology based on the clinical question. The decision to
perform HyCoSy in obese patients is sonologist’s dependent
by MRI, given its all-encompassing assess- tions. Although teratogenesis is not a concern
ment of abdominal organs [81]. after gadolinium administration, carcinogen-
While ovarian endometriomas are eas- esis is a potential risk. However, it is deemed
ily identified with TVUS, mature teratomas, safe to breastfeed immediately after intrave-
or dermoids, can still pose a challenge, espe- nous gadolinium injection.
cially when the calcium, or fat, components
are minimal. In these instances, MRI aids in
providing a definitive diagnosis, particularly 5.6.2 MRI Technical Considerations
in the pediatric population [83].
Uterine fibroids are typically evaluated The basic principle of MRI is the application
by TVUS, however, in those instances where of a directional magnetic field to the human
multiple leiomyomas are present and the pre- body, where the free hydrogen nuclei align
ferred surgical approach is minimally invasive, with the direction of the magnetic field. Once
such as via classical or robotic laparoscopy, aligned, a radiofrequency pulse is applied,
MRI-mapping of the preferred method. The perpendicular to the magnetic field, and when
surgeon can then determine the number of this is removed, the nuclei realign themselves
uterine incisions and can minimize the chance and lose energy by emitting their own RF
of neglecting to remove an occult leiomyoma. signal, returning to equilibrium. Different tis-
Misconceptions exist about performing sues will recover their original alignment with
MRI during pregnancy, which is considered to the external magnetic field at different rates
be dangerous for the fetus, however, evidence- and different times, which will originate the
based indications have been d eveloped for MRI image. The image contrast depends on
specific maternal and fetal conditions [84]. two other tissue-specific factors, the longitu-
Although iodine contrast is safe in pregnancy, dinal relaxation time, or T1, and the trans-
intravenous gadolinium is contraindicated verse relaxation time, or T2. On T1-weighted
and should be used only for selected indica- images, water is darker (low signal intensity)
133 5
than fat, which appears as bright white (high C. Transvaginal ultrasound (TVUS)
signal intensity). Fluid that appears bright is D. Saline infusion sonography (SIS)
likely to be hemorrhagic or proteinaceous [85]. E. Hysterosalpingo-foam sonography
On T2-weighted images, both fat and fluid are (HyFoSy)
bright. Fat-suppression techniques can be
used in T2-weighted sequences which makes ??2. What are indications for performing a
the fat produce a low intensity signal, thereby hysterosalpingogram (HSG)?
accentuating the remaining bright fluid sig- A. Evaluation of uterine cavity abnor-
nal. When the resonance signal is encoded for malities
each dimension, it will produce a 3D image. B. Evaluation of tubal patency
Because of its intrinsic principles, MRI is C. Evaluation of recurrent early preg-
not operator-dependent, it does not expose nancy loss
patients to ionizing radiation, and imaging is D. All of the above
not limited by patients’ BMI, which make it a E. None of the above
very versatile and precise imaging tool.
??3. A patient is suspected to have a bicor-
nuate uterus because two cervical ostia
5.6.3 Limitations were noted on speculum exam. What is
the imaging of your choice to confirm
Most important limitations of MRI are that the diagnosis?
it needs to be performed in a radiology suite A. Hysterosalpingogram (HSG)
and that it is expensive. Other limitations to B. Hysterosalpingo-contrast sonogra-
performing MRI include patients wearing phy (HyCoSy)
pacemakers and other medical or surgical C. Magnetic Resonance imaging (MRI)
implants, who should not undergo an MRI D. Saline infusion sonography (SIS)
procedure. Claustrophobia is an additional E. 3D transvaginal ultrasound (3D-
concern that may limit the use of this proce- TVUS)
dure. Gadolinium use is contraindicated in
patients with known hypersensitivity. When ??4.
A 27 years old, gravida 0, female
gadolinium is used in patients with severe presents with primary infertility for
renal failure (stage IV or V) caution should be 24 months. She reports irregular men-
used because of the risk of subsequent neph- strual cycles every 35–40 days with
rogenic systemic fibrosis [86]. oligo-
ovulation and menorrhagia, in
addition to a history of chlamydia when
she was a teenager. Her primary gyne-
cologist obtained a hysterosalpingo-
5.7 Review Questions gram a year ago, which showed patent
tubes and no evidence of hydrosalpinx.
??1.
A 31 year-old, gravida 1, para 1001, She is eager to start fertility treatments.
female presents with secondary infertil- What is your next step?
ity for 16 months. She reports a history A. Obtain an ultrasound
of a term vaginal delivery followed by B. Obtain a saline infusion sonogra-
post-partum endometritis. You suspect phy
intrauterine adhesions as the cause of C. Proceed to fertility treatments with
her infertility. What imaging procedure ovulation induction
do you order? D. Repeat a hysterosalpingogram
A. Magnetic resonance imaging (MRI) E. Obtain a magnetic resonance imag-
B. Hysterosalpingogram (HSG) ing
134 L. Detti
5.8 Answers of IVF treatment: a systematic review and meta-

analysis. Hum Reprod. 2010;25:418–29.
8. Somigliana E, Vercellini P, Daguati R, Pasin R,
vv1. D. Saline infusion sonography (SIS). De Giorgi O, Crosignani PG. Fibroids and female
reproduction: a critical analysis of the evidence.
vv2. B. Evaluation of tubal patency. Hum Reprod Update. 2007;13:465–76.
9. Nirgianakis K, Kalaitzopoulos DR, Schwartz
ASK, Spaanderman M, Kramer BW, Mueller
vv3.
E. 3D Transvaginal ultrasound (3D-
MD, et al. Fertility, pregnancy and neonatal out-
TVUS). comes of patients with adenomyosis: a systematic
review and meta-analysis. Reprod Biomed Online.
vv4. B. Obtain a saline infusion sonography 2021;42:185–206.
10. Bahgavath B, Greiner E, Griffiths K, Winter T,
5 (SIS). Explanation: The previously
Alur-Gupta S, Richardson C, et al. Uterine malfor-
obtained HSG did not allow evaluation of
mations: an update of diagnosis, management, and
the myometrium and endometrium. The outcomes. Obstet Gynecol Surv. 2017;72:377–92.
patient has a history of oligo-ovulation 11. Woelfer B, Salim R, Banerjee S, Elson J, Regan L,
and menorrhagia, which place her at risk Jurkovic D. Reproductive outcomes in women with
of having endometrial polyps, submuco- congenital uterine anomalies detected by three-
dimensional ultrasound screening. Obstet Gynecol.
sal fibroids, or other uterine cavity abnor-
2001;98:1099–103.
malities. Obtaining an SIS will allow for 12. Checa MA, Bellver J, Bosch E, Espinós JJ, Fabreg-
evaluation of endometrial or myometrial ues F, Fontes J, et al. Hysteroscopic septum resec-
abnormalities that would preclude her fer- tion and reproductive medicine: a SWOT analysis.
tility or pose a risk for pregnancy loss. Reprod Biomed Online. 2018;37:709–15.
13. Detti L, Christiansen ME, Peregrin-Alvarez I,
Roman RA, Levi D’Ancona R, Gordon JC. Correc-
tion of uterine subseptations re-establishes standard
References uterine cavity measurements. J Imaging. 2020;6:58.
https://doi.org/10.3390/jimaging6070058.
1. Benacerraf BR, Abuhamad AZ, Bromley B, Gold- 14. Detti L, Peregrin-Alvarez I, Roman RA, Levi
stein SR, Groszmann Y, Shipp TD, et al. Consider D’Ancona R, Gordon JC, Christiansen ME. Diag-
ultrasound first for imaging the female pelvis. Am J nosis of uterine subseptations and indication for
Obstet Gynecol. 2015;212:450–5. surgical correction: a comparison of four systems.
2. AIUM practice guideline for the performance of Minerva Obstet Gynecol. 2021;73:376–83.
pelvic ultrasound examinations. American Insti- 15. Bermejo C, Martinez Ten P, Cantarero R, Diaz D,
tute of Ultrasound in Medicine. J Ultrasound Med. Perez Pedregosa J, Barron E, et al. 3D ultrasound
2010; 29:166–72. in the diagnosis of Müllerian duct anomalies and
3. Yuzpe AA, Brown SE, Casper RF, Nisker J, Graves concordance with MRI. Ultrasound Obstet Gyne-
G, Shatford L. Transvaginal, ultrasound-guided col. 2010;35:593–601.
oocyte retrieval for in vitro fertilization. J Reprod 16. Bocca SM, Oehninger S, Stadmauer L, Agard J,
Med. 1989;34:937–42. Duran EH, Sarhan A, et al. A study of the cost,
4. Strickler RC, Christianson C, Crane JP, Curato accuracy and benefits of 3-dimensional sonogra-
A, Knight AB, Yang V. Ultrasound guidance for phy compared with hysterosalpingogram in females
human embryo transfer. Fertil Steril. 1985;43: with uterine abnormalities. J Ultrasound Med.
54–61. 2012;31:81–5.
5. Fischer K, McDannold NJ, Tempany CM, 17. Dishuck CF, Perchik JD, Porter KK, Gunn
Jolesz FA, Fennessy FM. Potential of minimally DD. Advanced imaging in female infertility. Curr
invasive procedures in the treatment of uterine Urol Rep. 2019;20:77.
fibroids: a focus on magnetic resonance-guided 18. Deutch TD, Abuhamad AZ. The role of
focused ultrasound therapy. Int J Women's Health. 3-dimensional ultrasonography and magnetic reso-
2015;13(7):901–12. nance imaging in the diagnosis of müllerian duct
6. Exacoustos C, Morosetti G, Conway F, Camilli S, anomalies: a review of the literature. J Ultrasound
Martire FG, Lazzeri L, et al. New sonographic clas- Med. 2008;27:413–23.
sification of adenomyosis: do type and degree of 19. Tsuboyama T, Takei O, Okada A, Wada K, Kuri-
adenomyosis correlate to severity of symptoms? J yama K. Effect of uterine position and intrapelvic
Minim Invasive Gynecol. 2020;27:1308–15. motions on the image quality of 3D T2-weighted
7. Sunkara SK, Khairy M, El-Toukhy T, Khalaf Y, MRI of the uterus: can short prescans predict
Coomarasamy A. The effect of intramural fibroids the non-diagnostic image quality? Eur J Radiol.
without uterine cavity involvement on the outcome 2020;130:109186.
135 5
20. Ergenoglu AM, Sahin Ç, Şimşek D, Akdemir A, sonography compared to two-dimensional saline
Yeniel AÖ, Yerli H, et al. Comparison of three- infusion sonography for the diagnosis of focal
dimensional ultrasound and magnetic resonance intracavitary lesions. Cochrane Database Syst Rev.
imaging diagnosis in surgically proven Müllerian 2017(5): CD011126.
duct anomaly cases. Eur J Obstet Gynecol Reprod 33. AIUM Practice Guideline for the Performance of
Biol. 2016;197:22–6. Sonohysterography. Guideline developed in collab-
21. Ghi T, Casadio P, Kuleva M, Perrone AM, Saveli L, oration with the American College of Radiology;
Giunchi S, et al. Accuracy of 3D ultrasound in the American College of Obstetricians and Gyne-
diagnosis and classification of congenital uterine cologists; Society of Radiologists in Ultrasound. J
anomalies. Fertil Steril. 2009;92:808–13. Ultrasound Med. 2015;34:1–6.
22. Caliskan E, Ozkan S, Cakirogly Y, Sarisoy HT, Cor- 34. ACOG practice bulletin No. 104: antibiotic prophy-
akci A, Ozeren S. Diagnostic accuracy of real-time laxis for gynecologic procedures. Obstet Gynecol.
3D sonography in the diagnosis of congenital mul- 2009;113:1180–9.
lerian anomalies in high-risk patients with respect 35. Hulka CA, Hall DA, McCarthy K, Simone
to the phase of the menstrual cycle. J Clin Ultra- JF. Endometrial polyps, hyperplasia, and carci-
sound. 2010;38:123–7. noma in postmenopausal women: differentiation
23. Sassone AM, Timor-Tritsch IE, Artner A, Westhoff with endovaginal sonography. Radiology. 1994;191:
C, Warren WB. Transvaginal sonographic charac- 755–8.
terization of ovarian disease: evaluation of a new 36. Detti L, Christiansen ME, Peregrin-Alvarez I.
scoring system to predict ovarian malignancy. Endometrial abnormalities: correlation between
Obstet Gynecol. 1991;78:70–6. different diagnostic modalities. J Ultrasound Med
24. Andreotti RF, Timmerman D, Strachowski LM, 2021 https://doi.org/10.1002/jum.15880. Online
Froyman W, Benacerraf BR, Bennett GL, et al. ahead of print.
O-RADS US risk stratification and management 37. Clevenger-Hoeft M, Syrop CH, Stovall DW, Van
system: a consensus guideline from the ACR Voorhis BJ. Sonohysterography in premenopausal
ovarian-adnexal reporting and data system commit- women with and without abnormal bleeding. Obstet
tee. Radiology. 2020;294:168–85. Gynecol. 1999;94:516–20.
25. Sokalska A, Timmerman D, Testa AC, Van Hols- 38. Munro MG, Critchley HO, Broder MS, Fraser
beke C, Lissoni AA, Leone FP, et al. Diagnostic IS. The FIGO Classification system (“PALM-
accuracy of transvaginal ultrasound examination COEIN”) for causes of abnormal uterine bleeding
for assigning a specific diagnosis to adnexal masses. in non-gravid women in the reproductive years,
Ultrasound Obstet Gynecol. 2009;34:462–70. including guidelines for clinical investigation. Int J
26. Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti Gynaecol Obstet. 2011;113:3–13.
AM, Melis GB. Transvaginal ultrasonography asso- 39. Mol BW, Collins JA, Burrows EA, van der Veen F,
ciated with colour Doppler energy in the diagnosis Bossuyt PM. Comparison of hysterosalpingogra-
of hydrosalpinx. Hum Reprod. 2000;15:1568–72. phy and laparoscopy in predicting fertility outcome.
27. Nannini R, Chelo E, Branconi F, Tantini C, Scar- Hum Reprod. 1999;14:1237–42.
selli GF. Dynamic echohysteroscopy: a new diag- 40. Luciano DE, Exacoustos C, Luciano AA. Contrast
nostic technique in the study of female infertility. ultrasonography for tubal patency. J Minim Inva-
Acta Eur Fertil. 1981;12:165–71. sive Gynecol. 2014;21:994–8.
28. Bonnamy L, Marret H, Perrotin F, Body G, Berger 41. Maheux-Lacroix S, Boutin A, Moore L, Bergeron
C, Lansac J. Sonohysterography: a prospective sur- ME, Bujold E, Laberge P, et al. Hysterosalpingo-
vey of results and complications in 81 patients. Eur sonography for diagnosing tubal occlusion in
J Obstet Gynecol Reprod Biol. 2002;102:42–7. subfertile women: a systematic review with meta-
29. Sanin-Ramirez D, Carriles I, Graupera B, Ajossa S, analysis. Hum Reprod. 2014;29:953–63.
Neri M, Rodriguez I, et al. Two-dimensional trans- 42. Mitri FF, Andronikou AD, Perpinyal S, Hofmeyr
vaginal sonography versus saline contrast sono- GJ, Sonnendecker EW. A clinical comparison of
hysterography for diagnosing endometrial polyps: sonopathic hydrotubation and hysterosapingogra-
systematic review and meta-analysis. Ultrasound phy. Br J Obstet Gynaecol. 1991;98:1031–6.
Obstet Gynecol. 2020;56:506–15. 43. Saunders RD, Shwayder JF, Nakajima ST. Current
30. Widrich T, Bradley LD, Mitchinson AR, Collins methods of tubal patency assessment. Fertil Steril.
RL. Comparison of saline infusion sonography with 2011;95:2171–9.
office hysteroscopy for the evaluation of the endo- 44. Epstein E, Ramirez AM, Skoog L, Valentin
metrium. Am J Obstet Gynecol. 1996;174:1327–34. L. Transvaginal sonography, saline contrast and
31. Vitale SG, Haimovich S, Lagana AS, Alonso L, Di hysteroscopy for the investigation of women
Spezio Sardo A, Carugno J. Endometrial polyps. An with postmenopausal bleeding and endometrium
evidence-based diagnosis and management guide. greater than 5 mm. Ultrasound Obstet Gynecol.
Eur J Obstet Gynecol Reprod Biol. 2021;260:70–7. 2001;18:157–62.
32. Nieuwenhuis LL, Hermans FJR, Bij de Vaate AJM, 45. Emanuel MH, Exalto N. First experiences with Hys-
Leeflang MMG, Brölmann HAM, Hehenkamp terosalpingo-Foam Sonography (HyFoSy) for office
WJK, et al. Three-dimensional saline infusion tubal patency testing. Hum Reprod. 2012;27:114–7.
136 L. Detti
46. Rajesh H, Lim SL, Yu SL. Hysterosalpingo-foam resolution of unilateral cornual obstruction during
sonography: patient selection and perspectives. Int HSG. Obstet Gynecol. 2003;101:1275–8.
J Women's Health. 2017;9:23–32. 60. Roest I, van Welie N, Mijatovic V, Dreyer K,
47. Hamed HO, Shahin AY, Elsamman AM. Bongers M, Koks C, et al. Complications after
Hysterosalpingo-contrast sonography versus radio- hysterosalpingography with oil- or water-based

graphic hysterosalpingography in the evaluation contrast: results of a nationwide survey. Human
of tubal patency. Int J Gynaecol Obstet. 2009;105: Reprod Open. 2020;2020(1):hoz045.
215–7. 61. Ayinda G, Kennedy S, Barlow D, Chamberlain P. A
48. Fenzl V. Effect of different ultrasound contrast comparison of patient tolerance of HyCoSy with
materials and temperatures on patient comfort dur- Echovist-200 and X-ray HSG for outpatient inves-
ing intrauterine and tubal assessment for infertility. tigation of infertile females. Ultrasound Obstet
Eur J Radiol. 2012;81:4143–5. Gynecol. 1996;7:201–4.
49. Exacoustos C, Zupi E, Carusotti C, Lanzi G, 62. Carrascosa P, Capunay C, Vallejos J, Carpio J,
5 Marconi D, Arduini D. Hysterosalpingo-contrast Baronio M, Papier S. Two-dimensional and three-
sonography compared with hysterosalpingogra- dimensional imaging of uterus and fallopian tubes
phy and laparoscopic dye pertubation to evalu- in female infertility. Fertil Steril. 2016, 105:1403–
ate tubal patency. J Am Assoc Gynecol Laparosc. 1420.e7.
2003;10:367–72. 63. Merritt BA, Behr SC, Khati NJ. Imaging of infer-
50. Exacoustos C, DiGiovanni A, Szabolos B, Roeo tility, part 1: hysterosalpingograms to magnetic
V, Romanini ME, Luciano D, et al. Automated resonance imaging. Radiol Clin N Am. 2020;58:
3D-coded contrast HyCoSy: feasibility in office 215–25.
tubal patency testing. Ultrasound Obstet Gynecol. 64. Mohd Nor H, Jayapragasam K, Abdullah B. Diag-
2012;41:328–35. nostic image quality of hysterosalpingography:
51. Beverley RM, Malik S, Collins RL, Jean K, San- ionic versus non ionic water soluble iodinated con-
filippo JS. Evaluation of tubal patency with a trast media. Biomed Imaging Interv J. 2009;5:e29.
saline-air device: can we move back to the office? J 65. Noorhasan D, Heard MJ. Gadolinium radiologic
Reprod Med. 2018;63:120–6. contrast is a useful alternative for hysterosalpingo-
52. Robertshaw I, Sroga JM, Batcheller AE, Martinez gram in patients with iodine allergy. Fertil Steril.
AM, Winter TC, et al. Hysterosalpingo-contrast 2005;84:1744.
sonography with a saline-air device is equivalent to 66. ACR practice guideline for the performance of
hysterosalpingography only in the presence of tubal hysterosalpingography 2011. http://www.acr.org/~/
patency. J Ultrasound Med. 2016;35:1215–22. media/B96D79998651431A8BD263017DE707A5.
53. Emanuel MH, Exalto N. Hysterosalpingo-foam pdf
sonography (HyFoSy): a new technique to visual- 67. Hunt RB, Siegler AM. Hysterosalpingography:
ize tubal patency. Ultrasound Obstet Gynecol. techniques & interpretation. Chicago: Year Book
2011;3:498–9. Medical Publishers; 1990.
54. Ludwin I, Ludwin A, Wiechec M, Nocun A, Banas 68. Pittaway ED, Winfield AC, Maxson W, Daniell J,
T, Basta P, et al. Accuracy of hysterosalpingo-foam Herberg C, Wentz AC. Prevention of acute pelvic
sonography in comparison to hysterosalpingo- inflammatory disease after hysterosalpingography:
contrast sonography with air/saline and to laparos- efficacy of acute pelvic inflammatory disease after
copy with dye. Hum Reprod. 2017;32:758–69. hysterosalpingography: efficacy of doxycycline pro-
55. Lindborg L, Thornburn J, Gergh C, Strandell phylaxis. Am J Obstet Gynecol. 2003;137:623–6.
A. Influence of HyCoSy on spontaneous preg- 69. Soules MR, Mack LA. Imaging of the reproductive
nancy: a randomized controlled trial. Hum Reprod. tract in infertile women: HSG, ultrasonography and
2009;24:1075–9. MRI. In: Keye WR, Chang RJ, Rebar RW, Soules
56. Evers JL, Land JA, Mol BW. Evidence-based medi- MR, editors. Infertility evaluation and treatment.
cine for diagnostic questions. Semin Reprod Med. Philadelphia: W.B. Saunders; 2005. p. 300–29.
2003;21:9–15. 70. Fife KA, Wilson DJ, Lewis CA. Entrance surface
57. Dessole S, Meloni GB, Capobianco G, Manzoni and ovarian doses in hysterosalpingography. Br J
MA, Ambrosini G, Canalis GC. A second hystero- Radiol. 1994;67:860–3.
salpingography reduces the use of selective tech- 71. Liang G, Zhu Q, He X, Wang X, Jiang L, Zhu C,
nique for treatment of a proximal tubal obstruction. et al. Effects of oil-soluble versus water-soluble con-
Fertil Steril. 2000;73:1037–9. trast media at hysterosalpingography on pregnancy
58. Dreyer K, van Rijswijk J, Mijatovic V, Goddijn M, outcomes in women with a low risk of tubal disease:
Verhoeve HR, van Rooij IAJ, et al. Oil-based or study protocol for a randomised controlled trial.
water-based contrast for hysterosalpingography in https://bmjopen.bmj.com/content/10/10/e039166.
infertile women. N Engl J Med. 2017;376:2043–52. Accessed 20 June 2021.
59. Hurd WW, Wyckoff ET, Reynolds DB, Amesse 72. Gibbons W, Buttram VC, Jan Behrman S, Jones H,
LS, Gruber JS, Horowitz GM. Patient rotation and Rock J. The American fertility society classifica-
137 5
tions of adnexal adhesions, distal tubal occlusion, 2021. https://doi.org/10.1111/aogs.14139. Online
tubal occlusion secondary to tubal ligation, tubal ahead of print.
pregnancies, Mullerian anomalies and intrauterine 80. Liu L, Li W, Leonardi M, Condous G, Da Silva
adhesions. Fertil Steril. 1988;49:944–55. Costa F, Mol BW, et al. Diagnostic accuracy of
73. Grimbizis GF, Gordts S, Di Spiezio SA, Brucker transvaginal ultrasound and magnetic resonance
S, De Angelis C, Gergolet M, et al. The ESHRE/ imaging for adenomyosis: systematic review and
ESGE consensus on the classification of female meta-analysis and review of sonographic diagnos-
genital tract congenital anomalies. Hum Reprod. tic criteria. J Ultrasound Med 2021. https://doi.
2013;28:2032–44. org/10.1002/jum.15635. Online ahead of print.
74. Chan YY, Jayaprakasan K, Zamora J, Thornton 81. Celli V, Ciulla S, Dolciami M, Satta S, Ercolani G,
JG, Raine-Fenning N, Coomarasamy A. Repro- Porpora MG, et al. Magnetic resonance imaging
ductive outcomes in women with congenital uter- in endometriosis-associated pain . Minerva Obstet
ine anomalies: a systematic review. Hum Reprod Gynecol. 2021. https://doi.org/10.23736/S2724-
Update. 2011;17:761–17. 606X.21.04782-1. Online ahead of print.
75. Tomaževic T, Ban-Frangež H, Virant-Klun I, 82. Gerges B, Li W, Leonardi M, Mol BW, Condous
Verdenik I, Požlep B, Vrtačnik-Bokal E. Septate, G. Meta-analysis and systematic review to deter-
subseptate and arcuate uterus decrease pregnancy mine the optimal imaging modality for the detection
and live birth rates in IVF/ICSI. Reprod Biomed of rectosigmoid deep endometriosis. Ultrasound
Online. 2010;21:700–5. Obstet Gynecol 2020. https://doi.org/10.1002/
76. Practice Committee of The American Society for uog.23148. Online ahead of print.
Reporductive Medicine. Uterine septum: a guide- 83. Saleh M, Bhosale P, Menias CO, Ramalingam P,
line. Fertil Steril. 2016;106:530–40. Jensen C, Iyer R, et al. Ovarian teratomas: clini-
77. Bazot M, Cortez A, Darai E, Rouger J, Chopin J, cal features, imaging findings and management.
Antione JH, et al. Ultrasounography compared Abdom Radiol (NY). 2021;46:2293–307.
with magnetic resonance imaging for the diagnosis 84. Chen MM, Coakley FV, Kaimal A, Laros RK Jr.
of adenomyosis: correlation with histopathology. Guidelines for computed tomography and magnetic
Hum Reprod. 2001;16:2427–33. resonance imaging use during pregnancy and lacta-
78. Bordonné C, Puntonet J, Maitrot-Mantelet L, tion. Obstet Gynecol. 2008;112:333–40.
Bourdon M, Marcellin L, Dion E, et al. Imaging 85. Kim MY, Rha SE, Oh SN, Jung SE, Lee YJ, Kim
for evaluation of endometriosis and adenomyosis. YS, et al. MR imaging findings of hydrosalpinx:
Minerva Obstet Gynecol. 2021;73:290–303. a comprehensive review. Radiographics. 2009;29:
79. Rees CO, Nederend J, Mischi M, van Vliet HAAM, 495–507.
Schoot BC. Objective measures of adenomyosis on 86. Khatami SM, Mahmoodian M, Zare E, Pashang
MRI and their diagnostic accuracy-a systematic M. Safety of older generations of gadolinium in mild
review & meta-analysis. Acta Obstet Gynecol Scand to moderate renal failure. Ren Fail. 2012;34:176–80.
139 6
Amenorrhea
Alexander M. Kotlyar and Eric Han
Contents
6.2 Diagnosis – 141

6.2.1 istory and Physical Exam – 141
H
6.2.2 Physical Examination – 141
6.2.3 Laboratory Testing – 141
6.2.4 Imaging – 142
6.3 Etiologies of Primary Amenorrhea – 143

6.3.1 onadal Dysgenesis – 143
G
6.3.2 Mullerian Agenesis – 145
6.3.3 Hypothalamic-Pituitary Disorders – 146
6.3.4 Constitutional Delay of Puberty – 146
6.3.5 Androgen Insensitivity Syndrome (AIS) – 146
6.3.6 Outflow Obstructions of the Genital Tract – 147
6.4 Etiologies of Secondary Amenorrhea – 147

6.4.1 ypothalamic Amenorrhea – 147
H
6.4.2 Post-contraception Amenorrhea – 148
6.4.3 Hyperandrogenic States – 148
6.4.4 Pituitary Disorders – 149
6.4.5 Acquired Disorders of the Genital Tract – 150
6.4.6 Primary Ovarian Insufficiency – 151
6.6 Answers – 154
References – 154

https://doi.org/10.1007/978-3-030-99596-6_6
140 A. M. Kotlyar and E. Han
ondary in nature, familiarity with the most

Key Points common causes and a systematic approach
55 Primary amenorrhea is defined as no to the evaluation of the amenorrheic patient
menses by age 14 without secondary sex- are necessary for rapid diagnosis and treat-
ual characteristics or by age 16 with sec- ment, thereby enabling restoration of menses
ondary sexual characteristics present. and management of hormonal aberrations to
55 The evaluation of amenorrhea requires a improve quality of life.
thorough physical exam and can answer Primary amenorrhea is defined as no
two fundamental questions: (1) if the menses by age 14 without secondary sexual
patient has a uterus and an intact outflow characteristics or no menses by age 16 with
tract and (2) if breast development is pres- secondary sexual characteristics. Secondary
ent indicating the presence of estrogen amenorrhea is defined as no menses for
and an intact hypothalamic-pituitary axis. 3 months with a history of regular menses or
6 55 Once pregnancy has been excluded, no menses for 6 months if the prior menstrual
assessment of serum follicle-stimulating pattern was irregular [1].
hormone (FSH), thyroid-stimulating hor- Amenorrhea affects approximately 4% of
mone (TSH), and prolactin (PRL) needs women in the United States. The vast major-
to be done as the basis for determining ity of those affected will experience secondary
any endocrine cause for amenorrhea. amenorrhea with approximately 0.1% experi-
55 A broad differential diagnosis needs to encing primary amenorrhea [2, 3]. While the
be maintained in approaching primary underlying causes are varied, ranging from
and secondary amenorrhea with careful pre-existing genetic issues to insults to the
consideration of genetic, endocrine, and hypothalamic-pituitary axis, Mullerian anom-
acquired/congenital structural causes. alies, and iatrogenic causes, this chapter seeks
to present a systemic approach to assessing
and treating patients with amenorrhea.
In this chapter we will present an overview
6.1 Introduction of the epidemiology, presentation, and etiol-
ogy of primary and secondary amenorrhea.
Amenorrhea is a condition that can have Additionally, we will present an overview of
far-ranging and profound implications for a treatment options for various forms of this
woman’s health. Whether it is primary or sec- condition.
Case Vignette
A 37-year-old gravida 3 para 3 presents to the intermittent hot flashes for the past several
clinic for evaluation of secondary amenorrhea months along with vaginal dryness and diffi-
lasting nearly 1 year. She underwent menarche culty sleeping. She is sexually active with a male
at age 16 after development of secondary sex partner and expressed interest in another child
characteristics. She has always had irregular in the future. Her medical history is otherwise
cycles occurring every 3–6 months until they notable for hypothyroidism and asthma man-
ceased about a year ago. Her obstetrical history aged with levothyroxine and Symbicort.
is notable for two full-term spontaneous vagi- Physical examination, including pelvic exami-
nal deliveries followed by a preterm cesarean nation, is unremarkable. Pregnancy test is nega-
delivery at 34 weeks due to preeclampsia with tive and initial testing reveals an elevated FSH
severe features. She has been experiencing to 47 and AMH of 0.01.
Amenorrhea
141 6
6.2 Diagnosis Special attention should be paid to the
development of the genital tract and Tanner
6.2.1 History and Physical Exam staging of pubic hair development. The depth
of the vagina and the presence of a cervix and
Obtaining a thorough history is essential to uterus in particular will determine the pres-
any evaluation of amenorrhea, as with any key ence of a Mullerian anomaly. For example, if
issue in reproductive medicine. Information a uterus is present and no cervix is seen, one
gathered should include a detailed past medi- should consider an obstructive cause such
cal, surgical, menstrual, and sexual history. as a transverse vaginal septum or hymenal
In addition, a detailed discussion of recent obstruction. Assessing the extent of pubic
changes in medications, new stressors, and hair will provide information regarding the
changes in diet and exercise is essential for patient’s androgen production and should be
effective history taking. A thorough general judged in the context of breast development.
and endocrine review-of-systems may provide Absent or attenuated pubic hair development,
insight into whether any signs of hormonal especially with the presence of vaginal atro-
dysfunction are present. Relevant features phy, would be suggestive of hypoestrogenemia
to ask the patient include signs of hirsutism (given the conversion of circulating andro-
(acne, male-pattern hair growth), nipple dis- stenediol and testosterone into estrone and
charge (suggestive prolactin excess), fatigue/ estradiol, respectively).
lethargy, and excessive sweating (signs of thy- The examining clinician must care-
roid hypo- or hyperfunction), among others. fully look for signs of endocrine dysfunc-
A detailed contraceptive history is also tion. The presence of excess terminal hair
crucial, given the risk of post-contraceptive on the face and/or acne would be sugges-
amenorrhea. Numerous current methods of tive of hyperandrogenism such as seen in
contraception can lead to amenorrhea such as PCOS. Furthermore, in the presence of obe-
Depo-Provera which can cause iatrogenic amen- sity and acanthosis nigricans, this would be
orrhea for up to 1 year after the last dose [4]. suggestive of insulin resistance. More severe
signs of androgen excess and virilization such
as clitoromegaly may be seen with nonclas-
6.2.2 Physical Examination sical congenital adrenal hyperplasia or the
adrenal/ovarian neoplasms. The presence of
Following obtaining a thorough history and central obesity, purple striae on the abdomen,
review-of-systems, a directed physical exam is and enlarged “moon” facies would indicate
the next essential step. In general, the physi- Cushing’s syndrome. If galactorrhea is noted,
cal exam should focus on an assessment of prolactin excess should be suspected, and, if
endocrine function and, especially in cases confirmed, prolactin-secreting pituitary mass
of primary amenorrhea, an assessment of should be ruled out, particularly if any visual
developmental stage (e.g., Tanner staging). field deficits are present. However, it should be
Therefore, the physical exam should encom- noted that only one-third of women with pro-
pass an evaluation of pubertal development, lactin excess experience galactorrhea [5].
height, weight, body mass index (BMI), a skin
exam looking for any signs of hyperandrogen-
ism, a neurological exam, and a gynecologic 6.2.3 Laboratory Testing
exam. However, the most critical questions
that must be addressed by the physical exam First and foremost, a pregnancy test must be
are: (1) “Does the patient have a uterus?” (2) performed, regardless of the patient’s age,
“Does the patient have breast development?” since pregnancy can occur well beyond the
By answering these two questions, the exam- conventional limits of a woman’s reproductive
iner addresses whether the patient has the life. The youngest and oldest known women
physical and endocrine potential to undergo to spontaneously conceive and give birth were
menses. 5 and 59 years old, respectively [1].
Once pregnancy has been excluded, assess- ful if an adrenal tumor is suspected. Of note,
ment of serum follicle-stimulating hormone excess DHEA-S is often converted to testos-
(FSH), thyroid-stimulating hormone (TSH), terone [7]. Hence, total testosterone is espe-
and prolactin (PRL) should be done (see cially high yield in cases of amenorrhea with
. Fig. 6.1 for an algorithm to evaluate amen- hirsutism/virilization. If the total testosterone
orrhea). FSH and LH typically vary in tan- is above 200 ng/dL or the DHEA-S is above
dem with each other; hence, obtaining an LH 700 μg/dL, then an ovarian or adrenal tumor,
is not necessary. If the FSH is elevated, espe- respectively, should be suspected.
cially in the setting of signs of hypoestrogen-
ism, then hypergonadotrophic hypogonadism
(i.e., premature ovarian insufficiency) should 6.2.4 Imaging
be considered, and a karyotype should be
obtained, especially if the patient is less than One of the first questions to answer for any
6 30 years of age [3]. An elevated TSH or PRL patient with primary amenorrhea is if a uterus
should prompt a further evaluation for hypo- is present. Transvaginal or transabdominal
thyroidism or pituitary mass, respectively. ultrasonography is an effective first imaging
Signs of hyperandrogenism should modality. If a uterus cannot be seen on ultra-
prompt an assessment of the level of 17α- sound or if there appears to be a congenital
hydroxyprogesterone and total testosterone. anomaly of the uterine/Mullerian structures,
Free testosterone levels are less useful as they then subsequent magnetic resonance imaging
are prone to substantial laboratory variation (MRI) should be performed [8]. Furthermore,
[6]. Obtaining a DHEA-S level is most use- MRI can also be used to assess the kidneys and
Negative Beta hCG
Measure FSH, PRL, TSH
PRL Normal TSH and PRL

TSH FSH
Normal TSH Normal or FSH
Primary Evaluate for Evaluate for

hypothyroidism hyperprolactinemia gonadal failure
Hirsutism or No hirsutism or
virilization present virilization
Measure T, DHEA-S Measure T
T > 200 ng/dL Normal or mild T Normal or mild T

Mild T Normal T
Or DHEA-S > 7.0 DHEA-S 5.0-7.0 and/or DHEA-S
(normal or LH) (normal or LH)
µg/mL µg/mL (normal or LH)
Consistently
PCO-like vs. HCA
low LH/FSH
Evaluate for ovarian

Evaluate for non- Evaluate for
or adrenal tumor
calssic CAH pituitary tumor
.. Fig. 6.1 Evaluation of amenorrhea

Amenorrhea
143 6
ureters since approximately 29% of patients such as Kallmann syndrome, and an obstructed
with a Mullerian anomaly exhibit renal mal- outflow tract as seen with cervical agenesis,
formations [1, 9]. transverse vaginal septum, or imperforate
Imaging can also be helpful in further nar- hymen. Just based upon this limited differential,
rowing down the cause of the amenorrhea. If one can already discern how the combination
a patient has a persistently elevated prolactin, of a thorough history and the aforementioned
an MRI of the pituitary gland should be done laboratory and imaging can quickly aid in dis-
to determine the presence of a lactotroph ade- tinguishing between these etiologies.
noma or a pituitary stalk-disrupting mass. If
a patient presents without any secondary sex-
ual development, presumably due to hypoes- 6.3.1 Gonadal Dysgenesis
trogenism, obtaining a bone age X-ray scan
would help confirm this. Gonadal dysgenesis is the cause of nearly
50% of cases of primary amenorrhea. This
term comprises a group of disorders in which
6.3 Etiologies of Primary the gonads did not properly form in utero.
Amenorrhea Among these conditions, Turner’s syndrome
is the most common exhibiting the classic
Primary amenorrhea can be caused by a 45, X karyotype. However, mosaicism which
plethora of congenital and acquired condi- may include a full or partial Y chromosome
tions (. Table 6.1). It must be noted that pri- is possible. Of note, patients with Turner’s
mary amenorrhea can have the same causes as syndrome are at substantially increased
secondary amenorrhea. However, certain dis- risk for cardiac and endocrine abnormali-
orders are peculiar to primary amenorrhea. ties (osteoporosis and hypothyroidism) [11].
The most common causes of primary amen- Patients with Swyer syndrome (46,XY) and
orrhea include gonadal dysgenesis, Mullerian 46,XX gonadal dysgenesis typically present as
agenesis (Mayer-Rokitansky-Kuster-Hauser prepubertal-appearing females [12]. Of note,
syndrome), hypothalamic disorders, and consti- any form of gonadal dysgenesis in which a full
tutional delay of puberty [10]. Rarer causes of or partial Y chromosome is seen does carry a
primary amenorrhea include androgen insen- 20% risk of gonadoblastoma; hence, gonad-
sitivity, hypothalamic-pituitary hypofunction ectomy is recommended.
.. Table 6.1 Classification of amenorrhea, both primary and secondary, and primary ovarian insufficiency [2]
Anatomic Müllerian agenesis (Mayer–Rokitansky–Kuster–Hauser syndrome)

defects
Complete androgen resistance (testicular feminization)
(outflow
tract) Intrauterine synechiae (Asherman syndrome)
Imperforate hymen
Transverse vaginal septum
Cervical agenesis—isolated
Cervical stenosis—iatrogenic
Vaginal agenesis—isolated
Endometrial hypoplasia or aplasia—congenital
(continued)
.. Table 6.1 (continued)
Primary Gonadal dysgenesis Abnormal karyotype Turner syndrome 45,X

hypogonad-
Mosaicism
ism
Normal karyotype Pure gonadal 46,XX
dysgenesis
46,XY (Swyer
syndrome)
Gonadal agenesis
Enzymatic deficiency 17α-Hydroxylase deficiency
17,20-Lyase deficiency
6 Aromatase deficiency
Primary ovarian X chromosomal causes
insufficiency (see also
Mutations associated with a 46,XY karyotype
. Table 6.2)
Autosomal causes
Environmental insults
Immune disturbances
Idiopathic causes
Hypotha- Dysfunctional Stress, exercise, or nutrition-related
lamic causes
Pseudocyesis
Other disorders Isolated gonadotropin deficiency Kallmann syndrome
Idiopathic hypogonadotropic
hypogonadism (IHH)
Infection
Tuberculosis
Syphilis
Encephalitis/meningitis
Sarcoidosis
Chronic debilitating disease
Tumors Craniopharyngioma
Germinoma
Hamartoma
Teratoma
Endodermal sinus tumor
Metastatic carcinoma
Proliferative Langerhans cell histiocytosis
Amenorrhea
145 6
Pituitary Tumors Prolactinomas

causes
Other hormone-secreting pituitary tumor Mutations of
(corticotropin, thyrotropin-stimulating hormone, FSH or LH
growth hormone, gonadotrophin) receptor
Fragile X
syndrome
Autoimmune disease
Galactosemia
Other Adrenal disease Adult-onset adrenal hyperplasia
endocrine
Cushing syndrome
gland
disorders Thyroid disease Hypothyroidism
Hyperthyroidism
Ovarian tumors Granulosa-theca cell tumors
Brenner tumors
Cystic teratomas
Mucinous/serous cystadenomas
Krukenberg tumors
Nonfunctional tumors (craniopharyngioma)
Metastatic carcinoma
Space-occupying Empty sella
lesions
Arterial aneurysm
Necrosis Sheehan syndrome
Panhypopituitarism
Inflammatory/ Sarcoidosis
infiltrative
Hemochromatosis
Lymphocytic hypophysitis
Gonadotropin mutations (FSH)
Multifacto- Polycystic ovary syndrome
rial causes
6.3.2 Mullerian Agenesis karyotype [9]. MRKH syndrome is autosomal

dominant with an incidence of 1/4500–5000
Women with Mullerian agenesis, also known as births and is seen in approximately 10% of
Mayer-Rokitansky-Kuster-Hauser (MRKH) primary amenorrhea [13, 14]. In an anatomic
syndrome, exhibit a rudimentary or com- sense, MRKH patients share the absence of
pletely absent uterus and absent cervix with Mullerian structures like patients with andro-
a shortened vagina (keeping in mind that the gen insensitivity syndrome (AIS). However,
Mullerian ducts contribute to the upper 2/3 of MRKH patients typically exhibit secondary
the vaginal canal) in the presence of a 46,XX sexual characteristics such as pubic and axil-
lary hair, while AIS patients typically do not. tropins. FSH receptor (FSHR) mutations have
Furthermore, serum gonadotropins, TSH, been described which can lead to amenorrhea,
prolactin, and androgen will be within normal lack of folliculogenesis, and infertility [19, 20].
female limits. Ultrasonography will show either Patients with LH receptor abnormalities typi-
a complete absence of Mullerian structures cally have normal puberty development, but
or rudimentary uterine horns. MRI can fur- will be unable to ovulate [21].
ther characterize these abnormalities and also Distinguishing between all of these etiolo-
assess for the aforementioned renal anomalies. gies requires careful clinical assessment utiliz-
Patients with MRKH also have an increased ing a complete history, physical exam, and an
prevalence of vertebral abnormalities [15]. evaluation of FSH and estradiol levels. GnRH
deficiency or inactivating GnRHR mutations
will typically present with delayed puberty.
6.3.3 Hypothalamic-Pituitary Function amenorrhea will often present with
6 Disorders primary or secondary amenorrhea with a his-
tory notable for the aforementioned condi-
Various disorders of the hypothalamus can tions.
cause amenorrhea (. Table 6.1). Some like
Kallmann syndrome preclude any gonado-
tropin secretion and lead to primary amen- 6.3.4 Constitutional Delay
orrhea. Many others can lead to secondary of Puberty
amenorrhea such as tumors, stress states,
intense physical activity, and chronic disease, Delayed puberty is defined by lack or delay of
especially infiltrative disorders. pubertal milestones 2.5 standard deviations
On initial presentation, various stages of later than the average age of onset of puberty.
pubertal development may be present; none- This entails lack of breast development by age
theless, circulating gonadotropin and sex 12, lack of menses by age 13 in the absence of
steroid levels are all low. In cases of gonad- breast or pubic hair growth, or lack of menses
otropin-releasing hormone (GnRH) defi- by age 15 with the presence of breast or pubic
ciency, patients typically present with delayed hair growth [3]. These patients typically expe-
puberty. In cases when patients also pres- rience delay of other pubertal milestones such
ent with additional symptoms such as color as thelarche and adrenarche. A family history
blindness and most commonly anosmia, these can be revealing as up to 50–75% of patients
should raise suspicion for Kallmann syn- have a sibling or parent that also experienced
drome. Kallmann syndrome most commonly delayed puberty [22].
arises from X-linked recessive mutations in
the KAL1 gene which produces the protein
ANOS1, which is necessary for migration of 6.3.5 Androgen Insensitivity
neurons to the olfactory bulb [16]. Similar Syndrome (AIS)
phenotypes can also be seen with GnRH
receptor (GnRHR) inactivating mutations. Androgen insensitivity is found in approxi-
Furthermore, a whole range of GnRH defi- mately 5% of patients with primary amen-
ciencies leading to hypothalamic amenorrhea orrhea [23]. This condition stems from the
can be seen [17, 18]. Physical or emotional inability of androgen receptors (ARs) in a
stress, chronic disease, and poor nutrition 46,XY male to bind to androgens. The exact
(e.g., anorexia nervosa) can also induce a state cause ranges from complete absence of a nor-
of hypothalamic amenorrhea. mally functioning receptor to defects in the
Interruptions in downstream signaling transcriptional action of the AR [24].The
through the FSH and LH receptors can also classic presentation of AIS is a phenotypic
render a patient insensitive to these gonado- female with Tanner 3 breast development
Amenorrhea
147 6
with small nipples and pale areolae, absent 6.4 Etiologies of Secondary
pubic and axillary hair, and a bind vagina. Amenorrhea
Due to the lack of testosterone effect, the
gonads may be present either abdominally Etiologies of secondary amenorrhea are much
or within the inguinal canal. One can con- more varied. Patients with this condition often
firm the diagnosis by performing a karyo- experience menarche at an appropriate age;
type showing 46,XY and testosterone levels however, due to some acquired or congenital
in the normal male range. A key point to reason, these menses cease. We define second-
note about AIS compared to other disorders ary amenorrhea as a lack of menses for 3 con-
of sexual development in which a whole or secutive months before 40 years of age with
partial Y chromosome is present is that the prior regular/monthly menses or 6 months
risk of gonadal tumors (gonadoblastoma with previously irregular menses. Three to
and dysgerminoma) is much smaller before five percent of all reproductive age women
puberty compared to other such disorders. will experience secondary amenorrhea [28].
Nonetheless, gonadectomy should be per- Secondary amenorrhea is commonly seen in
formed after puberty is complete as there is women whose weight is below or exceeds the
an approximately 14% risk of germ cell tumor normal range, such as those with polycystic
by adulthood [25]. ovary syndrome (PCOS) or hypothalamic
amenorrhea [29].
6.3.6 Outflow Obstructions

of the Genital Tract 6.4.1 Hypothalamic Amenorrhea
Obstructive genital tract abnormalities result Secondary amenorrhea can be due to a spec-
from malformations of the Mullerian ducts trum of hypothalamic disorders. States of
and/or external genitalia. Such genital tract high physical stress, emotional distress, and
malformations can be found in 15% of young limited nutrition can result in diminished
women who are seen for primary amenorrhea. hypothalamic function and decreased GnRH
In addition to Mullerian agenesis (MRKH), signaling to the pituitary. A classic case is a
adolescents can present with a transverse competitive athlete presenting for evalua-
vaginal septum or imperforate hymen. The tion of amenorrhea. In fact, menstrual cycle
most common obstructive anomaly is an abnormalities are seen in up to 43% of bal-
imperforate hymen which is found in 0.1% let dancers and in up to 26% of long-dis-
cases of primary amenorrhea. Transverse tance runners. In similar fashion, patients
vaginal septum is much less frequent, seen in with calorie-limiting eating disorders such as
roughly 1 in 80,000 cases of primary amenor- anorexia nervosa and bulimia can also experi-
rhea [3]. These patients typically present with ence amenorrhea. Emotional stress such as in
cyclic pelvic pain due to the retained men- aftermath of sexual assault, physical violence,
strual products. Of note, these patients are and situations of grief can also lead to hypo-
at higher risk of having endometriosis likely thalamic amenorrhea. Of growing relevance
attributed to increased retrograde menstrua- is opioid use-related amenorrhea, as its use
tion [26]. On exam, patients with an imperfo- can substantially inhibit GnRH release and
rate hymen can present with a bulging, bluish may be linked with stressors that a patient
hymenal membrane with a hematocolpos may be experiencing [30]. Given all of these
proximal to this. While significant hema- contributors to hypothalamic amenorrhea, it
tocolpos or hematometra could be seen on is essential for clinicians to assess the patient’s
ultrasound, MRI will provide improved soft lifestyle, diet, and level of exercise [31]. As
tissue definition to detect a transverse vaginal with all forms of amenorrhea, a thorough
septum while also assessing for other pelvic menstrual history needs to be obtained in
structural issues [27]. addition to a physical exam focusing on the
thyroid, skin (for signs of hyperandrogen- ity, (2) hyperandrogenism (either biochemical
emia), presence of galactorrhea, and any signs or clinical), and (3) polycystic ovaries seen on
of bulimia such as poor dentition. ultrasound [37]. Laboratory evaluation often
Treatment first and foremost requires shows elevated LH (possibly secondary to
removing the underlying insult that is con- hyperinsulinemia), elevated total testosterone,
tributing to the patient’s hypothalamic dys- decreased sex hormone-binding globulin, and
function. Incorporating nonpharmacologic signs of glucose intolerance/insulin resistance
treatments aimed at improving mental health, [38, 39]. PCOS patients are at higher risk of
such as counseling, in addition to hormone metabolic and cardiovascular disease owing
replacement will be essential. Estrogen supple- to increased predisposition to insulin resis-
mentation is often needed to prevent contin- tance (and overt type 2 diabetes mellitus) and
ued decline in bone mineral density, and oral increased low-density lipoprotein levels [40].
contraceptives are an excellent first-line treat- The treatment of PCOS is multifactorial,
6 ment option [32]. As with all forms of amen- aimed at menstrual regulation/endometrial
orrhea, occult ovulation cannot be excluded; protection, improving features of hyperan-
hence, a pregnancy test should be performed drogenism, improving fertility efforts, and
prior to the start of any hormonal therapies. mitigating associated metabolic abnormali-
ties. Menstrual function can be restored using
oral contraceptive pills (OCPs) which can both
6.4.2 Post-contraception lead to regular menses via direct endometrial
effects and also suppresses excess LH produc-
Amenorrhea
tion and ameliorates excess androgen produc-
Acquired amenorrhea can occur immediately tion. Androgen production is decreased not
following the use of hormonal contraceptives. only via suppression of LH release but also
The most likely cause is a pre-existing men- through the increase of SHBG level due to
strual disorder as documented by numerous the estrogen component. OCPs are the first-
studies in the 1970s when higher-dose oral line treatment and should be attempted for at
formulations were more common [33, 34]. least 6 months to see any meaningful effect.
Depo medroxyprogesterone (Depo-Provera) If androgenic symptoms persist, then an anti-
has been consistently linked with amenorrhea androgen such as spironolactone should be
following discontinuation. Patients should be used [41]. In patients with infertility, ovula-
counseled that menses will typically resume tion induction with letrozole with or without
7–10 months after their last injection [35, 36]. intrauterine insemination is the best approach
to achieve pregnancy [42]. Any concomitant
obesity/metabolic disease should also be
simultaneously addressed using lifestyle/exer-
6.4.3 Hyperandrogenic States cise and diet counseling to encourage weight
loss. Metformin should be initiated if glucose
6.4.3.1 Polycystic Ovary Syndrome intolerance is present. However, metformin
Polycystic ovary syndrome (PCOS) is the should not be seen as a method to induce ovu-
cause of 70–80% of all cases of anovulation lation [43]. Expeditious treatment is especially
(see 7 Chap. 7). While many patients experi- crucial in the setting of fertility since various
ence oligomenorrhea, 24% of these patients adverse pregnancy outcomes are increased in
will exhibit amenorrhea [3]. PCOS comprises patients with PCOS including preeclampsia,
a wide spectrum of features in addition to gestational diabetes, and overall increased
menstrual dysfunction, including hirsutism/ perinatal morbidity and mortality [44].
hyperandrogenemia, obesity, and insulin
resistance. The Rotterdam criteria are com- 6.4.3.2 Elevated Androgen States
monly used to make the diagnosis, requiring Other conditions such as Cushing’s syndrome
two of the three following criteria: (1) oligo- and congenital adrenal hyperplasia (CAH)
ovulation or anovulation/menstrual irregular- can lead to a hyperandrogenic state like PCOS,
Amenorrhea
149 6
but the onset of hirsutism is typically much secondary amenorrhea patients will have a
more rapid. Cushing’s syndrome can lead to prolactinoma [47, 48]. Common symptoms
amenorrhea due to excess adrenal DHEA and include oligomenorrhea/amenorrhea, galac-
DHEA-S production, which affects follicu- torrhea, infertility, headaches, and visual
lar development and also suppresses GnRH disturbances. It must be noted, however, that
secretion [45]. A spectrum of enzyme defi- the relationship between galactorrhea, hyper-
ciencies which comprise CAH can also lead prolactinemia, and menstrual pattern is not
to amenorrhea via similar mechanisms with always consistent. One-third of women with
excess androgen affecting both follicular and galactorrhea and hyperprolactinemia will
hypothalamic functions [46]. have regular menses, and one-third of women
A careful history and physical exam will with hyperprolactinemia will not have galac-
help discriminate between these conditions. torrhea [49]. One elevated prolactin level
Central obesity and moon facies would be more should be repeated with a fasting sample. If
consistent with Cushing’s syndrome, while hir- hyperprolactinemia persists, a pituitary MRI
sutism and possibly hypotension (rarely hyper- should be performed [47]. A key point is
tension) would be seen with CAH. If Cushing’s that given the persistent dopaminergic inhi-
is suspected, the best screening test would be a bition of pituitary secretion, any pituitary
dexamethasone suppression test. A 17-hydro- mass could potentially disrupt this signal-
progesterone level should be obtained to assess ing and lead to hyperprolactinemia [50]. For
for CAH. In addition, all patients with signs example, a nonfunctioning pituitary tumor
of hyperandrogenism should have a total tes- will often secrete the alpha subunits shared
tosterone and dehydroepiandrosterone sulfate by FSH, LH, and TSH, and, if it compresses
(DHEA-S). Ovarian imaging will often show a the pituitary stalk, would lead to an elevation
polycystic appearance. in prolactin. Other etiologies of hyperprolac-
tinemia include chest wall injury, renal failure,
and primary hypothyroidism (due to elevated
6.4.4 Pituitary Disorders thyrotropin-releasing hormone).
Treatment of prolactin-secreting tumors,
6.4.4.1 Disorders of the Anterior especially if they are smaller than 10 mm
Pituitary Gland and do not lead to symptoms of increased
Pituitary tumors can lead to menstrual intracranial pressure, includes dopamine ago-
irregularities and even overt amenorrhea nists like bromocriptine and cabergoline. If a
due to impairment of proper GnRH release patient is otherwise asymptomatic and desires
and function of the anterior pituitary gland. contraception, she could be treated with oral
Among the most common of these tumors contraceptives. Both treatments will provide
are prolactin-secreting tumors. Patients may the necessary estrogenic exposure to prevent
present with galactorrhea, and, in cases when osteoporosis [51].
tumors exceed 10 mm in size, patients can
present with mass effect symptoms such as 6.4.4.3 Postpartum Pituitary
headaches and bitemporal hemianopsia due Necrosis (Sheehan Syndrome)
to compression of the optic chiasm. Severe obstetrical hemorrhage can lead to
postpartum necrosis of the pituitary second-
6.4.4.2 Prolactin-Secreting ary to prolonged and/or severe hypotension or
Adenomas shock [52]. The low-pressure vascular system
and Hyperprolactinemia in pituitary combined with pituitary hyper-
Lactotroph tumors or prolactin-secreting trophy during pregnancy increases vascular
adenomas comprise 40% of pituitary tumors. demand without a commensurate increase in
Hyperprolactinemia is the most common eti- blood flow [1]. Therefore, prolonged disrup-
ology of amenorrhea due to pituitary dys- tion in blood flow can easily lead to pituitary
function [3]. Furthermore up to one-third of ischemia and subsequent necrosis. Symptoms
indicative of pituitary hypofunction include ACTH excess is from a pituitary tumor and
fatigue, slow mentation, hypotension, nausea/ termed Cushing’s disease. If the CRH stimu-
vomiting, and lack of lactation [53]. Imaging lation test and HD-DST are negative, then
consisting of a brain MRI will likely show one is likely dealing with Cushing’s syndrome
a severely attenuated pituitary gland or an due to an ectopic source of ACTH, often a
empty sella turcica filled with cerebrospinal bronchial carcinoid lung tumor [45].
fluid [53].
6.4.4.6 Postirradiation
6.4.4.4 Pituitary Apoplexy Hypopituitarism
This is a serious condition seen in 2–12% Therapeutic radiation when used to treat mid-
of patients with pituitary adenomas [54]. It line nasopharyngeal/brain/pituitary tumors
involves abrupt hemorrhage into often non- can lead to local tissue destruction and later
functioning pituitary tumors. Patients typi- result in hypopituitarism and amenorrhea. In
6 cally present with abrupt, severe headaches one retrospective review of patients getting up
and visual disturbances. Substantial fatigue to 60–70Gy of fractionated radiation to the
and even loss of consciousness (LOC) may pituitary, 17–55% developed some degree of
also occur. Precipitating factors include an hypopituitarism [56]. Common hormone defi-
acute increase in intracranial pressure, arte- ciencies (from most likely to least) are growth
rial hypertension, hemorrhage due to anti- hormone (GH), gonadotropin (FSH/LH),
coagulation, and even dynamic testing. If ACTH, and TSH. Symptoms can develop
this condition is suspected, head CT or brain decades after irradiation, which can include
MRI will often show a hemorrhagic or even fatigue, hypotension, signs of hypoestrogen-
necrotic pituitary tumor. Treatment is almost ism (vaginal dryness, vasomotor symptoms),
exclusively dependent on neurosurgical inter- and amenorrhea [56]. Such patients require
vention; however, in cases without visual close follow-up to address any hormone defi-
disturbance and lack of LOC, conserva- ciencies.
tive management is increasingly being used.
Additionally assessment of other potentially
life-
threatening conditions, such as cortisol 6.4.5 Acquired Disorders
deficiency and other pituitary deficits, should of the Genital Tract
be performed [55].
Acquired anatomical causes of amenorrhea
6.4.4.5 Cushing’s Disease stem primarily from the development of
and Syndrome intrauterine adhesions, commonly known as
Excess adrenal function due to a pituitary Asherman’s syndrome (AS). AS comprises
or ectopic source of ACTH can also lead to 7% of all cases of secondary amenorrhea.
amenorrhea. Once a patient presents with Any procedure that can potentially denude
signs and symptoms suggestive of cortisol the endometrium past the stratum basalis
excess, screening tests such as the low-dose and thereby prevent normal regeneration of
dexamethasone suppression test, late-night the endometrial lining can result in AS. The
salivary cortisol, and the 24-hr urine free degree of AS can lead to cyclic pain due to
cortisol collection should be performed to obstructed menses, and, similar to women
confirm cortisol excess. ACTH level then with imperforate hymen or a transverse vagi-
can be drawn to determine if the excess is nal septum, these patients are at higher risk
an A CTH-dependent or ACTH-independent of developing endometriosis [57]. Treatment
process. If found to be ACTH-dependent, for AS typically involves gentle cervical dila-
and subsequent provocative testing using a tion with hysteroscopic excision of scar tissue.
corticotropin-releasing hormone (CRH) stim- Placement of an intrauterine balloon for at
ulation and high-dose dexamethasone sup- least 7 days postoperatively is often done with
pression test (HD-DST) is positive, then the concomitant hormone replacement to ensure
Amenorrhea
151 6
that lining regrows properly [58]. Another The vast majority (90%) of POI cases
acquired cause of outflow obstruction is cer- are idiopathic. However, it can be associated
vical stenosis, which can stem from excisional with a myriad of underlying pathologies, as
procedures for the treatment of cervical dys- outlined in . Table 6.2. For example, many
plasia such as electrocautery and cold-knife instances of POI have genetic causes/chro-
cone biopsies. mosomal abnormalities such as fragile X syn-
drome [59]. In the case of fragile X syndrome,
a family history of early menopause and espe-
6.4.6 Primary Ovarian Insufficiency cially of male developmental delay is typically
found. For patients experiencing POI before
Approximately 10% of women experience the age of 30, a karyotype is warranted to
menopause by the age of 45, well before the rule out Turner’s syndrome and to determine
average age of menopause of 51.2 [1]. Such if a Y chromosome is present, which would
patients experience early ovarian aging that necessitate gonadectomy to reduce the risk
is most likely due to early follicle depletion. of gonadal malignancy [60]. It must be noted
Patients who experience signs of menopause that POI patients have a 6% chance of achiev-
before the age of 40 and have elevated FSH ing a spontaneous pregnancy. Hence, contra-
levels (>30–40 IU/L) on two occasions more ceptive counseling should be performed [61].
than a month apart meet the criteria for pri- Autoimmune disease accounts for approx-
mary ovarian insufficiency (POI). POI, which imately 5% of cases of POI [62]. In particular,
arises from follicular dysfunction and deple- POI is associated with autoimmune adrenal
tion, comprises 4–18% of cases of secondary and thyroid conditions. While antithyroid
amenorrhea. antibodies (anti-thyroglobulin and anti-TPO)
.. Table 6.2 Causes of primary ovarian insufficiency [3]
X chromosomal Structural alterations With the stigmata of Turner syndrome (45,X or mosaic)
causes or mutations in or
Without the stigmata of Turner Mutations in
absence of an X
syndrome premature ovarian
chromosome
failure 1 (Xq26-q28)
Mutations in
premature ovarian
failure1 in association
with Fragile X
premutation (Xq27.3)
Mutations in
premature ovarian
failure 2A (Xq22)
Mutations in
premature ovarian
failure 2B (Xq21)
Mutations in
premature ovarian
failure 4 in association
with mutations in bone
morphogenetic protein
15 (Xp11.2
Trisomy X with or without mosaicism
(continued)
Mutations Mutations in Xp22.11-p21.2 (Swyer syndrome)

associated with
Mutations in 5 cen
a 46,XY
karyotype
Autosomal Mutations involving Galactosemia (galactose-1-phosphate uridyltransferase
causes enzymes important for deficiency) (9p13)
reproduction
17α-Hydroxylase deficiency (CPY17A1) (10q24.3)
Mutations involving Mutations of luteinizing hormone or follicle-stimulating
reproductive hormone or both rendering them biologically inactive (theoreti-
hormones, their cal)
receptors, and action
6 Mutations of inhibin (theoretical)
Receptor mutations Follicle-stimulating
hormone receptor
(2p21-p16)
Luteinizing hormone/
human chorionic
gonadotropin
receptor (2p21)
Mutations in the hormone action pathways
Other mutations Blepharophimosis, ptosis, and epicanthus inversus, type 1
(BPES) (premature ovarian failure 3) (3q23)
Premature ovarian failure 5 (newborn ovary homeobox) (7q35)
Autoimmune polyendocrine syndrome, type 1(APS1) (autoim-
mune polyendocrinopathy-candidiasis-ectodermal dystrophy,
APECED) (autoimmune regulator gene, AIRE) (21q22.3)
Vanishing white matter leukodystrophy with ovarian failure
(genes encoding the translation initiation factor E1F2B) (14q24,
Chr 12, 1p34.1, 3q27, 2p23.3)
Congenital disorders of glycosylation, type 1a (CDG1a) (genes
encoding phosphomannomutase-2, PMM2) (16p13.3-p13.2)
Environmental Chemotherapeutic (especially alkylating) agents
insults
Ionizing radiation
Viral infection (documented for mumps)
Surgical injury or extirpation
Immune In association with other autoimmune diseases
disturbances
Isolated
In association with congenital thymic aplasia
Idiopathic causes
Amenorrhea
153 6
are the most common autoimmune antibod- A. Obtain an ultrasound to assess for
ies seen in POI patients, those that have anti- a uterus.
adrenal/anti-steroidogenic enzyme antibodies B. Obtain a karyotype.
(e.g., 21-hydroxylase) are at greater risk of C. Recommend that she proceed to
developing autoimmune oophoritis [62, 63]. gonadectomy.
Therefore, any patients with such positive D. Perform a brain MRI.
antibodies should have their adrenal function E. All of the above.
assessed. Addison’s disease patients can also
experience POI 8–14 years prior to the devel- ??2. A 28-year-old G2P1 presents to your
opment of adrenal insufficiency [64]. Any clinic with 3 weeks of nipple discharge,
patient positive for anti-adrenal antibodies and menses have been absent for the
should have an AM serum cortisol checked past 4 months (previously monthly).
and, if less than 18 mg/dL, should undergo an Her primary care physician obtained
ACTH stimulation test [65]. a random prolactin level which was
A key point to note is that POI and early 96 ng/mL; beta-HCG was negative. Her
menopause are associated with higher all- mother had breast cancer and her sister
cause mortality in numerous studies. In paris BRCA1 positive. What is the next best
ticular, there is a higher risk of cardiovascular step in management?
disease and osteoporosis [66, 67]. Hence, judi- A. Proceed with a breast exam.
cious use of hormone replacement therapy is B. Obtain a morning, fasting prolac-
essential for these patients at least up until the tin.
age of natural menopause [68]. C. Perform a brain MRI.
D. Perform a mammogram.
6.4.6.1 ther Causes of Primary
O
Ovarian Insufficiency ??3. Your new patient is a 19-year-old G2P0
Patients with FSH abnormalities and defects who present with missed menses for
in steroidogenesis, such as 17-hydroxylase the past 3 months. This patient is also
deficiency, can also lead to POI [69]. Patients experiencing increasing vaginal dryness.
with these conditions typically exhibit an ele- She also has a maternal male cousin
vated FSH level. In addition, metabolic dis- with developmental delay. Her history is
orders, such as galactosemia resulting from notable for two surgical pregnancy ter-
a deficiency of galactose-1-phosphate uridyl minations. All pregnancy tests have been
transferase, can lead to POI. Fortunately, negative. The remainder of her history
galactosemia is typically diagnosed shortly is unremarkable. Which test is the most
after birth due to intolerance of milk and helpful in determining the diagnosis?
signs of galactose excess [70]. A. Saline-infusion sonography
B. TSH
C. FSH
6.5 Review Questions D. Karyotype
E. All of the above
??1. A 15-year-old G0 is seen for primary
amenorrhea. Her exam is notable for ??4. In the course of evaluating an 18-year-old
Tanner stage 5 breast development, an for primary amenorrhea, you note that
absence of pubic hair, and truncal obe- her karyotype is 45 XO consistent with
sity. She has been sexually active for the Turner’s syndrome. Her cardiac evalua-
past year, but intercourse remains pain- tion is unremarkable, and you counsel her
ful. She also complains of persistent on her reproductive outlook. Her AMH
headaches over the past 6 months. What is 0.04 ng/mL. What is the best character-
is your next step in management? ization of her ability to conceive?
A. While unlikely, she still has a 6% 9. Chandler TM, Machan LS, Cooperberg PL,
chance of conceiving. Harris AC, Chang SD. Mullerian duct anoma-
lies: from diagnosis to intervention. Br J Radiol.
B. It will be impossible for her to con-
2009;82(984):1034–42.
ceive. 10. Timmreck LS, Reindollar RH. Contemporary
C. She will need in vitro fertilization issues in primary amenorrhea. Obstet Gynecol
to achieve conception. Clin N Am. 2003;30(2):287–302.
11. Allybocus ZA, Wang C, Shi H, Wu
Q. Endocrinopathies and cardiopathies in patients
with Turner syndrome. Climacteric. 2018;21(6):
6.6 Answers 536–41.
12. McDonough PG, Byrd JR. Gonadal dysgenesis.
vv1. A Clin Obstet Gynecol. 1977;20(3):565–79.
13. Committee on Adolescent Health Care. ACOG
Committee Opinion No. 728: Müllerian agenesis:
vv2. A
6 diagnosis, management, and treatment. Obstet
Gynecol. 2018;131(1):e35–42.
vv3. C 14. Simpson JL. Genetics of the female reproductive
ducts. Am J Med Genet. 1999;89(4):224–39.
vv4. A 15. Bjørsum-Meyer T, Herlin M, Qvist N, Petersen
MB. Vertebral defect, anal atresia, cardiac defect,
tracheoesophageal fistula/esophageal atresia, renal
defect, and limb defect association with Mayer-
References Rokitansky- Küster-Hauser syndrome in co-
occurrence: two case reports and a review of the
1. Fritz M, Speroff L. In: Taylor HS, Seli E, Pal L, literature. J Med Case Rep. 2016;10(1):374.
editors. Clinical gynecologic endocrinology and 16. Stamou MI, Georgopoulos NA. Kallmann
infertility. Philadelphia: Wolters Kluwer Health/ syndrome: phenotype and genotype of hypo-
Lippincott Williams & Wilkins; 2020. gonadotropic hypogonadism. Metabolism.
2. Marsh CA, Grimstad FW. Primary amenorrhea: 2018;86:124–34.
diagnosis and management. Obstet Gynecol Surv. 17. Beneduzzi D, Trarbach EB, Min L, Jorge
2014;69(10):603–12. AA, Garmes HM, Renk AC, et al. Role of
3. Practice Committee of American Society for gonadotropin- releasing hormone receptor muta-
Reproductive Medicine. Current evaluation of tions in patients with a wide spectrum of pubertal
amenorrhea. Fertil Steril. 2008;90(5 Suppl): delay. Fertil Steril. 2014;102(3):838–46.e2.
S219–25. 18. Fourman LT, Fazeli PK. Neuroendocrine causes
4. Sims J, Lutz E, Wallace K, Kassahun- of amenorrhea--an update. J Clin Endocrinol
Yimer W, Ngwudike C, Shwayder J. Depo- Metab. 2015;100(3):812–24.
medroxyprogesterone acetate, weight gain and 19. Desai SS, Roy BS, Mahale SD. Mutations and
amenorrhea among obese adolescent and adult polymorphisms in FSH receptor: functional impli-
women. Eur J Contracept Reprod Health Care. cations in human reproduction. Reproduction.
2020;25(1):54–9. 2013;146(6):R235–48.
5. Luciano AA. Clinical presentation of hyperpro- 20. Gromoll J, Simoni M, Nordhoff V, Behre HM,
lactinemia. J Reprod Med. 1999;44(12 Suppl): De Geyter C, Nieschlag E. Functional and clinical
1085–90. consequences of mutations in the FSH receptor.
6. Miller KK, Rosner W, Lee H, Hier J, Sesmilo G, Mol Cell Endocrinol. 1996;125(1–2):177–82.
Schoenfeld D, et al. Measurement of free testos- 21. Toledo SP, Brunner HG, Kraaij R, Post M, Dahia
terone in normal women and women with andro- PL, Hayashida CY, et al. An inactivating muta-
gen deficiency: comparison of methods. J Clin tion of the luteinizing hormone receptor causes
Endocrinol Metab. 2004;89(2):525–33. amenorrhea in a 46,XX female. J Clin Endocrinol
7. Kamilaris TC, DeBold CR, Manolas KJ, Metab. 1996;81(11):3850–4.
Hoursanidis A, Panageas S, Yiannatos J. 22. Harrington J, Palmert MR. Clinical review:
Testosterone-secreting adrenal adenoma in a peri- distinguishing constitutional delay of growth
pubertal girl. JAMA. 1987;258(18):2558–61. and puberty from isolated hypogonadotropic
8. Robbins JB, Broadwell C, Chow LC, Parry JP, hypogonadism: critical appraisal of available

Sadowski EA. Müllerian duct anomalies: embry- diagnostic tests. J Clin Endocrinol Metab. 2012;
ological development, classification, and MRI 97(9):3056–67.
assessment. J Magn Reson Imaging. 2015;41(1): 23. Jagiello J. Prevalence of testicular feminization.
1–12. Lancet. 1962;1:329.
Amenorrhea
155 6
24. Hughes IA, Werner R, Bunch T, Hiort O. Androgen ate gonadotropin secretion in polycystic ovary syn-
insensitivity syndrome. Semin Reprod Med. drome. J Clin Invest. 1976;57(5):1320–9.
2012;30(5):432–42. 39. Lobo RA, Carmina E. The importance of diag-
25. Deans R, Creighton SM, Liao LM, Conway nosing the polycystic ovary syndrome. Ann Intern
GS. Timing of gonadectomy in adult women with Med. 2000;132(12):989–93.
complete androgen insensitivity syndrome (CAIS): 40. Fauser BC, Tarlatzis BC, Rebar RW, Legro
patient preferences and clinical evidence. Clin RS, Balen AH, Lobo R, et al. Consensus on
Endocrinol. 2012;76(6):894–8. women’s health aspects of polycystic ovary syn-
26. Amitai E, Lior Y, Sheiner E, Saphier O, Leron drome (PCOS): the Amsterdam ESHRE/ASRM-
E, Silberstein T. The impact of hymenectomy on Sponsored 3rd PCOS Consensus Workshop
future gynecological and obstetrical outcomes. J Group. Fertil Steril. 2012;97(1):28–38.e25.
Matern Fetal Neonatal Med. 2020;33(8):1400–4. 41. Legro RS, Arslanian SA, Ehrmann DA, Hoeger
27. Williams CE, Nakhal RS, Hall-Craggs MA, Wood KM, Murad MH, Pasquali R, et al. Diagnosis
D, Cutner A, Pattison SH, et al. Transverse vagi- and treatment of polycystic ovary syndrome: an
nal septae: management and long-term outcomes. Endocrine Society clinical practice guideline. J
BJOG. 2014;121(13):1653–8. Clin Endocrinol Metab. 2013;98(12):4565–92.
28. Meczekalski B, Katulski K, Czyzyk A, Podfigurna- 42. Franik S, Eltrop SM, Kremer JA, Kiesel L,
Stopa A, Maciejewska-Jeske M. Functional Farquhar C. Aromatase inhibitors (letrozole) for
hypothalamic amenorrhea and its influence on subfertile women with polycystic ovary syndrome.
women’s health. J Endocrinol Investig. 2014;37(11): Cochrane Database Syst Rev. 2018;5(5):Cd010287.
1049–56. 43. Practice Committee of the American Society
29. Golden NH, Carlson JL. The pathophysiology of for Reproductive Medicine. Electronic address:
amenorrhea in the adolescent. Ann N Y Acad Sci. ASRM@asrm.org; Practice Committee of the
2008;1135:163–78. American Society for Reproductive Medicine. Role
30. Gordon CM, Ackerman KE, Berga SL, Kaplan of metformin for ovulation induction in infertile
JR, Mastorakos G, Misra M, et al. Functional patients with polycystic ovary syndrome (PCOS):
hypothalamic amenorrhea: an Endocrine Society a guideline. Fertil Steril. 2017;108(3):426–41.
clinical practice guideline. J Clin Endocrinol 44. Boomsma CM, Eijkemans MJ, Hughes EG,
Metab. 2017;102(5):1413–39. Visser GH, Fauser BC, Macklon NS. A meta-
31. Berga SL. Behaviorally induced reproductive analysis of pregnancy outcomes in women with
compromise in women and men. Semin Reprod polycystic ovary syndrome. Hum Reprod Update.
Endocrinol. 1997;15(1):47–53. 2006;12(6):673–83.
32. Hergenroeder AC, Smith EO, Shypailo R, Jones 45. Barnett R. Cushing’s syndrome. Lancet. 2016;
LA, Klish WJ, Ellis K. Bone mineral changes in 388(10045):649.
young women with hypothalamic amenorrhea 46. El-Maouche D, Arlt W, Merke DP. Congenital
treated with oral contraceptives, medroxyproges- adrenal hyperplasia. Lancet. 2017;390(10108):
terone, or placebo over 12 months. Am J Obstet 2194–210.
Gynecol. 1997;176(5):1017–25. 47. Schlechte J, Dolan K, Sherman B, Chapler F,
33. Jacobs HS, Knuth UA, Hull MG, Franks S. Post- Luciano A. The natural history of untreated
“pill” amenorrhoea--cause or coincidence? Br Med hyperprolactinemia: a prospective analysis. J Clin
J. 1977;2(6092):940–2. Endocrinol Metab. 1989;68(2):412–8.
34. Steele SJ, Mason B, Brett A. Amenorrhoea after 48. Kleinberg DL, Noel GL, Frantz AG. Galactorrhea:
discontinuing combined oestrogen-progestogen a study of 235 cases, including 48 with pituitary
oral contraceptives. Br Med J. 1973;4(5888):343–5. tumors. N Engl J Med. 1977;296(11):589–600.
35. Schwallie PC, Assenzo JR. The effect of depo- 49. Schlechte J, Sherman B, Halmi N, VanGilder J,
medroxyprogesterone acetate on pituitary and Chapler F, Dolan K, et al. Prolactin-secreting pitu-
ovarian function, and the return of fertility follow- itary tumors in amenorrheic women: a comprehen-
ing its discontinuation: a review. Contraception. sive study. Endocr Rev. 1980;1(3):295–308.
1974;10(2):181–202. 50. Chen L, White WL, Spetzler RF, Xu B. A prospec-
36. Fotherby K, Howard G. Return of fertility in tive study of nonfunctioning pituitary adenomas:
women discontinuing injectable contraceptives. J presentation, management, and clinical outcome. J
Obstet Gynaecol (Lahore). 1986;6 Suppl 2:S110–5. Neuro-Oncol. 2011;102(1):129–38.
37. Lauritsen MP, Bentzen JG, Pinborg A, Loft A, 51. Melmed S, Casanueva FF, Hoffman AR,
Forman JL, Thuesen LL, et al. The prevalence of Kleinberg DL, Montori VM, Schlechte JA, et al.
polycystic ovary syndrome in a normal population Diagnosis and treatment of hyperprolactinemia:
according to the Rotterdam criteria versus revised an Endocrine Society clinical practice guideline. J
criteria including anti-Mullerian hormone. Hum Clin Endocrinol Metab. 2011;96(2):273–88.
Reprod. 2014;29(4):791–801. 52. Sheehan HL, Murdoch R. Postparum necrosis of
38. Rebar R, Judd HL, Yen SS, Rakoff J, Vandenberg the interior pituitary: pathological and clinical
G, Naftolin F. Characterization of the inappropri- aspects. J Obstet Gynaecol Br Emp. 1938;45:456.
53. Kilicli F, Dokmetas HS, Acibucu F. Sheehan’s syn- auto-immune adrenal insufficiency in young
drome. Gynecol Endocrinol. 2013;29(4):292–5. women with spontaneous premature ovarian fail-
54. Briet C, Salenave S, Bonneville JF, Laws ER, ure. Hum Reprod. 2002;17(8):2096–100.
Chanson P. Pituitary apoplexy. Endocr Rev. 64. Turkington RW, Lebovitz HE. Extra-adrenal
2015;36(6):622–45. endocrine deficiencies in Addison’s disease. Am J
55. Barkhoudarian G, Kelly DF. Pituitary apoplexy. Med. 1967;43(4):499–507.
Neurosurg Clin N Am. 2019;30(4):457–63. 65. Kim TJ, Anasti JN, Flack MR, Kimzey LM,
56. VanKoevering KK, Sabetsarvestani K, Sullivan Defensor RA, Nelson LM. Routine endocrine
SE, Barkan A, Mierzwa M, McKean EL. Pituitary screening for patients with karyotypically normal
dysfunction after radiation for anterior skull base spontaneous premature ovarian failure. Obstet
malignancies: incidence and screening. J Neurol Gynecol. 1997;89(5 Pt 1):777–9.
Surg B Skull Base. 2020;81(1):75–81. 66. Gong D, Sun J, Zhou Y, Zou C, Fan Y. Early age at
57. March CM. Management of Asherman’s syn- natural menopause and risk of cardiovascular and
drome. Reprod Biomed Online. 2011;23(1):63–76. all-cause mortality: a meta-analysis of prospec-
58. Yang X, Liu Y, Li TC, Xia E, Xiao Y, Zhou F, et al. tive observational studies. Int J Cardiol. 2016;203:
6 Durations of intrauterine balloon therapy and
adhesion reformation after hysteroscopic adhe- 67.
115–9.
Faubion SS, Kuhle CL, Shuster LT, Rocca
siolysis: a randomized controlled trial. Reprod WA. Long-term health consequences of premature
Biomed Online. 2020;40(4):539–46. or early menopause and considerations for man-
59. Nelson LM. Clinical practice. Primary ovarian agement. Climacteric. 2015;18(4):483–91.
insufficiency. N Engl J Med. 2009;360(6):606–14. 68. Committee opinion no. 698 summary: hormone
60. De Vos M, Devroey P, Fauser BC. Primary ovarian therapy in primary ovarian insufficiency. Obstet
insufficiency. Lancet. 2010;376(9744):911–21. Gynecol. 2017;129(5):963–4.
61. Committee opinion no. 605: primary ovarian 69. Kovanci E, Schutt AK. Premature ovarian fail-
insufficiency in adolescents and young women. ure: clinical presentation and treatment. Obstet
Obstet Gynecol. 2014;124(1):193–7. Gynecol Clin N Am. 2015;42(1):153–61.
62. Hoek A, Schoemaker J, Drexhage HA. Premature 70. Spencer JB, Badik JR, Ryan EL, Gleason TJ,
ovarian failure and ovarian autoimmunity. Endocr Broadaway KA, Epstein MP, et al. Modifiers of
Rev. 1997;18(1):107–34. ovarian function in girls and women with clas-
63. Bakalov VK, Vanderhoof VH, Bondy CA, Nelson sic galactosemia. J Clin Endocrinol Metab.
LM. Adrenal antibodies detect asymptomatic 2013;98(7):E1257–65.
157 7
Polycystic Ovary
Syndrome
Tommaso Falcone and William W. Hurd
Contents
7.2 Epidemiology – 159
7.3 Diagnosis of PCOS – 159

7.3.1 iagnostic Criteria – 159
D
7.3.2 Exclude Other Etiologies – 160
7.4 Pathophysiology – 161
7.5 Conditions Associated with PCOS – 161

7.5.1 I nsulin Resistance – 162
7.5.2 Diabetes Mellitus – 162
7.5.3 Obesity – 162
7.5.4 Metabolic Syndrome – 162
7.5.5 Infertility – 162
7.5.6 Endometrial Cancer – 163
7.6 Initial Evaluation – 163

7.6.1 istory – 163
H
7.6.3 Pelvic Ultrasound – 164
7.7 Laboratory Evaluation – 164

7.7.1 ndrogens – 164
A
7.7.2 Detecting Other Underlying Diseases – 165
7.7.3 Less Useful Laboratory Tests – 165

https://doi.org/10.1007/978-3-030-99596-6_7
7.8 Management – 166
7.8.1 eriodic Testing – 166
P
7.8.2 Treatment – 166
7.10 Answers – 168
References – 168
Polycystic Ovary Syndrome
159 7
Case Vignette
Key Points
55 Several different phenotypes of poly- A 24-year-old woman consults for irregular
cystic ovary syndrome (PCOS) exist periods. She has noticed slow increase in
based on the presence or absence of facial hair since puberty and mild acne. She
androgen excess, ovulatory dysfunction, used electrolysis to remove unwanted facial
and polycystic ovarian morphology. hair. She has never used the oral contracep-
55 Exclusion of other hyperandrogenic tive agent. On physical examination, her
disorders is necessary before diagnosing body mass index (BMI) is 35 kg/m2, her
PCOS. Ferriman-Gallwey score is 6, and she has
55 Women with PCOS should be assessed no signs of virilization. Initial laboratory
for commonly associated mood, body evaluation reveals a normal serum prolac-
image, and eating disorders. tin and TSH, and mildly elevated total tes-
55 As many as 30% of women with PCOS tosterone. You order a test to exclude an
will not be overweight or obese. adrenal cause of her condition.
55 Lifestyle changes, such as diet and exer-
cise, should be included in the man-
agement plans of obese women with 7.2 Epidemiology
PCOS.
55 Metabolic abnormalities associated with PCOS is the single most common endocrine
PCOS should be actively managed to disorders among reproductive-aged women
decrease the risk of cardiovascular disease. throughout the world, with an estimated prev-
55 Combined estrogen-progestin con- alence ranging from 6% to 15% [1]. Prevalence
traceptives are the most useful and estimates vary as a result of the diagnostic cri-
frequently used pharmacologic inter- teria used and ethnicity of the population, as
vention for women with PCOS not cur- well as the study design used.
rently pursuing fertility. The worldwide incidence of PCOS has
somewhat increased over the last decades.
However, this increase appears to be much
less than the increased incidence of obesity.
7.1 Introduction This supports the concept that, although
obesity and related insulin resistance play a
Polycystic ovary syndrome (PCOS) is one of causal role in many women with PCOS, obe-
the most common hormonal conditions diag- sity results in PCOS only in women that are
nosed in reproductive-aged women with some metabolically predisposed to this condition.
combination of androgen excess, ovulatory
dysfunction, and/or ovaries with polycystic
morphology, in the absence of other causal dis- 7.3 Diagnosis of PCOS
ease processes. The underlying etiologies of this
complex gynecologic-endocrine disorder vary 7.3.1 Diagnostic Criteria
among individuals, and manifest as at least four
heterogeneous phenotypes that include meta- PCOS is defined by three conditions, clinical
bolic and reproductive components. Women or hormonal evidence of androgen excess,
with PCOS are at increased risk for a number of ovulatory dysfunction, and polycystic mor-
morbidities, including infertility, obesity, type 2 phology on ultrasound, after other under-
diabetes mellitus, endometrial cancer, and met- lying conditions have been excluded. These
abolic disorders that increase the risk of cardio- three conditions form the basis of commonly
vascular disease. In this chapter, we will briefly used diagnostic criteria: (a) US National
present PCOS epidemiology and pathophysiol- Institutes of Health (NIH) criteria, (b)
ogy followed by a cogent approach to diagnosis, Androgen Excess-Polycystic Ovary Syndrome
treatment, and long-term follow-up. (AE-PCOS) Society Criteria, and (c) Rotter-
160 T. Falcone and W. W. Hurd
dam criteria developed by a consensus panel haps most commonly used of these is the Rot-
of the European Society of Human Repro- terdam criteria, which requires the presence
duction and Embryology (ESHRE) and the of any two of these three conditions.
American Society for Reproductive Medicine
(ASRM) (. Table 7.1). The broadest and per-
7.3.2 Exclude Other Etiologies
.. Table 7.1 Most commonly used PCOS Any of the three conditions used to diagnose
diagnostic criteria PCOS can be the result of other underlying
conditions (. Table 7.2). Androgen excess
Criteria Necessary conditions for
can be the result of congenital adrenal
diagnosis
enzyme deficiency (nonclassical congenital
NIH Must include hyperandrogen- adrenal hyperplasia) or neoplasm originat-
ism ing in the ovary or adrenal gland. Ovulatory
and dysfunction can result from a number of
7 Oligo- or anovulation
diseases specific to the hypothalamic-pitu-
itary-ovarian axis (e.g., hyperprolactinemia)
AE-PCOS Must include hyperandrogen- or systemic disease such as hypothyroid-
Society ism ism or Cushing syndrome. Polycystic ovary
and either morphology (i.e., >12 antral follicles visu-
alized by ultrasound) is a normal finding
Oligo-ovulation/anovulation
in women under 25 years of age, and com-
or mon in women with hypothalamic amenor-
Polycystic ovary morphology rhea. A diagnosis of PCOS should be made
with caution in adolescents, since most will
Rotterdam Must include two of the
following: have polycystic ovary morphology on ultra-
sound, and many will have puberty-related
Hyperandrogenism
anovulatory cycles and signs of androgen
Oligo-ovulation/anovulation excess (acne) which resolve with maturation.
Polycystic ovary morphology Screening tests for these conditions are dis-
cussed below.
.. Table 7.2 Common conditions that can mimic PCOS
Associated conditions
Androgen excess Ovulatory dysfunction Polycystic ovary morphology
Nonclassical CAH X X
Ovarian tumors X X
Adrenal tumors X X
Hypothyroidism X X
Hyperprolactinemia X
Hypothalamic amenor- X X
rhea
Adolescence X X X
Women < 25 years old X
Abbreviation: CAH congenital adrenal hyperplasia

161 7
7.4 Pathophysiology abnormalities of gonadotropin secretion
occur as a result of abnormal GnRH pulses.
The pathogenesis of PCOS is complex and Alterations in LH pulse frequency, amplitude,
can differ between women with this syndrome. and concentration appear to be dampened in
Specific gene mutations cannot be identified the presence of obesity [4]. Overexpression of
in the majority of these patients. In some LH receptors on stromal and thecal cells can
women, PCOS appears to be the result of be associated with increased production of
an interaction between obesity-related insu- androgens.
lin resistance and increased genetic suscepti- However, gonadotropin abnormalities
bility. To complicate matters, the syndrome cannot be identified in all women with PCOS,
itself appears to predispose to weight gain. and other hormonal aberrations have been
However, at least 1/3 of women with PCOS identified. Increased intraovarian androgen
are not obese, and the dramatic world obe- levels can result in abnormal follicle devel-
sity epidemic has not resulted in proportional opment. Increased anti-Mullerian hormone
increase in PCOS. Although obesity alone (AMH) levels appear to accentuate abnormal
does not appear to a cause PCOS, it does folliculogenesis.
worsen many aspects of the PCOS phenotype,
especially those that increase cardiovascular
risk [2]. 7.5 Conditions Associated
Insulin resistance with compensatory
with PCOS
increase in insulin is found in up to 90% of
obese, and at least 25% of nonobese PCOS
A number of gynecologic and non-gyneco-
patients. Increased insulin reduces hepatic
logic conditions are associated with PCOS
secretion of sex hormone-binding globulin
(7 Box 7.1).
(SHBG) and increases androgen secretion
by the ovaries most likely by stimulating glu-
cose transporter (GLUT4) expression [3].
The severity of insulin resistance correlates Box 7.1 Disorders Associated with PCOS
with the severity of a number of associated 55 Gynecologic
symptoms, including ovulatory dysfunction, –– Endometrial cancer
hirsutism, metabolic abnormalities, and sleep –– Infertility
apnea. –– Ovulatory dysfunction
Total and free androgens are often mildly –– Abnormal uterine bleeding
increased in women with PCOS. Testosterone 55 Non-gynecologic
is derived primarily from the ovarian, fol- –– Hyperandrogenism
lowed by peripheral conversion. DHEAS is –– Insulin resistance, hyperinsulinemia,
produced exclusively in the adrenal glands. glucose intolerance
Androstenedione is derived primarily from –– Obesity
the ovaries followed by adrenal glands. –– Metabolic syndrome
Androgens are bound to SHBG, and the –– Hypertension
effects of androgens are magnified by the –– Abnormal lipid profiles
decreased SHBG often found in women with –– Cardiovascular disease
PCOS. This explains why even mildly elevated –– Sleep apnea
or upper normal-range testosterone may have –– Nonalcoholic liver disease
androgenic effects. –– Mood disorders (anxiety, depres-
In some women with PCOS, hyperandro- sion)
genicity is explained, at least in part, by an
increased LH/FSH ratio. In these women,
7.5.1 Insulin Resistance [7]. These guidelines have been endorsed by

several societies.
Insulin resistance (IR) is believed to play a
causal role in PCOS particularly in obese
women. IR is present in at least 90% of obese 7.5.3 Obesity
women and more than 25% of nonobese
women with PCOS. The incidence of obesity in women with
Insulin resistance is diagnosed in women PCOS varies from 30% to 80% depending on
with PCOS who have glucose intolerance, i.e., the populations studied [6, 8]. The relation-
type 2 DM or prediabetes. In the remainder ship between PCOS and obesity is complex,
of these women, there is no standard clinical since PCOS appears to result in obesity in
test for IR. As a result, some clinicians make some women, while at the same time, obesity-
a presumptive diagnosis of IR in women associated insulin resistance (IR) appears to
with elevated insulin levels, either fasting or play a causal role in some of the clinical mani-
2 hours after a standard glucose load. For festations of PCOS, including hirsutism and
7 practical purposes, most obese women with anovulation. As a result, weight loss for obese
PCOS can be presumed to have IR, whereas a women with PCOS will, in part, reverse these
much smaller percentage of lean women with clinical manifestations. However, the major-
PCOS will have IR. ity of women with obesity will not develop
PCOS, indicating that a metabolic predisposi-
tion must be present for women before PCOS
7.5.2 Diabetes Mellitus develops [2].
At least 10% of women presenting with PCOS

will be found to have type 2 diabetes mellitus 7.5.4 Metabolic Syndrome
(DM), and an additional 2% will develop type
2 DM annually thereafter [5]. For this reason, Metabolic syndrome is defined as a group of
all women diagnosed with PCOS should be metabolic disorders including insulin resis-
evaluated for type 2 DM initially and at regu- tance, hyperlipidemia, central obesity, and
lar intervals thereafter. hypertension. Women with this syndrome are
Several DM screening strategies have been at increased risk for diabetes and cardiovas-
studied. Fasting glucose has been found to cular disease. Almost 50% of women with
be inaccurate for women with PCOS, and PCOS will meet the criteria for metabolic syn-
the 2-h glucose tolerance test (2hGTT) has drome, which is twice the rate of the general
thus become a standard method used to both population, even after adjusting for age and
screen for and diagnose type 2 DM in these BMI [9]. For this reason, women with PCOS
women. More recently, hemoglobin A1c should be regularly screened for hypertension
(HbA1c) has been shown to be an accurate and hyperlipemia in addition to glucose intol-
DM screening test in the general population erance, and those with abnormalities treated
and appears to give very similar results to the accordingly.
2hGTT in women with PCOS [6]. However, in
women with PCOS at higher risk for diabetes,
such as with a BMI of more than 25 kg/m2, 7.5.5 Infertility
history of impaired fasting glucose or glucose
tolerance, gestational diabetes, family history Women with PCOS will seek treatment for
of type 2 DM, and hypertension or ethnic infertility, primarily as a result of anovula-
groups at higher risk for DM, a 75 g OGTT tion but also due to obesity [10]. Weight loss
should be offered. Furthermore, women plan- as little as 5% can increase ovulation in obese
ning an immediate pregnancy or fertility treat- women with PCOS, and thus lifestyle modi-
ment should also be screened with 75 g OGTT fications are the first step in these women. In
163 7
women with PCOS and IR, insulin sensitizers bleeding, particularly after prolonged period
(e.g., metformin) also appear to increase ovu- of amenorrhea in the absence of progestin
lation, particularly those with a BMI >35 kg/ therapy.
m2.
Oral agents are the primary fertility treat-
ment for anovulatory women with PCOS, with 7.6 Initial Evaluation
the primary risk of multiple gestations occur-
ring in >5% if pregnancies [11]. Clomiphene The investigation of women who present with
citrate is the only FDA-approved oral medi- symptoms and signs of PCOS serves three
cation for ovulation induction and is reason- important goals: confirmation the diagnosis
ably effective for women with PCOS. The of PCOS, exclusion other underlying diagno-
aromatase inhibitor letrozole has been shown ses (. Table 7.2), and assessment for associ-
in several studies to have improved pregnancy ated disorders (7 Box 7.1). The evaluation
and live birth rates compared to clomiphene consists of history and physical examination,
citrate [11]. However, letrozole has yet to be transvaginal ultrasonography, and labora-
FDA approved for ovulation induction. tory evaluation. A tentative PCOS diagnosis
Injectable human gonadotropins have can often be made on the basis of history and
been used for ovulation induction for women physical examination in women with irregular
with PCOS resistant to oral agents. However, menses and hirsutism [7].
the risk of multiple gestations is increased
compared to oral agents, even when used with
the utmost of care [12]. 7.6.1 History
In vitro fertilization can lower the risk of
multiple gestations by appropriately limiting A thorough history should include a careful
the number of embryos transferred. Although family and past medical histories. PCOS is
significantly more expensive per cycle, the often a familial problem, and many women
ability to freeze embryos for subsequent preg- with PCOS will have multiple first or second
nancies make this a suitable option for some relatives with similar problems.
women with PCOS who do not conceive with It is important to characterize the pres-
oral ovulation induction agents. ence and onset of menstrual abnormality
and any clinical signs of androgen excess.
Menstrual irregularity can begin in women
7.5.6 Endometrial Cancer with PCOS immediately after menarche dur-
ing adolescence or later in life concurrent with
It is well established that women with PCOS weight gain. However, the use of oral contra-
have an increased risk of developing endome- ceptives can obscure menstrual irregularity.
trial hyperplasia and an approximately three- Additionally, some women with PCOS will
fold increased risk of endometrial cancer [13]. report regular uterine bleeding despite chronic
The most obvious link between PCOS and anovulation. These women will be unable to
endometrial cancer is anovulation resulting detect a mid-cycle luteal surge, and mid-luteal
in prolonged endometrial exposure to unop- serum progesterone will be low.
posed estrogen. However, hyperandrogenism The most common clinical manifestation
and prolonged elevated LH levels have also of androgen excess is hirsutism, with grad-
been proposed to play a role. ual increasing midline body hair on the face
Prevention of endometrial hyperplasia and/or lower abdomen. Acne can also be a
and cancer consists of progestin therapy as symptom of androgen excess, although the
discussed below when not trying to conceive. high incidence of acne during puberty makes
Early detection consists of surveillance with this symptom less helpful before the age of
transvaginal ultrasound and the liberal use 20. Rapid progression of hirsutism or signs
of endometrial biopsy for women with thick- of virilization (e.g., male-pattern hair loss,
ened endometrium and/or abnormal uterine clitoromegaly, deepening of the voice) are
uncommon for women with PCOS, increas-

ing the concern for an androgen-secreting
tumor.
7.6.2 Physical Examination
Two important aspects of the physical exam

are detecting clinical signs of androgen
excess and signs of other underlying illness
or of comorbidities. Body mass index (BMI),
blood pressure, and abdominal girth should
be assessed at every visit. Signs of androgen
.. Fig. 7.1 This is the classical image of PCOS with an
excess should be documented, including hir- enlarged ovary containing an increased number of small
sutism, acne, clitoromegaly, male-pattern hair follicles around the periphery of the cortex, resembling
7 loss, and voice deepening. Acanthosis nigri- a string of pearls, along with a bright echogenic stroma
cans (i.e., darkened velvety skin of the neck or
inner thigh) can result from hyperinsulinemia, Antral follicle count (AFC) is relatively
but is a relatively nonspecific finding that subjective, and an increased number of antral
can be associated with excess corticosteroids, follicles are normal in young women. For this
pineal tumors, and a number of other endo- reason, the diagnosis of PCOS should not be
crine disorders [14]. made based on an isolated ultrasound find-
Hirsutism can be quantified using the ing of polycystic ovary morphology in the
Ferriman-Gallwey score. A score >4–6 is consid- absence of other diagnostic criteria. This is
ered suggestive of hyperandrogenism. However, particularly important for adolescents and
the diagnosis of hirsutism can be made difficult women within 8 years of menarche, since
by the use of hair removal methods, and eth- most of them will have polycystic ovary mor-
nicity. Hair follicle concentration varies greatly phology using these definitions [16].
according to ethnicity. Consequently, hirsutism
is less common in women of East/Southeast
Asian, Native American, or Ashkenazi Jewish 7.7 Laboratory Evaluation
descent, whereas it is more common in Hispanic
women and those with ethnic origins in the Laboratory evaluation can confirm the diag-
Middle Eastern, South Asian, or African [15]. nosis of PCOS in women without clinical signs
of androgen excess and is essential for exclud-
ing other underlying diagnoses (. Table 7.2)
7.6.3 Pelvic Ultrasound or associated disorders (7 Box 7.1). Andro-
gen assessment is important both for anovu-
Typical polycystic ovary morphology on ultra- latory women with no clear demonstration
sound is present in the majority of women of clinical hyperandrogenism and for those
with PCOS [7]. The Rotterdam criteria defi- with symptoms suggestive of an androgen-
nition for polycystic ovary morphology is an secreting tumor.
antral follicle count (AFC) ≥12 and/or an
ovarian volume >10 cm3. However, modern
high-resolution ultrasound transducers will 7.7.1 Androgens
visualize AFC >12 in a large percentage of
reproductive-aged women. As a result, newer Androgens routinely measured include tes-
PCOS diagnostic criteria use an AFC >20 fol- tosterone (both free and total), dehydro-
licles in at least one ovary and/or an ovarian epiandrosterone sulfate (DHEAS), and
volume of >10 cm3 [7] (. Fig. 7.1). 17-hydroxyprogesterone. For women with-
165 7
out clinical signs of hyperandrogenism, Cushing syndrome is a relatively uncom-
mild elevation of free or total testosterone mon condition that can be confused with
or DHEAS fulfills one of the three diag- PCOS. However, this syndrome should be
nostic criteria for PCOS. However, marked considered in women with physical find-
elevation of testosterone (e.g., >150 ng/dL) ings suggestive of increased cortisol, such
is often the result of an ovarian or adrenal as central obesity, purple abdominal striae,
tumor, and marked DHEAS elevation (e.g., hypertension, and proximal muscle weakness.
>800 mcg/dL) warrants further evaluation of DHEAS levels can be normal or elevated in
an adrenal tumor. the presence of an ACTH-secreting pituitary
Several commonly used medications can tumor (Cushing disease) and normal or low
suppress ovarian androgen secretion, includ- in women with a steroid-secreting adrenal
ing hormonal contraception (both oral and tumor. The most sensitive screening test for
parenteral), spironolactone, and metformin. Cushing syndrome is a 24-hour urine cortisol
This makes the diagnosis of PCOS using measurement, since cortisol is normally high-
serum androgen levels less useful in women est during the day and low at night.
taking any of these medications. However,
there is little clinical advantage to discontinu-
ing these medications for 3 months before 7.7.3 Less Useful Laboratory Tests
repeat androgen testing in women who already
meet the diagnostic criteria for PCOS. Anti-Mullerian hormone (AMH) strongly
Early morning follicular phase17-hydroxy- correlates with AFC and is usually elevated
progesterone can be elevated in women with in women with PCOS. As a result, elevated
nonclassical congenital adrenal hyperplasia AMH has been suggested as a new criterion
(NCCAH), most commonly resulting from to diagnose PCOS. Although AMH has not
a 21-hydroxylase deficiency. However, some become a part of any of the standard PCOS
women with milder forms of NCCAH will diagnostic criteria, it remains a useful part of
have normal basal 17- hydroxyprogesterone a fertility evaluation, particularly for those
that becomes abnormally elevated only after considering IVF. Markedly elevated AMH
stimulation with an ACTH analog. Thus, an (range 4.9–8.4 ng/mL) is supportive of the
ACTH stimulation test is indicated if there is diagnosis of PCOS. However, assay variabil-
a high index of suspicion for this familial con- ity and lack of consensus on the threshold for
dition. DHEAS is not elevated in women with diagnosis have resulted in AMH being used
NCCAH [17]. as supportive of the diagnosis rather than
replacing ultrasound. COC suppresses AMH
and makes the determination equivocal.
7.7.2 etecting Other Underlying
D As with the limited utility of ultrasound in
Diseases adolescent patients suspected of having PCOS,
AMH also shows a similar weak association
Amenorrhea and oligomenorrhea have a num- with PCOS in this age group. Therefore, the
ber of causes other than PCOS (. Table 7.2). diagnosis of PCOS in adolescent age group
Pregnancy is certainly the most important, should rely solely on the presence of a men-
and HCG should be measured, even in women strual disorder and hyperandrogenism.
with years of menstrual abnormalities. Other It has been long appreciated that the ratio
subtle causes include hypothyroidism and of LH to FSH and the estrone level are often
hyperprolactinemia, and thus serum TSH elevated in women with PCOS. However, like
and prolactin are important screening tests AMH, this ratio and the estrone level are not
in these women. In women who appear to be part of any of the standard PCOS diagnostic
hypoestrogenic, measuring FSH and estradiol criteria. Since the results of these lab values
can help detect women with ovulation dys- rarely if ever help in the diagnosis or manage-
function on the basis of ovarian insufficiency ment, measuring them is not helpful in the
or hypogonadal hypogonadism. diagnosis of PCOS.
7.8 Management All women should be assessed for mood

disorders such as anxiety and depression with
Long-term management of women with PCOS simple questionnaires. The approach to con-
consists of regular surveillance of comorbidi- traception in women with PCOS should be
ties associated with this syndrome and active the same as other women, considering their
treatment of associated abnormalities and dis- risk factors and prevention of chronic expo-
eases. sure to unopposed estrogen. For this reason
the estrogen-progestin contraceptives are ideal
as they can also help with management of the
7.8.1 Periodic Testing hyperandrogenic problems. Management of
infertility secondary to anovulation associ-
Women with PCOS should be seen annually ated with PCOS is covered in a separate chap-
to detect and/or monitor associated comor- ter. However, the general principles are that
bidities. Physical examination should focus weight loss is important and that letrozole is
on blood pressure and weight. A transvaginal the agent of choice for ovulation induction.
7 ultrasound is indicated in women with abnor-
mal uterine bleeding, particularly if they are
not being treated with long-term hormonal 7.8.2 Treatment
suppression with progestins or COC.
Annual laboratory evaluation for obese For women with PCOS not currently desir-
women with PCOS should include a fasting ing pregnancy, management focuses on pre-
lipid profile and, for those not already deter- venting, detecting, and adequately treating
mined to be prediabetic or diabetic, a glucose comorbidities to optimize quality of life and
intolerance screening test. It has been appre- minimize long-term morbidity and mortality.
ciated for years that a fasting blood glucose Anovulation can be managed with cyclic
is not an adequate screening test for women combined oral contraceptives, progestin-only
with PCOS, and for this reason, a 2-hour oral contraceptives (e.g., oral, progestin-releasing
glucose tolerance test (2hOGTT) has been IUD, progestin depot, or implant) or cyclic
recommended as both a screening and diag- progestin with an alternate contraception
nostic test in these women. More recently, a plan. Long-term treatment of women with
HbA1C has been recognized as a less expen- PCOS with oral contraceptives has been
sive and accurate screening test for glucose shown to decrease the risk of endometrial
intolerance in the general population. Small cancer by at least 50% [13]. Although less well
studies have demonstrated that Hb1C and the studied, it is likely that other forms of chronic
2hGTT provide similar results in the PCOS progestin therapy are also effective. Such
population [6]. However, in high-risk patients therapy should be continued until pregnancy
with PCOS, the 75 g OGTT is still recom- is desired or until the natural age of meno-
mended [7]. pause to decrease the risk of abnormal uterine
Patients with sleep apnea should be bleeding and endometrial cancer.
referred to specialized sleep medicine centers. Type 2 DM and prediabetes can be man-
There are no special tests or imaging recom- aged with an oral insulin sensitizer (e.g., met-
mended for screening patients for endometrial formin), diet, increased exercise, and weight
cancer. Anovulation and chronic estrogen loss when appropriate. Some patients will
exposure without progesterone are associated become insulin-dependent. Hypertension and
with increased risk of endometrial cancer. lipid disorders should be managed using stan-
Furthermore obesity and increased insulin dard algorithms.
levels are independent risk factors for endo- Hirsutism can be managed cosmetically
metrial cancer. The strategy should be to pre- and medically with oral contraceptives to
vent chronic estrogen exposure by exposing increase SHBG production and, if neces-
the endometrium to progesterone including sary, spironolactone to block androgen recep-
the use of progestin intrauterine devices. tors. Women with refractory hirsutism can be
167 7
referred to a dermatologist who specializes in lism (VTE) but are not be considered first line.
treating hirsutism. Anti-androgens can be added after 6 months
The management of hyperandrogenic if no acceptable response is seen. The most
phenotypes such as acne, hirsutism, and hair commonly used anti-androgen is spironolac-
loss requires long-term intervention [7, 18]. tone. The starting dose is typically 50–100 mg
The initial medical intervention is with an twice daily. Other anti-androgens can be
oral combined estrogen-progesterone con- considered in women with severe androgenic
traceptive agent (COC). A low-dose estrogen manifestations. These drugs should never be
(20 mcg) progestin formulation containing a used without appropriate counseling and con-
low androgen profile progestin such as nor- traception. Mechanical methods such as elec-
ethindrone is recommended. If suppression is trolysis and laser treatment are effective. The
not achieved with a low-dose COC, a higher use of topical cream with eflornithine hydro-
dose (30–35 mcg) formulation can be offered. chloride (13.9%) can help, but recurrence is
Formulations with progestins with lower high after discontinuing the treatment. Insulin
androgen profile such as cyproterone acetate, sensitizers such as metformin are not effec-
and drospirenone, are acceptable in women tive. 7 Box 7.2 lists some general concepts of
with very low risk for venous thromboembo- management of patients with PCOS.
Box 7.2 International Evidence-Based Guideline for the Assessment of Polycystic Ovary
Syndrome [7]
55 Evidence-based recommendation- –– Pelvic ultrasound should not be used for
–– Serum total and free testosterone is diagnosis of PCOS in adolescents
used for biochemical confirmation of –– Endovaginal ultrasound diagnosis of PCOS
hyperandrogenism is made with a cut-off follicle number between
–– Serum AMH is not part of the diag- 2 and 9 mm per ovary of >20 and/or an ovar-
nostic criteria for PCOS ian volume of > of 10 mL
–– Combined oral contraceptives is recom- –– Screening for lipid disorders in overweight
mended for management of irregular and obese women
menstrual cycles and hyperandrogenism –– Screen for glucose intolerance
55 Clinical consensus recommendation –– Lifestyle modifications with diet and exer-
–– Documentation of anovulation cise should be part of all management
–– Documentation of hyperandrogenism strategies
The cornerstone of treatment for overweight is effective but compliance is low [19]. Bariatric
and obese women with PCOS is weight man- surgery should be considered in obese women
agement via diet and exercise. The goal is to with other serious comorbidities such as type 2
decrease the long-term health risks associated DM, hypertension, sleep apnea, nonalcoholic
with PCOS, including type 2 DM, cardiovas- fatty liver disease, and heart disease.
cular risk, and endometrial cancer, and to Women with PCOS seeking fertility can
optimize the chances of pregnancy for those usually be managed with an oral agent for
desiring children. ovulation induction (OI), with the addition
Obesity is a challenge to manage and of metformin for those with IR (see 7 Chap.
involves a multidisciplinary approach with 16). Those who do not conceive with oral OI
dieticians and other specialists. Standard medi- agents can be treated with either injectable
cal therapy with calorie restriction and exercise gonadotropins for OI or in vitro fertilization
(IVF), the latter of which has the advantage ??3. A 30-year-old woman presents with rap-
of a lower risk of multiple gestations. idly increasing facial and body hair and
Risks of adverse maternal-fetal complica- irregular periods over the last 6 months.
tions such as gestational diabetes should be On examination she has male-pattern
discussed. In addition to the maternal com- baldness and enlarged clitoris. A pelvic
plications associated with obesity and other ultrasound is normal. Which blood test
metabolic problems such as gestational diabe- would be most accurate to identify the
tes, there are data that show that the children cause?
of women with PCOS are at increased risk of A. DHEAS
offspring obesity from early age and diabetes B. Cortisol
in female offspring from late adolescence [20]. C. Free- Testosterone
D. Aldosterone

7.10 Answers
7 ??1.
A 24-year-old woman consults for
irregular periods. She has noticed slow vv1. E
increase in facial hair since puberty
and mild acne. She used electrolysis vv2. A
to remove unwanted facial hair. She
has never used the oral contraceptive vv3. A
agent. On examination her body mass
index (BMI) is 35 kg/m2. Her Ferriman-
Gallwey score is 6. There are no signs References
of virilization. Initial investigation
included normal serum prolactin and 1. Bozdag G, Mumusoglu S, Zengin D, Karabulut
TSH, and mildly elevated total testos- E, Yildiz BO. The prevalence and phenotypic
features of polycystic ovary syndrome: a sys-
terone. Which test will rule out a con- tematic review and meta-analysis. Hum Reprod.
genital adrenal cause for this disorder? 2016;31(12):2841–55. https://doi.org/10.1093/hum-
A. Cortisol rep/dew218. Epub 2016 Sep 22. PMID: 27664216.
B. DHEAS 2. Legro RS. Obesity and PCOS: implications for
C. DHEA diagnosis and treatment. Semin Reprod Med.
2012;30(6):496–506. https://doi.org/10.1055/s--
D. Androstenedione 0032-1328878. Epub 2012 Oct 16. PMID:
E. 17-hydroxprogesterone 23074008; PMCID: PMC3649566.
3. Chen YH, Heneidi S, Lee JM, Layman LC, Stepp
??2. A 30-year-old woman presents with rap- DW, Gamboa GM, Chen BS, Chazenbalk G,
idly increasing facial and body hair and Azziz R. miRNA-93 inhibits GLUT4 and is over-
expressed in adipose tissue of polycystic ovary syn-
irregular periods over the last 6 months. drome patients and women with insulin resistance.
On examination she has male-pattern Diabetes. 2013;62(7):2278–86.
baldness and enlarged clitoris. A pel- 4. Taylor AE, McCourt B, Martin KA, Anderson EJ,
vic ultrasound revealed a solid mass of Adams JM, Schoenfeld D, Hall JE. Determinants
approximately 4 cm on the left ovary. of abnormal gonadotropin secretion in clinically
defined women with polycystic ovary syndrome. J
Adrenal CT scan was normal. Which Clin Endocrinol Metab. 1997;82(7):2248.
hormone is most likely to be elevated in 5. American College of Obstetricians and
a serum sample? Gynecologists’ Committee on Practice Bulletins—
A. Testosterone Gynecology. ACOG practice bulletin no. 194:
B. DHEAS polycystic ovary syndrome. Obstet Gynecol.
2018;131(6):e157–71. https://doi.org/10.1097/
C. 17(OH) progesterone AOG.0000000000002656.
D. DHEA 6. Hurd WW, Abdel-Rahman MY, Ismail SA,
E. Estradiol Abdellah MA, Schmotzer CL, Sood A. Comparison
169 7
of diabetes mellitus and insulin resistance screen- Hum Reprod Open. 2019;2019(1):hoy021. https://
ing methods for women with polycystic ovary syn- doi.org/10.1093/hropen/hoy021. PMID: 31486807;
drome. Fertil Steril. 2011;96(4):1043–7. https://doi. PMCID: PMC6396642.
org/10.1016/j.fertnstert.2011.07.002. Epub 2011 13. Dumesic DA, Lobo RA. Cancer risk and
Aug 3. PMID: 21813121. PCOS. Steroids. 2013;78(8):782–5. https://doi.
7. Teede HJ, Misso ML, Costello MF, Dokras org/10.1016/j.steroids.2013.04.004. Epub 2013 Apr
A, Laven J, Moran L, Piltonen T, Norman RJ, 24. PMID: 23624028.
International PCOS Network. Recommendations 14. Phiske MM. An approach to acanthosis nigri-
from the international evidence-based guideline cans. Indian Dermatol Online J. 2014;5(3):239–49.
for the assessment and management of polycystic https://doi.org/10.4103/2229-5178.137765.
ovary syndrome. Fertil Steril. 2018;110(3):364. 15. Afifi L, Saeed L, Pasch LA, et al. Association of
8. Azziz R. Polycystic ovary syndrome. Obstet ethnicity, Fitzpatrick skin type, and hirsutism:
Gynecol. 2018;132(2):321–36. https://doi.org/10. a retrospective cross-sectional study of women
1097/AOG.0000000000002698. with polycystic ovarian syndrome. Int J Womens
9. Behboudi-Gandevani S, Amiri M, Bidhendi Dermatol. 2017;3(1):37–43. Published 2017 Mar
Yarandi R, Noroozzadeh M, Farahmand M, 13. https://doi.org/10.1016/j.ijwd.2017.01.006.
Rostami Dovom M, Ramezani Tehrani F. The 16. Dumesic DA, Oberfield SE, Stener-Victorin
risk of metabolic syndrome in polycystic ovary E, Marshall JC, Laven JS, Legro RS. Scientific
syndrome: a systematic review and meta-analysis. statement on the diagnostic criteria, epidemi-
Clin Endocrinol. 2018;88(2):169–84. https://doi. ology, pathophysiology, and molecular genet-
org/10.1111/cen.13477. Epub 2017 Oct 16. PMID: ics of polycystic ovary syndrome. Endocr Rev.
28930378. 2015;36(5):487–525. https://doi.org/10.1210/er.
10. Balen AH, Morley LC, Misso M, Franks S, Legro 2015-1018.
RS, Wijeyaratne CN, Stener-Victorin E, Fauser 17. Papadakis G, Kandaraki EA, Tseniklidi E, Papalou
BC, Norman RJ, Teede H. The management of O, Diamanti-Kandarakis E. Polycystic ovary syn-
anovulatory infertility in women with polycystic drome and NC-CAH: distinct characteristics and
ovary syndrome: an analysis of the evidence to common findings. A systematic review. Front
support the development of global WHO guid- Endocrinol (Lausanne). 2019;10:388. https://doi.
ance. Hum Reprod Update. 2016;22(6):687–708. org/10.3389/fendo.2019.00388. PMID: 31275245;
https://doi.org/10.1093/humupd/dmw025. Epub PMCID: PMC6593353.
2016 Aug 10. 18. Martin KA, Anderson RR, Chang RJ, Ehrmann
11. Franik S, Eltrop SM, Kremer JA, Kiesel L, Farquhar DA, Lobo RA, Murad MH, Pugeat MM, Rosenfield
C. Aromatase inhibitors (letrozole). Cochrane RL. Evaluation and treatment of hirsutism in pre-
Database Syst Rev. 2018;5(5):CD010287. Published menopausal women: an Endocrine Society clini-
2018 May 24. https://doi.org/10.1002/14651858. cal practice guideline. J Clin Endocrinol Metab.
CD010287.pub3. 2018;103(4):1233.
12. Costello MF, Misso ML, Balen A, Boyle J, Devoto 19. Harrison CL, Lombard CB, Moran LJ, Teede
L, Garad RM, Hart R, Johnson L, Jordan C, Legro HJ. Exercise therapy in polycystic ovary syn-
RS, Norman RJ, Mocanu E, Qiao J, Rodgers RJ, drome: a systematic review. Hum Reprod Update.
Rombauts L, Tassone EC, Thangaratinam S, 2011;17(2):171–83.
Vanky E, Teede HJ; International PCOS Network. 20. Chen X, Koivuaho E, Piltonen TT, Gissler M,
Evidence summaries and recommendations from Lavebratt C. Association of maternal polycystic
the international evidence-based guideline for the ovary syndrome or anovulatory infertility with obe-
assessment and management of polycystic ovary sity and diabetes in offspring: a population-based
syndrome: assessment and treatment of infertility. cohort study. Hum Reprod. 2021;36(8):2345–57.
171 8
Abnormal Uterine
Bleeding
Sonia Elguero, Bansari Patel, Anna V. Jones,
and William W. Hurd
Contents

8.1.1 revalence – 174
P
8.1.2 Terminology – 174
8.2 Normal Menstrual Cycle and Menstruation – 174
8.3 Diagnostic Classifications – 175
8.4 Systemic Causes of AUB – 175

8.4.1 vulatory Dysfunction – 175
O
8.4.2 Mechanisms of Bleeding in Anovulatory Patients – 176
8.4.3 Causes of Ovulatory Dysfunction – 177
8.4.4 Hormonal Therapy and AUB – 179
8.4.5 Coagulopathies – 180
8.5 Pregnancy – 180

8.5.1 iable Intrauterine Pregnancy – 181
V
8.5.2 Early Pregnancy Loss – 181
8.5.3 Ectopic Pregnancy – 181
8.5.4 Molar Pregnancy – 181
8.6 Infection – 181

8.6.1 elvic Inflammatory Disease – 181
P
8.6.2 Endometritis – 182
8.6.3 Cervicitis – 182
8.6.4 Vaginitis – 183
8.7 Neoplasms – 183

8.7.1 Benign Uterine Neoplasms – 183

https://doi.org/10.1007/978-3-030-99596-6_8
8.7.2 alignant and Premalignant Uterine Neoplasms – 184
M
8.7.3 Ovarian Malignancies – 184
8.7.4 Vaginal Malignancies – 185
8.8 linical Evaluation of Abnormal

C
Vaginal Bleeding – 185
8.8.1 E xclude Pregnancy – 185
8.8.2 Characterize Bleeding – 185
8.8.3 Medical History – 187
8.8.5 Laboratory Testing – 187
8.8.6 Papanicolaou Smear – 188
8.8.7 Endometrial Biopsy – 189
8.8.8 Imaging – 189
8.8.9 Hysteroscopy – 190
8.9 Acute Management of AUB – 190

8.9.1 E mergency AUB Treatment for Hemodynamically
Unstable Patients – 190
8.9.2 Acute Outpatient Treatment of AUB – 191
8.10 L ong-Term Management of Ovulatory

Dysfunction – 191
8.10.1 vulation Induction – 192
O
8.10.2 Hormonal Treatment of Anovulatory Bleeding – 192
8.11 Treatment of AUB in Ovulatory Patients – 193

8.11.1 edical Treatment – 193
M
8.11.2 Surgical Treatment of AUB – 194

8.13 Answers – 196
References – 196
Abnormal Uterine Bleeding
173 8
Abnormal uterine bleeding (AUB) is a
Key Points subset of abnormal vaginal bleeding where
55 Abnormal vaginal bleeding is one of vaginal bleeding originates from either the
the most common gynecologic prob- uterine fundus or cervix and does not include
lems of reproductive-aged women. bleeding related to pregnancy or that originat-
55 Abnormal uterine bleeding (AUB) is an ing in the lower genital tract [2]. AUB can be
important subset of abnormal vaginal described according to bleeding pattern using
bleeding defined as bleeding that occurs in terms such as heavy menstrual bleeding; non-
nonpregnant, reproductive-aged women menstrual bleeding that is irregular, intermen-
originating from the uterine fundus or strual, or prolonged; or any combination of
cervix. these bleeding patterns.
55 The PALM-COEIN classification system Experienced clinicians are well aware that
advocated by ACOG includes many of what appears to be AUB has a broad spectrum
the most common causes of AUB. of possible causes and can be related to preg-
55 The SPIN (Systemic, Pregnancy, Infection, nancy or originate from non-uterine sources,
Neoplasms) classification system offers including the vagina, bladder, or rectum. With
a comprehensive system for managing this in mind, every gynecologist must develop
women with abnormal vaginal bleeding. a thorough and cost-effective approach to the
55 Pregnancy should be excluded in all diagnosis and management of abnormal vagi-
reproductive-aged women presenting nal bleeding. The ability to expediently evaluate
with presumed AUB. and treat women with abnormal vaginal bleed-
55 The most common cause of AUB is ing depends on a broad understanding of its
anovulatory bleeding, often related to various causes and their diverse presentations.
polycystic ovary syndrome, but also
commonly occurring in the healthy Case Vignette
peri-menarcheal and perimenopausal
women. A 37-year-old G0 P0 presents to her gyne-
55 AUB related to structural abnormalities cologist’s office with profuse vaginal bleed-
is most commonly treated surgically; ing that began the prior evening. Her
AUB in women with normal pelvic anat- gynecologic history is significant for a diag-
omy can usually be managed medically nosis of polycystic ovary syndrome (PCOS)
with hormones, antibiotics, antifibrino- and only 3–4 menses per year. She is not
lytics, nonsteroidal anti-inflammatory using any contraceptive method but has
drugs, or a combination of these. not been able to get pregnant for 3 years.
Her vital signs are stable, and she has no
symptoms other than bleeding. Her pelvic
exam reveals clots in the vagina and blood
8.1 Introduction actively coming from a normal-appearing
cervix. Bimanual pelvic examination, made
Vaginal bleeding that occurs outside the difficult by her obesity, does not reveal
parameters of normal menstruation is one of uterine or adnexal masses or tenderness.
the most common clinical problems confront- Pelvic ultrasound shows a normal-sized
ing women and their gynecologists. The pos- anteverted uterus with a 16 mm endome-
sible etiologies of abnormal vaginal bleeding trial stripe and what appear to be clots in
range from a temporary interruption of the the uterine cavity. Laboratory evaluation
normal menstrual cycle to the earliest symp- includes a negative urine pregnancy test,
tom of a potentially life-threatening condi- white blood cell count of 9500 per mcL,
tion. Chronic abnormal vaginal bleeding hemoglobin of 8.8 g/dL, and platelet count
impairs quality of life as a result of significant of 250,000 per mcL. Other laboratory
physical, emotional, sexual, social, and finan- results are pending.
cial burdens [1].
174 S. Elguero et al.
8.1.1 Prevalence ing that can almost always be identified using

the more sophisticated diagnostic techniques
Abnormal vaginal bleeding is one of the most available today [7]. The ability of clinicians to
common chief complaints for which women identify a specific etiology for the vast major-
see obstetrician-gynecologists. AUB accounts ity of AUB has resulted in an increased likeli-
for approximately 30% of all gynecology vis- hood of effective treatment for AUB without
its [3]. Despite its frequency, AUB remains a having to resort to hysterectomy.
difficult diagnostic and therapeutic challenge
and still accounts for 10–20%of all hyster-
ectomies performed in the USA [4]. In years 8.2 ormal Menstrual Cycle
N
past, approximately 20% of hysterectomy and Menstruation
specimens removed for AUB have no discern-
ible pathology [5]. More recently, the use of A solid understanding of the normal men-
hysterectomy to treat AUB has decreased as strual cycle is essential to effectively evalu-
more of these patients are treated using effec- ate and treat women with abnormal vaginal
tive medical or minimally invasive surgical bleeding. Complex interactions between
modalities. the hypothalamus, pituitary, and ovary (see
8 7 Chap. 1) result in monthly ovulation, which
leads to either pregnancy or menstruation
8.1.2 Terminology within approximately 2 weeks. Each month,
the endometrium of normally ovulating
The narrowly defined term AUB refers only women is exposed to physiologic levels of
to vaginal bleeding that occurs outside the estradiol (50–250 pg/mL), accompanied in the
parameters of normal menstruation and (a) last 12–14 days of each cycle by progesterone
originates from the uterine fundus or cervix, (mid-luteal phase progesterone >12 nmol/L).
(b) occurs during the reproductive years, and The result is a structurally stable endometrium
is (c) unrelated to pregnancy [2]. AUB is char- 5–16 mm thick as measured by transvaginal
acterized in terms of volume, duration, fre- ultrasound.
quency, regularity, and chronicity. The arcane Menstruation is the universal breakdown
terms “menorrhagia” and “metrorrhagia” and uniform shedding of the endometrial
have been recommended for replacement with functional layer. Unless pregnancy occurs,
the simplified terms “heavy menstrual bleed- involution of the corpus luteum results in rapid
ing” and “intermenstrual bleeding,” although decreases in both progesterone and estrogen.
both sets of terms remain in common usage. This hormonal withdrawal activates matrix
When AUB has persisted for 6 months or metalloproteinases, which enzymatically dis-
more, it is termed “chronic.” solve the endometrium [8]. Hemostasis is
The single most common cause of AUB is achieved by a combination of vasoconstriction
anovulatory bleeding resulting from exposure of the spiral arterioles and normal coagulation
of the endometrium to estrogen, unopposed mechanisms. Normal menstruation occurs
by progesterone. Anovulatory bleeding has every 28 ± 7 days with duration of flow of
been classified by the International Federation 4 ± 2 days and a blood loss of 40 ± 40 mL [9].
of Gynaecology and Obstetrics (FIGO) as Normal menstruation should not cause
“Abnormal uterine bleeding associated with severe pain or include passage of large clots.
ovulatory dysfunction (AUB-O)”. A simi- However, what constitutes “normal” menstru-
lar, outdated term is “dysfunctional uterine ation is subjective and varies between indi-
bleeding” (DUB) defined as excessive uterine vidual women and between cultures. In most
bleeding when no uterine pathology can be women, 90% of blood loss per cycle occurs
identified [6]. Use of the term DUB is dis- within the first 3 days of menstruation [10].
couraged because it encompasses a wide array The amount of blood lost during a normal
of unrelated nonanatomical causes of bleed- menstrual period should be <80 mL. However,
175 8
menstrual blood loss is extremely difficult to from the nonpregnant uterus, thus excluding
estimate clinically as much of the menstrual both pregnancy-related bleeding and bleeding
effluent is dissolved endometrium rather than originating from elsewhere within the repro-
blood. Clinically, heavy menstrual bleeding ductive tract (e.g., vagina). In clinical prac-
(i.e., menorrhagia or AUB-H) is diagnosed tice, all sources and possible causes must be
when a woman is changing pads or tampons considered in every patient presenting with
more than once per hour. abnormal vaginal bleeding.
With this in mind, we have constructed
a comprehensive classification of abnormal
8.3 Diagnostic Classifications vaginal bleeding based on the acronym SPIN
(Systemic, Pregnancy, Infection, Neoplasms)
Classification systems have been developed and subcategorized according to anatomic
to organize the multiple possible etiologies of locations where appropriate (. Table 8.1).
abnormal vaginal bleeding. The most widely The remainder of this chapter will examine
used is the PALM-COEIN classification for the various causes of abnormal vaginal bleed-
AUB, developed by the FIGO and endorsed ing using this SPIN classification.
by the American College of Obstetricians and
Gynecologists (ACOG) [2] [11]. This system
classifies the majority of AUB etiologies as 8.4 Systemic Causes of AUB
either structural or nonstructural using the
PALM-COEIN acronym as a memory aid Monthly menstruation depends on a systemic
(7 Box 8.1). orchestration of a number of hormones origi-
nating in the brain and ovaries. Anything that
disrupts this coordinated process will mani-
Box 8.1 PALM-COEIN Classification for fest as anovulation and AUB. Thus, anovu-
Abnormal Uterine Bleeding (AUB) latory dysfunction can be either a primary
55 PALM (structural) process or secondary to other systemic dis-
–– Polyp eases that interfere with hormone production
–– Adenomyosis or metabolism. AUB also includes the disrup-
–– Leiomyoma tive effects of exogenous hormones taken for
–– Malignancy and hyperplasia contraception.
55 COEIN (nonstructural)
–– Coagulopathy
8.4.1 Ovulatory Dysfunction
–– Ovulatory dysfunction
–– Endometrial
Ovulatory dysfunction is the final common
–– Iatrogenic
pathway connecting systemic disorder to
–– Not yet classified
AUB. Anovulation is the result of disruption
of the complex hormonal process involved in
ovulation on either a temporary or chronic
The PALM-COEIN classification system, basis and is one of the most common causes of
although simple, has its limitations. In order AUB. It can be a primary problem or secondary
to form a memorable mnemonic, this classifi- to an identifiable disease process (7 Box 8.2).
cation uses several imprecise terms (e.g., endo- Occasional anovulation is common in the
metrial, iatrogenic, not yet classified). Another early and late reproductive years. Chronic ovu-
limitation is that it does not include a number latory dysfunction is a central characteristic
of relatively common causes of AUB, includ- of the most common endocrine abnormality
ing endometritis, cervicitis, cervical dysplasia, of reproductive-aged women, polycystic ovary
hypothyroidism, and hyperprolactinemia. A syndrome (PCOS). Anovulation can also be
third limitation of this classification is that the most obvious manifestation of a number
it classifies only vaginal bleeding originating of other systemic conditions.
.. Table 8.1 SPIN classification
Uterine fundus Cervix Adnexa Vagina Other
Systemic – – – – Anovulatory
bleeding
Systemic
conditions
Hormone therapy
Coagulopathy
Preg- Viable pregnancy Ectopic Ectopic pregnancy – –
nancy Spontaneous abor- pregnancy
tion
Molar pregnancy
Infection Endometritis Cervicitis Pelvic inflammatory Vagini- –
disease tis
Neo- Fibroids Polyp Cancer Cancer –
plasms Polyps Dysplasia
8 Adenomyosis
Hyperplasia
Cancer
Cancer
Box 8.2 Causes of Ovulation Dysfunction on etiology. In the absence of postovulatory

55 Physiologic oligo-ovulation: progesterone, prolonged endometrial expo-
–– Perimenarchal sure to unopposed estrogen results in break-
–– Perimenopasual through bleeding which can manifest clinically
–– Papanicolaou smear in dramatically different ways ranging from
–– Polycystic ovary syndrome spotting to massive hemorrhage. Chronically
–– Hyperandrogenic states low estrogen levels result in endometrial atro-
–– Congenital adrenal hyperplasia, phy which can also result in AUB.
adultonset
–– Cushing’s syndrome 8.4.2.1 Estrogen Breakthrough
–– Ovarian and adrenal tumors Bleeding
–– Systemic diseases that interfere Endometrial stimulation by estrogen results in
with ovulation endometrial growth, manifested as increased
–– Hypothyroidism endometrial stroma and glands, and increased
–– Hyperprolactinemia size and depth of the spiral arteries supply-
–– Renal failure ing the endometrium [12]. In contrast, endo-
–– Liver disease metrial stimulation by progesterone results
in decreased endometrial proliferation and
thickness, increased structural support, and
8.4.2 Mechanisms of Bleeding development of more complex, glycogen-
in Anovulatory Patients filled glands. In the absence of cyclic pro-
gesterone exposure, prolonged endometrial
The mechanism of bleeding in anovulatory exposure to normal estrogen levels results in
patients depends on whether the estrogen lev- increased thickness and structurally incom-
els are normal or low, which in turn depends petent. Rather than the universal endometrial
177 8
shedding that occurs in menstruation, asyn- micro-erosions and a chronic inflammatory
chronous shedding of portions of the endo- reaction that results in a cascade of events
metrium results in bleeding unaccompanied similar to chronic endometritis as discussed
by vasoconstriction, termed estrogen break- in 7 Sect. 8.6.2.
through bleeding.
Estrogen breakthrough bleeding can mani-
fest in a variety of different ways, including 8.4.3 Causes of Ovulatory
occasional spotting, prolonged periods of Dysfunction
moderate bleeding, and/or infrequent and
potentially life-threateningly heavy AUB. Since The complex interactions of the hypothalamic-
the blood resulting from breakthrough bleed- pituitary-
ovarian (HPO) axis can be easily
ing is not lysed by endometrial enzymes, blood perturbed, resulting in anovulation. Typically,
clots are often passed, usually resulting in women ovulate monthly throughout their repro-
increased menstrual cramping. Prolonged peri- ductive years. However, occasional anovulation
ods of bleeding without universal endometrial is not uncommon among reproductive- aged
shedding can result in subclinical endometri- women not using hormonal contraception.
tis, which can further exacerbate bleeding by Chronic anovulation occurs in >10% of all
interfering with normal clotting mechanisms, reproductive-aged women.
thus making the endometrium unresponsive to
hormonal therapy [13]. 8.4.3.1 Extremes of the Reproductive
In addition to breakthrough bleeding, pro- Years
longed endometrial exposure to unopposed Adolescents often have anovulatory cycles
estrogen can result in the development of during the peri-menarchal years as part of
endometrial polyps, endometrial hyperplasia, the maturation process of the hypothalamic-
and endometrial cancer. In turn, these condi- pituitary-
ovarian axis [14]. In the peri-
tions can result in persistent AUB unrespon- menopausal years (40–50 years of age),
sive to hormonal therapy. anovulatory cycles again become more com-
mon as the remaining antral follicles become
8.4.2.2 Endometrial Atrophy less sensitive to LH and FSH, resulting in
Endometrial atrophy can result from pro- a higher prevalence of anovulatory cycles
longed periods of exposure to low estrogen [15]. In both groups, occasional anovulation
levels, exogenous progestins, or elevated andro- results in increased and variable menstrual
gens. Prolonged low estrogen levels result cycle length and can result in clinically sig-
in atrophy of both endometrial glands and nificant AUB.
stroma. Histologically, scanty, small glands are
observed in dense stroma. Secretory changes 8.4.3.2 Polycystic Ovary Syndrome
are minimal, but stromal decidualization is Polycystic ovary syndrome (PCOS) is the
present, resulting in discordance between single most common cause of ovulatory dys-
small inactive glands and decidualized stroma. function, affecting 6–10% of reproductive-
Numerous granular lymphocytes are often aged women [16]. PCOS is a heterogeneous
present. Transvaginal ultrasonography will endocrine and metabolic disorder that is diag-
reveal an endometrial thickness of <4 mm. nosed when a woman without an underlying
AUB resulting from endometrial atrophy medical condition is found to have two out
is the result of inflammation and is usually of the following three criteria: (1) oligo- or
described as spotting [12]. Atrophic endome- anovulation, (2) clinical and/or biochemical
trium lacks the fluid present in healthy endo- evidence of hyperandrogenemia, and (3) poly-
metrium that prevents intracavitary friction cystic ovaries [17]. These women have circu-
between apposing endometrial surfaces. lating estrogen levels in the normal range, but
This friction results in surface epithelium anovulatory progesterone levels.
Insulin resistance is believed to be the Nonclassic CAH should be suspected when-

underlying cause of PCOS in many women, ever PCOS symptoms occur simultaneously
particularly those who are obese. However, as with menarche. Cushing’s and androgen-
many as 50% of women with PCOS are not secreting tumors should be suspected when
obese [18]. Insulin resistance will be found hyperandrogenism and ovulation dysfunction
in approximately 95% of women with PCOS present rapidly in a woman with previously
who are obese, but <25% of those who are not normal menstrual cycles.
obese [19]. The primary purpose of measuring andro-
In women with insulin resistance, elevated gen levels in women with PCOS is to detect
insulin levels appear to stimulate increased pathologic conditions associated with hyper-
androgen production by the ovaries, primar- androgenemia that can mimic PCOS. Women
ily androstenedione and testosterone [20]. with PCOS often have mildly elevated dehy-
Insulin increases androgen secretion by both droepiandrosterone sulfate (DHEAS), or free
theca cells and ovarian stroma cells. These and/or total testosterone, and these elevations
increased androgens can contribute to hir- fulfill the PCOS diagnostic criteria for hyper-
sutism and may contribute to the increased androgenemia. Marked elevation of DHEAS
body mass often seen in PCOS patients. is an indication of adrenal dysfunction or
These androgens can be aromatized peripher- tumor. Substantial elevation of total testos-
8 ally in both fat and muscle to estrogen (pri- terone most likely indicates the presence of an
marily estrone), which acts on the pituitary ovarian or adrenal tumor. Marked elevation
to increase secretion of LH, stimulating the of either DHEAS or testosterone requires
ovaries to secrete more androgens in concert careful imaging of the ovaries with transvagi-
with insulin. The positive feedback loop that nal ultrasound and the adrenal glands with
results is believed to be the cause of PCOS in computerized tomography. Any elevation of
insulin-resistant women. The accuracy of this 17-hydroxyprogesterone suggests the presence
interpretation is supported by the observa- of nonclassic CAH.
tion that in many overweight patients, either Serious systemic illness can mimic PCOS
weight loss or the use of an insulin-sensitizing by chronically interrupting ovulation. Both
agent (e.g., metformin) will simultaneously hypothyroidism and hyperprolactinemia are
improve insulin resistance and restore regular relatively common conditions that can pres-
ovulatory cycles. ent with ovulatory dysfunction as the initial
manifestation. Accordingly, all women pre-
8.4.3.3 Systemic Conditions senting with what appears to be PCOS should
Mimicking PCOS be screened with a TSH and prolactin.
Some patients with oligo- or anovulatory that Serious systemic disease, such as chronic
appear to have PCOS actually have an under- liver or kidney disease, often results in
lying systemic disease. Systemic medical con- chronic ovulatory dysfunction and infertil-
ditions that can result in signs and symptoms ity [22, 23]. Liver dysfunction appears to
identical to PCOS can be divided into two interfere with ovulation by hindering ste-
groups: conditions that cause hyperandrogen- roid hormone metabolism, whereas the
emia and systemic illnesses. mechanisms by which chronic kidney dis-
Any condition that causes hyperandrogen- ease results in anovulation are uncertain. In
emia can interfere with ovulation and result general, patients with liver or kidney disease
in a clinical syndrome often indistinguish- significant enough to impair ovulation will
able from PCOS [21]. Most common among have other recognizable symptoms of their
these are nonclassic (“adult-onset”) congeni- disease process [24]. Women with AUB and
tal adrenal hyperplasia (CAH), Cushing’s symptoms of serious liver or kidney disease
syndrome or disease, and androgen-secreting should undergo targeted evaluation for their
neoplasms of the ovaries or adrenal glands. condition.
179 8
8.4.3.4 Hypogonadism 8.4.4.1 Hormone Contraceptives
Cessation of ovarian function, either pri- At least ten million women in the USA are
mary (e.g., menopause, premature ovarian using some type of hormonal contraception,
insufficiency) or central (i.e., secondary to including combination oral contraceptives,
hypothalamic-pituitary dysfunction), manifests progestin-only pills, depot medroxyprogester-
as anovulation and hypoestrogenemia, and con- one acetate injections, progestin-containing
sequent endometrial atrophy. Although amen- intrauterine devices, subdermal levonorgestrel
orrhea is more common in this situation, AUB implants, transdermal combination hor-
can result, usually in the form of spotting. mone patches, or intravaginal rings. For these
The most common cause of hypoestro- women, AUB is a frequent reason to visit pri-
genemia is cessation of ovarian function. mary care physicians and gynecologists, and a
Menopause, the physiologic loss of ovarian common reason for discontinuing a number
function, occurs at an average age of approx- of different types of contraception [26].
imately 51 years, but occurrence any time During the first 3 months of combination
after the age of 40 is considered to be within oral contraceptive use, as many as one-third
the normal range [25]. Premature meno- of women will experience AUB. For the vast
pause before the age of 40 years of age, i.e., majority of women, the most effective treat-
primary ovarian insufficiency (POI), occurs ment approach is reassurance and watch-
in approximately 1% of women. Women ful waiting. As the uterus adapts to the new
diagnosed with POI should be further eval- regimen of hormonal exposure, the monthly
uated for a number of possible causes (see withdrawal bleeding becomes regular, lighter,
7 Chap. 6). and less painful than natural menstruation in
With normally functioning ovaries, hypogo- most women.
nadism results from lack of gonadal hormonal If abnormal bleeding persists beyond the
stimulation secondary to hypothalamic or pitu- first 3 months of hormonal contraceptive use,
itary dysfunction, collectively referred to as other common causes should be excluded.
hypogonadotropic hypogonadism. Hypotha- Subclinical uterine infections remain a prob-
lamic amenorrhea can be secondary to congen- lem for some subgroups of sexually active
ital or acquired hypothalamic pathology (e.g., women, and sexually transmitted diseases
Kallmann syndrome or hypothalamic tumors), should be excluded. One study of women with
the result of chronic physiologic stress (e.g., intermenstrual spotting while on oral contra-
excessive exercise, eating disorders), or idio- ceptives found that one-third had otherwise
pathic. Pituitary tumors, most commonly pro- asymptomatic Chlamydia trachomatis infec-
lactinomas, can result in hypogonadism related tions [27].
to hyperprolactinemia. When hypogonadism is Once infectious causes have been excluded,
suspected, screening tests should include pro- an often effective treatment of AUB for women
lactin, FSH, LH, and estradiol. Further investi- on combined oral contraceptives is changing
gation will depend on the age of the patient, as to a different oral contraceptive formulation.
discussed in 7 Chap. 6. Women on low estrogen dose formulations
often benefit from changing to a higher estro-
gen dose. Those on monophasic formulations
8.4.4 Hormonal Therapy and AUB might have better success with multiphasic
contraceptives and vice versa.
Irregular uterine bleeding is one of the most Women using continuous combined formu-
common complaints of women receiving lations or progestin-only contraceptives (oral
exogenous hormone therapy, e.g., hormone or implant) can have AUB related to endome-
contraceptives or hormone replacement ther- trial atrophy resulting from prolonged proges-
apy (see 7 Chaps. 9 and 25). AUB is the most terone exposure (see 7 Sect. 8.4.2.2). For those
common reason for discontinuation of these using continuous combined formulations, tak-
hormone therapies. ing a week off the pills will often allow endome-
trial regeneration and AUB resolution. Those tor interacting with platelets to form a platelet
using progestin-only oral contraceptives might plug. A fibrin clot will then form on this plug.
have to switch to combined oral contracep- There are three main types of von Willebrand
tives. Women using progestin implants can be disease. The mild form (type 1) is responsible
treated with the addition of supplemental oral for over 70% of cases and is characterized by
estrogen or low-dose combination oral contra- an absolute decrease in the protein. The mech-
ceptives for 2–3 months. Persistent irregular anism by which an abnormal factor leads to
bleeding is a common reason for discontinua- bleeding at the level of the endometrium is
tion of these contraception methods. unclear. The vast majority of women with this
disease report AUB, specifically menorrhagia.
The prevalence of this disorder in adults can
8.4.5 Coagulopathies range from 7% to 20%. Other inherited condi-
tions include thrombocytopenia and rare clot-
Persistent menorrhagia can be the result of ting factor deficiencies (e.g., factors I, II, V,
any condition that interferes with the body’s VII, X, XI, XIII).
normal hemostatic mechanisms (7 Box 8.3).
8.4.5.2 Acquired Bleeding Disorders
Women with the new onset of extremely heavy
8 menses not amenable to hormonal therapy
Box 8.3 Most Common Coagulopathies
55 Hereditary bleeding disorders will sometimes be found to have an acquired
–– von Willebrand disease bleeding abnormality, usually apparent on a
–– Disorders of platelet function and CBC. Such abnormalities include idiopathic
fibrinolysis thrombocytopenic purpura (ITP) and hema-
55 Acquired bleeding abnormalities tologic diseases affecting platelet production,
–– Idiopathic thrombocytopenic pur- such as leukemia. Women with grave systemic
pura diseases, such as sepsis and liver disorders, can
–– Leukemia develop hemostatic disorder resulting in AUB.
–– Aplastic anemia
8.4.5.3 Anticoagulant Therapy
55 Anticoagulation therapy
Excessive bleeding can be a significant prob-
lem for women on anticoagulant therapy,
including both conventional anticoagulants
8.4.5.1 Hereditary Bleeding (i.e., warfarin, heparin) and the new genera-
Disorders tion of direct oral anticoagulants (e.g., apix-
von Willebrand disease and less common dis- aban, rivaroxaban, edoxaban, dabigatran).
orders of platelet function and fibrinolysis are Although the overall risk of severe uterine
characterized by excessive menstrual bleeding bleeding during anticoagulation is <0.2%,
that begins at menarche and is usually regular this risk in women treated with rivaroxaban
[28]. Of adolescents who present with menor- might be as high as 1% [30]. In rare cases,
rhagia significant enough to cause anemia or emergency hysterectomy can be necessary to
hospitalization, as many as 20% will be found effectively treat life-threatening uterine bleed-
to have a bleeding disorder. However, it is ing in women taking anticoagulants [31].
important to remember that most AUB in this
age group is due to anovulation.
The most common hereditary bleeding 8.5 Pregnancy
disorder is von Willebrand disease, which
affects 1–2% of the population [29]. This Vaginal bleeding is common during both nor-
hereditary deficiency (or abnormality) of the mal and abnormal pregnancies. Pregnancy
von Willebrand factor results in decreased must be excluded in every reproductive-aged
platelet adherence, with von Willebrand fac- woman presenting with apparent AUB, even in
181 8
women with other apparent etiologies such as 8.5.4 Molar Pregnancy
PCOS and prolonged amenorrhea. Fortunately,
the availability of inexpensive, quick, and accu- A molar pregnancy, also known as a hyda-
rate pregnancy tests has made the historically tidiform mole, refers to any one of a group of
difficult task of diagnosing early pregnancy genetically abnormal pregnancies character-
exceedingly easy. ized by cystic degeneration of chorionic villi.
These gestational trophoblastic diseases repre-
sent <0.5% of pregnancies in North America
8.5.1 Viable Intrauterine Pregnancy and Europe. In the past, uterine bleeding in
early pregnancy was the initial presentation in
As many as 50% of pregnant women will expe- 84% of cases [35]. However, this percentage is
rience uterine spotting or bleeding during the likely to have decreased with the widespread
first trimester. At least half of these pregnancies application of transvaginal ultrasound in early
will progress normally beyond the first trimester, pregnancy prior to the occurrence of vaginal
while the remainder will prove to be nonviable bleeding. Risks of molar pregnancy include
pregnancies [32]. The majority of nonviable preg- life-threatening hemorrhage and malignancy.
nancies are spontaneous abortions, while<2% Although rare, molar pregnancies can coexist
are ectopic or molar pregnancies. with a twin viable pregnancy.
8.5.2 Early Pregnancy Loss 8.6 Infection

Early pregnancy loss, defined as spontane- Infections of the reproductive tract are
ous abortions occurring prior to 13 weeks probably one of the most unrecognized
of gestation, complicates at least 20% of and thus undiagnosed and treated causes
intrauterine pregnancies [32]. In the past, the of AUB. Although the original publication
majority of nonviable intrauterine pregnan- of the PALM-COEIN classification had no
cies ended with spontaneous uterine bleed- mention of this important, and often sub-
ing culminating in spontaneous abortion. tle, cause of AUB, subsequent publications
However, with the widespread utilization of include infection causes under “Not yet clas-
transvaginal ultrasound in early pregnancy, sified” [2, 11].
an ever-increasing percentage of spontaneous
abortions are diagnosed and treated prior to
the onset of bleeding [32]. 8.6.1 Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an

8.5.3 Ectopic Pregnancy inflammatory disorder of the upper female
genital tract that includes any combination
Ectopic pregnancies implanted outside the of endometritis, salpingitis, tubo-ovarian
endometrial cavity make up <2% of all preg- abscess, and pelvic peritonitis, commonly
nancies [33]. Pregnancies implanted within in association with cervicitis [36]. The clini-
a fallopian tube account for >90%ectopic cal presentation of PID can range in sever-
pregnancies, with the remainder implanting ity from subclinical to life-threatening. In
within a cesarean scar, ovary, cervix, or abdo- obvious cases of PID, vaginal bleeding will
men [34]. Ectopic pregnancies often present be one of their presenting symptoms for
with uterine bleeding. Almost 20% of women approximately 40% of patients [37, 38]. This
presenting to the emergency department with can be the result of hormonal disturbances
first-trimester vaginal bleeding, or abdominal secondary to ovarian inflammation, cervici-
pain, or both, will be found to have an ecto- tis, or the universally presence of endometri-
pic pregnancy. Diagnosis and management tis [39].
details are presented in Chap. 23.
8.6.2 Endometritis diagnosis of PID should be given to women

with AUB associated with tenderness of the
Endometritis is an important and often cervix, uterine fundus, or adnexa, and they
unrecognized cause of AUB. Endometritis is should be treated following CDC guidelines
often present in women with other causes of [36]. Women who do not meet the criteria for
AUB, including infectious causes such as PID hospitalization should be treated with a com-
and cervicitis, and structural abnormalities, bination of intramuscular and oral antibiot-
including endometrial polyps and leiomyo- ics, such as ceftriaxone plus doxycycline with
mas [40]. or without metronidazole [36]. In the absence
Endometritis can manifest as AUB unre- of tenderness, women with AUB and a pre-
sponsive to hormonal therapy even in the sumptive diagnosis of endometritis can be
absence of infectious or structural uterine treated effectively with either doxycycline or
abnormalities [41]. Normal endometrial azithromycin [44].
hemostasis depends on thrombus formation
via platelet aggregation and fibrin deposition
[42]. Infection and inflammation of the endo- 8.6.3 Cervicitis
metrium interferes with these normal hemo-
Cervicitis is a common cause of intermen-
8 static mechanisms by consuming platelets and
strual AUB, often described as postcoital
clotting proteins necessary for clotting [13].
Menstrual blood is an excellent bacterial cul- spotting. Acute cervicitis is usually infectious,
ture media [43], theoretically explaining why while chronic cervicitis is more likely to be
prolonged AUB is often unresponsive to hor- idiopathic. Infectious agents that commonly
monal therapy. cause cervicitis include sexually transmitted
diseases (e.g., chlamydia, gonorrhea) and
8.6.2.1 Diagnosis and Treatment common infectious causes of vaginitis, includ-
For research purposes, the diagnosis of ing trichomonas [45]. Treatment of cervicitis
endometritis is made by endometrial biopsy. is important to avoid ascending infections and
Classically, endometritis has been defined bothersome symptoms.
histologically by the presence of plasma cells The diagnosis of cervicitis is made when
on biopsy. However, in the presence of AUB, cervical examination reveals purulent dis-
endometritis can manifest as reactive changes charge originating from the cervical ectropion
in the surface endometrium in the absence of and external os, accompanied by a friable
identifiable inflammatory cells [39]. endocervix that bleeds upon contact with a
In women with AUB, a presumptive diag- cotton-tipped swab. Nucleic acid amplifica-
nosis of endometritis should be made in the tion testing is performed to detect chlamydia
presence of pelvic pain or tenderness. These and gonorrhea. When cervicitis is accompa-
patients should be treated for PID, even in the nied by vaginitis, standard evaluation should
absence of more overt signs of pelvic infec- be carried out to identify bacterial vaginosis
tion, such as the presence of chlamydia or or trichomonas. Verification of a recent nega-
gonorrhea by nucleic acid amplification test, tive Papanicolaou smear is also important
purulent cervicitis, WBC elevation, and fever since cervical cancer and dysplasia can mani-
[36]. Subclinical endometritis should be sus- fest as cervical bleeding [46].
pected in women with AUB unresponsive to Cervicitis is treated with targeted anti-
hormonal therapy, particularly the presence biotics when specific organisms have been
of cervicitis or vaginitis, or structural abnor- identified, e.g., chlamydia, gonorrhea, and
malities such as submucosal leiomyomas. trichomonas. When no specific organism is
Women with AUB presumed to have endo- identified, initial treatment is empiric using
metriosis should be treated empirically while broad-spectrum antibiotics that are known
awaiting the results of nucleic acid amplifi- to treat the most common vaginal patho-
cation tests for chlamydia or gonorrhea. A gens, such as doxycycline and azithromycin.
183 8
Chronic cervicitis that does not respond to Leiomyomas most likely to result in men-
antibiotic therapy is presumed noninfectious. orrhagia are located either submucosal and
Nonresponsive chronic cervicitis will often intracavitary and are presumed to have a
respond to treatments such as cryotherapy, direct effect on the adjacent endometrium.
silver nitrate, and electrosurgery that induce In addition, intramural leiomyomas that are
squamous metaplasia of the columnar cells large and/or multiple can also result in menor-
of the ectropion and endocervix. rhagia, although the mechanism is uncertain.
Small intramural or subserosal leiomyomas
and those that are pedunculated on the uterine
8.6.4 Vaginitis exterior are less likely to be related to AUB.
Vaginitis during the reproductive years can 8.7.1.2 Endometrial Polyps

cause vaginal spotting, although the symptoms Endometrial polyps are localized overgrowths
of vaginitis usually overshadow complaints of of the endometrium that project into the uter-
vaginal spotting. As discussed above, women ine cavity. These polyps may be broad-based
with vaginitis often have subclinical endome- (sessile) or pedunculated. Endometrial pol-
tritis which can result in AUB. After meno- yps are common in both pre- and postmeno-
pause, vaginal bleeding can be the primary pausal women and are found in at least 20%
manifestation of atrophic vaginitis related to of women undergoing hysteroscopy or hys-
estrogen deficiency. Appropriate diagnosis terectomy [49]. The incidence of these polyps
and treatment of vaginitis will often resolve rises steadily with increasing age, peaks in the
associated AUB. fifth decade of life, and gradually declines
after menopause.
In premenopausal women complaining
8.7 Neoplasms of AUB, studies have shown that from 5% to
33% will be found to have endometrial polyps
Reproductive tract neoplasms, including benign, [50]. Endometrial polyps are commonly found
premalignant, and malignant processes, are in patients with a long history of anovulatory
one of the leading causes of vaginal bleeding. bleeding, suggesting that polyps may be the
Focal intracavitary lesions, e.g., leiomyoma and result of chronic anovulation in some women.
polyps, account for up to 40% of cases of AUB Polyps can also be found in women complaining
[47]. Malignant and premalignant lesions of the of postmenstrual spotting or bleeding in ovula-
cervix and uterine fundus, while not the most tory cycles or during cyclic hormonal therapy.
common causes of AUB, are certainly the most Endometrial polyps in premenopausal
important to identify and treat. Neoplasms of women are almost always benign [49].
the ovary can indirectly cause irregular bleed- However, the risk of endometrial malignancy
ing by interfering with ovulation, as discussed increases with age, and one study reported
below. the risk of malignancy in polyps in women
>65 years old was >50%.
8.7.1.3 Adenomyosis
8.7.1 Benign Uterine Neoplasms
This benign condition involves the penetration
8.7.1.1 Leiomyomas of the endometrium into the myometrium.
Microscopic examination of the uterus reveals
These remarkably common benign tumors of
endometrial glands and stroma deep within
the myometrium can be found in almost 70%
the endometrium surrounded by hypertrophic
of white women and >80% of black women
and hyperplastic myometrium. This histo-
upon ultrasonographic examination by age 50
pathologic diagnosis is found in over 60% of
[48]. While the majority of these leiomyomas
hysterectomy specimens [51]. Clinically, two-
are subclinical, 20–40% will be symptomatic.
thirds of patients with adenomyosis will com- frequent in women on oral contraceptives and
plain of menorrhagia and dysmenorrhea, and with chronic cervicitis; however, the etiology
pelvic examination usually reveals a diffusely remains unclear. Endocervical polyps are rela-
enlarged and tender uterus. tively common among sexually active women.
Diagnostic tests that help suggest the diag- Many endocervical polyps are asymptom-
nosis of adenomyosis include both transvagi- atic and are discovered incidentally on visual
nal ultrasonography and magnetic resonance examination of the cervix. In other instances,
imaging. The sensitivity for ultrasonography these polyps can manifest as intermenstrual
approaches 50%, and the sensitivity of MRI and/or postcoital spotting.
ranges from 80% to 100% [51]. Research con- Microscopically, endocervical polyps con-
tinues to focus on more effective adenomyo- sist of a vascular core surrounded by a glan-
sis diagnostic testing and treatments short of dular mucous membrane and may be covered
hysterectomy. completely or partially with stratified squa-
mous epithelium. In some polyps, the con-
nective tissue core may be relatively fibrous.
8.7.2 Malignant and Premalignant Endocervical polyps removed from women
Uterine Neoplasms taking oral contraceptives can show a pattern
of microglandular hyperplasia [54].
8 8.7.2.1 Endometrial Hyperplasia
and Cancer 8.7.2.3 Cervical Dysplasia and Cancer
Cervical dysplasia and cancer can both pres-
Endometrial hyperplasia is commonly found
ent as postcoital bleeding. In one study of
in women with AUB caused by prolonged
women presenting with postcoital spotting,
anovulation [52]. Rather than a primary etiol-
17% were found to have cervical dysplasia
ogy of AUB, it is the result of prolonged unop-
and 4% had invasive cervical cancer [46]. In
posed estrogen exposure of the endometrium
the absence of a visible lesion, Papanicolaou
that occurs in women with chronic anovula-
smears, human papillomavirus (HPV) testing,
tion. Endometrial hyperplasia is a precursor
and colposcopy (if indicated) are important
to endometrial cancer and, in the presence of
diagnostic tools. In the presence of a visible
atypia, can be a marker for concurrent endo-
cervical lesion, it is critical to biopsy the lesion
metrial cancer elsewhere in the uterus.
to determine the diagnosis.
Endometrial cancer is the most important
disease to identify early in woman with AUB,
particularly those who are peri- or postmeno-
pausal. Approximately 20% of endometrial 8.7.3 Ovarian Malignancies
cancer is diagnosed in women before meno-
pause and 5% before the age of 40 years [53]. Ovarian malignancies are uncommon in
After the menopause, approximately 10% of reproductive-aged women, and mainly occur
women with AUB not taking exogenous hor- in postmenopausal women. The presence of
mones will be found to have endometrial can- an ovarian tumor can interfere with the func-
cer, and the incidence rises with each decade tion of the HPO axis, and as a result, AUB
of life thereafter. can be an early symptom for some women
with an ovarian malignancy. However, the
8.7.2.2 Endocervical Polyps most common early symptoms of an ovarian
These soft, fleshy growths originate from the malignancy are gastrointestinal complaints
mucosal surface of the endocervical canal. [55]. However, the majority of ovarian malig-
They usually arise from a stalk and pro- nancies present at an advanced stage of dis-
trude through the cervical os, although some ease with symptoms including for pain and
may be broad-based. They commonly range abdominal distension related to ascites.
in size from 3 to 20 mm but can be larger. Granulosa cell tumors are a notable excep-
Endocervical polyps are known to be more tion and differ from other ovarian malignan-
185 8
cies in terms of both age distribution and lation can be associated with endometrial
presentation [56]. Although granulosa cell hyperplasia and/or cancer. Careful evalua-
tumors represent <5% of all ovarian malig- tion of the patient for multiple simultaneous
nancies, approximately half of these estrogen- causes of AUB is important.
secreting tumors occur in reproductive-aged
women, and AUB is the most common present-
ing symptoms. In reproductive-aged women, 8.8.1 Exclude Pregnancy
AUB usually manifests as irregular menses,
menorrhagia, and intermenstrual bleeding, In reproductive-aged women, the presence of
although amenorrhea might also result. In signs and symptoms of pregnancy is impor-
older women, postmenopausal bleeding is one tant to determine. Pregnancy should be one
of the most common presenting symptoms. of the first causes of abnormal bleeding that is
Unopposed estrogen secreted by granulosa ruled out. Current contraceptive methods and
cell tumors results in an association between past pregnancy history are also important.
these tumors and both endometrial hyperpla-
sia in up to 50% of these women and endome-
trial carcinoma in up to >10%. 8.8.2 Characterize Bleeding
Once pregnancy is excluded, the amount

8.7.4 Vaginal Malignancies and character of the bleeding is important
to ascertain. Careful, stepwise retrospective
Vaginal malignancies are uncommon, mak- questioning will usually give a clear picture
ing up <2% of gynecologic cancers [57] that of the bleeding pattern over the previous
arise in the female genital system. Over 80% days, months, and even years. In nonemer-
are squamous cell carcinoma, usually related gency cases of bleeding, the use of a prospec-
to HPV infections. Most other vaginal cancers tive menstrual calendar is an excellent way to
are adenocarcinomas. They occur most com- document the problem as well as the response
monly in older women, with the median age to therapy. It is important to determine when
at diagnosis of 68 years [58]. One of the most the bleeding problems were first noticed, since
common presenting symptoms is intermen- menorrhagia starting at menarche should
strual spotting [57], and the diagnosis is made alert the clinician to the possibility of an
by directed biopsies. underlying bleeding disorder.
The amount of bleeding is probably the
most difficult to elicit from the patient, since
8.8 Clinical Evaluation normal or heavy menstrual bleeding can be
of Abnormal Vaginal Bleeding very subjective. For research purposes, men-
orrhagia can be defined as a monthly blood
The evaluation of abnormal vaginal bleeding loss of >80 mL on three consecutive menses
should be tailored to the clinical presentation, as measured by the alkaline hematin method
and importantly, the age of the patient should [59]. Unfortunately, this type of accurate
be taken into consideration (. Fig. 8.1). The evaluation is neither cost-effective nor readily
clinician should be aware of common causes available.
of AUB that might not be clinically obvious In adolescents with menorrhagia, it is
but still must be excluded. important to determine any past history of
An important point to keep in mind is excess bleeding during surgical, dental, or
that AUB can often have more than one etiol- obstetric procedures since this has been found
ogy. Sometimes subtle comorbid conditions, to be predictive of von Willebrand disease
such as endometritis, can make single-factor [60]. Interestingly, in this same study, epistaxis
therapy surprisingly ineffective [41]. In other and easy bruising were not clear discrimina-
women, obvious causes of chronic anovu- tory symptoms.
History and physical
Initial lab evaluation

• CBC, platelet count
• beta-hCG
• Pap smear
Pregnancy Cervical lesion
Transvaginal ultrasonography
Transvaginal sonohysterography Biopsy
ultrasonography
• Viable Normal Endometrial Myometrial

• Spontaneous uterus pathology pathology:
abortion • Leiomyoma
8 • Ectopic
• Biopsy
• Adenoymosis
• Molar
• Hysteroscopy
Regular
Taking Irregular
menses
hormonal menses
(assume
therapy (anovulatory)
ovulatory)
Intermenstrual Excessive Lab evaluation

spotting menses • TSH
• Prolactin
• Hemoglobin A1c
Adolescent
Signs of androgen excess:
• Testosterone (Total)
Lab evaluation Lab evaluation • DHEAS
• Chlamydia • Bleeding
• Gonorrhea disorders
Endometrial biopsy
if >40 years old
.. Fig. 8.1 Algorithm for evaluating women with abnormal uterine bleeding (AUB)
187 8
8.8.3 Medical History ordering every test at the first visit, laboratory
tests should be obtained in a stepwise fashion
A careful history is the most important fac- based on presentation (. Fig. 8.1).
tor in determining the appropriate diagnostic
approach. This should include the patient’s
menstrual patterns and history, the extent of Box 8.4 Laboratory Testing for AUB
recent bleeding, sexual activity, and contra- 55 All patients
ception. Important questions include symp- –– Pregnancy test
toms of pregnancy, infection, changes in –– Complete blood count (including
body hair, excessive bleeding, and systemic platelets)
disease. Current medication and informa- –– Papanicolaou smear
tion about prior Papanicolaou smears are –– Cervical tests for gonorrhea and
also important. The review of systems should chlamydia
include symptoms of systemic disease, such as 55 Anovulatory bleeding
weight gain or loss, abdominal swelling, som- –– Thyroid-stimulating hormone
nolence, and nipple discharge. –– Prolactin
–– Hemoglobin A1c
–– Testosterone (total and free)
8.8.4 Physical Examination – – Dehydroepiandrosterone sulfate
(DHEAS)
The physical examination is intended to 55 >40 years of age
detect both gynecologic and systemic diseases. –– Endometrial biopsy
Special care should be taken to document the 55 New-onset heavy menstrual bleeding
presence of hirsutism, acne, or other signs of –– Prothrombin time
excess androgens, as well as galactorrhea. –– Activated partial thromboplastin time
The pelvic examination begins with a –– Bleeding time
speculum examination to inspect the cervix 55 Heavy menstrual bleeding since men-
for polyps, signs of infection, or inflamma- arche
tion. A bimanual examination is important to –– Above plus
determine uterine size and the presence and –– Iron profile, serum creatinine
location of any tenderness. In the presence of –– Factor VII level
bleeding in early pregnancy, great care should –– von Willebrand factor (vWF) antigen
be taken to avoid adnexal compression dur- –– Ristocetin cofactor
ing the bimanual examination since this can –– Platelet aggregation studies
lead to rupture of an ectopic pregnancy. The 55 If the above are negative, consider
role of bimanual examination for detecting –– Factor XI level
and characterizing adnexal masses has been –– Euglobulin clot lysis time
replaced for the most part by more accurate
and precise transvaginal ultrasound, particu-
larly in overweight women.
8.8.5.1 Urine Tests
The most important test for all reproductive-
8.8.5 Laboratory Testing aged women complaining of AUB is an
hCG test for pregnancy. This can be readily
Laboratory evaluation is an important part obtained through urine testing as a prelimi-
of the initial evaluation of all patients with nary qualitative test. If positive, quantitative
AUB (7 Box 8.4). However, rather than serum HCG testing can be completed.
8.8.5.2 Blood Tests with nonclassic CAH will have normal base-
For all cases, except the most insignificant line levels of 17-
hydroxyprogesterone and
bleeding, a CBC (including platelets) is impor- demonstrate elevated levels only after stimu-
tant to detect significant anemia and disor- lation with an ACTH analogue. If ovulation
ders of platelet production or survival. Unless dysfunction and signs of androgen excess
precluded by extremely heavy bleeding, a begin at the time of puberty, such women
Papanicolaou smear should be performed on should be investigated appropriately (see
any woman who has not had recent screening 7 Chap. 7).
as per the current screening guidelines. For
patients with apparent oligo- or anovulation, 8.8.5.3 Evaluation for Hemostatic
thyroid-stimulating hormone (TSH) and pro- Disorders
lactin testing will detect subtle pituitary func- Patients with new onset of significant menor-
tion disorders that might present with AUB rhagia should be evaluated for bleeding disor-
as the earliest symptom. Since cervical and ders with a CBC, prothrombin time, activated
uterine infections are common, nucleic acid partial thromboplastin time, and bleeding
amplification tests for gonorrhea and chla- time [62]. Any patient with a history of men-
mydia are helpful in women with intermen- orrhagia since menarche, especially with a
8 strual spotting, as well as any woman at risk
for these infections.
history of surgical or dental-related bleeding
or postpartum hemorrhage, should be evalu-
Several patient groups may require addi- ated for heritable bleeding disorders. These
tional ancillary tests. Obese patients with tests include specific tests for von Willebrand
apparent AUB are at increased risk for type disease, such as von Willebrand factor anti-
2 diabetes. Several authors recommend mea- gen, von Willebrand factor functional activity
surement of hemoglobin A1c (HbA1c) as a (ristocetin cofactor activity), and factor VIII
good diabetes screen that does not require level. These levels can fluctuate; therefore,
fasting or a return visit for provocative test- these tests should be repeated if clinical suspi-
ing. Patients with hirsutism or other evi- cion is high. Normal ranges should be adjusted
dence of androgen excess should be screened for the observation that von Willebrand factor
for ovarian and adrenal malignancies with levels are 25% lower in women with blood type
total testosterone and DHEAS. All women O compared with other blood groups. Further
>45 years old should have an endometrial studies, such as platelet aggregation studies,
biopsy to rule out endometrial hyperplasia may also be required [62]. If these studies are
or cancer. Similarly, women younger than 45 negative, factor XI level and euglobulin clot
with persistent abnormal bleeding or chronic lysis time can be evaluated.
unopposed estrogen exposure should have an
endometrial biopsy after pregnancy has been
excluded. 8.8.6 Papanicolaou Smear
PCOS and nonclassic CAH may sometimes
be indistinguishable by clinical presentation, In the setting of mild vaginal bleeding, a Pap
since both disorders are often characterized smear should be performed to rule out bleed-
by hirsutism, acne, menstrual abnormalities, ing from cervical carcinoma. It is important
and infertility [61]. Unfortunately, no dis- to not delay this sampling due to the bleeding,
criminatory screening test exists for this heter- and a large cotton-tipped swab can be used
ologous condition, which is most commonly to carefully clear the bleeding before obtain-
caused by 21-hydroxylase or 11-beta-hydrox- ing sampling. Importantly, other forms of
ylase deficiency. Measuring baseline serum cervical bleeding such as cervical polyps and
17-hydroxyprogesterone will detect nonclassic ectropion can be ruled out through physical
CAH in the majority of women with this con- examination.
dition. However, as many as 10% of women
189 8
8.8.7 Endometrial Biopsy the nature of both palpable and nonpalpable
adnexal masses. Knowledge about the size
For premenopausal women over the age of and location of leiomyoma and the potential
40 years old, AUB is often the result of anovu- that an ovarian mass might be malignant is
latory bleeding, which is a normal physiologi- invaluable prior to surgery.
cal response to declining ovarian function.
However, the risk of endometrial hyperplasia 8.8.8.2 Sonohysterogram
and carcinoma also increases with age. For this Sonohysterography can be used to accurately
reason, once pregnancy has been excluded, an visualize most intrauterine abnormalities
endometrial biopsy should be obtained in all once pregnancy has been excluded. Accurate
women older than 45 years of age who present evaluation of the uterine cavity is of the
with AUB. Endometrial biopsy should also be utmost importance for the evaluation and
performed in all women who are younger than treatment of AUB. This procedure involves
45 years of age who have a history of persis- injection of sterile saline into the uterus while
tent AUB, unopposed estrogen exposure, or a transvaginal sonogram is performed. It may
failed medical management [11]. cause a small amount of discomfort to the
patient. When the uterine cavity is distended
with saline, intracavitary lesions (e.g., pol-
8.8.8 Imaging yps, fibroids, cancer) as small as 3 mm can be
clearly seen (. Fig. 8.2).
Over the last two decades, our ability to
visualize the uterine cavity and adnexa 8.8.8.3 Hysterosalpingogram
has dramatically increased. In addition to A hysterosalpingogram can be used to evalu-
the bimanual pelvic examination, the only ate the uterine cavity and fallopian tubes. It
other available methods were hysterosal- involves injection of contrast dye through
pingogram (HSG) and dilation and curet- the cervical canal. This can be used to evalu-
tage. Although the radiation exposure and ate for intracavitary lesions such as fibroids.
discomfort associated with HSG are both Additional imaging such as sonohysterog-
considered acceptable, this technique effec- raphy or hysteroscopy can provide more
tively identifies only marked abnormalities specificity and accuracy on the type of lesion
of the uterine cavity. Lesions <1 cm in size including characterization of the lesion.
are often missed. Likewise, the previously
blind procedure of dilation and curettage
gave the operator only the roughest idea of
the depth and contour of the uterine cavity.
Intrauterine findings at the time of hysterec-
tomy were often a surprise. In obese patients
in whom bimanual examinations are diffi-
cult, unexpected ovarian masses at laparot-
omy were commonplace.
8.8.8.1 Transvaginal Ultrasound

Today, transvaginal ultrasonography and
sonohysterography have made unexpected
findings at surgery much less common (See
7 Chaps. 5 and 6). Ultrasonography and
sonohysterography have become important
steps in the evaluation of AUB. Transvaginal
ultrasonography can accurately determine .. Fig. 8.2 Endometrial polyps diagnosed by sonohys-
uterine size and configuration, and reveal terography (SIS)
8.8.9 Hysteroscopy hemodynamic compromise. This degree of

hemorrhage can be the result of a number of
Hysteroscopy (See 7 Chaps. 5 and 16) is causes, most notably gynecologic malignan-
another excellent outpatient method for visu- cies and anovulatory bleeding after prolonged
alizing the uterine cavity, and in experienced amenorrhea. Evaluation of all patients with
hands can be performed safely in the office. AUB should include assessment for signs of
The discomfort and risk can be greater than anemia, and potential hemodynamic insta-
sonohysterography, and the procedure can bility related to hypovolemia [64]. This is
be difficult in the presence of cervical steno- particularly important for older women with
sis or when the cervix is difficult to visualize. additional risk factors for cardiovascular dis-
However, the color photographs depicting the ease for whom extreme anemia and/or hypo-
lesion can be very informative for patients. tension could provoke a cardiac event [65].
Hysteroscopy done in the OR can be both For women with AUB who are hemo-
diagnostic and therapeutic. Diagnostic hys- dynamically unstable, the first step is estab-
teroscopy can provide information on uterine lishing intravenous access in an acute care
contour, presence of inflammation (visually environment followed by replacement of flu-
and via endometrial biopsy), and the depth and ids and blood products. Once stabilized, care-
ful assessment to determine the AUB etiology
8 size of intracavitary lesions, such as fibroids
can be carried out.
and polyps. These lesions can then be removed,
and importantly a tissue diagnosis ruling out Definitive treatment will depend on AUB
malignancy can be obtained. Endometrial etiology as described elsewhere in this chapter.
sampling can be wider, effectively ruling out Urgent treatment of two of the most common
hyperplasia and carcinoma. Performing hys- causes of acute hemorrhage, anovulatory
teroscopy in the OR setting allows for patient bleeding and malignancy, deserves special
comfort and definitive management. It is a attention.
safe and effective minimally invasive treatment
approach when performed appropriately [63]. 8.9.1.1 Hemorrhage Related
to Anovulation
The approach for women who present with
8.9 Acute Management of AUB acute hemorrhage with presumed anovulatory
bleeding and normal pelvic anatomy should
Targeted, expedient, and effective management be done in a stepwise manner. Bleeding in this
of AUB is a cornerstone of gynecologic prac- circumstance is related to asynchronous endo-
tice. Once pregnancy has been excluded, vari- metrial shedding and originates from innu-
ous systemic, infectious, and neoplastic causes merable spiral arterioles in the endometrium.
of AUB must be effectively treated. Most After the patient is stabilized with intravascu-
patients presenting with AUB will be hemo- lar resuscitation, the initial approach can be
dynamically stable, allowing outpatient treat- intravenous conjugated equine estrogen for
ment. On occasion, these patients will present patients not at increased risk for thromboem-
with vaginal hemorrhage requiring emergency bolism [64]. Intravenous estrogens, the only
intervention and possibly hospital admission FDA-approved hormonal treatment for AUB,
for stabilization and definitive treatment. has been reported to stop bleeding in >60% of
these patients.
Anovulatory patients who continue to
8.9.1 Emergency AUB Treatment hemorrhage despite treatment with intrave-
for Hemodynamically nous estrogens will usually respond to uterine
Unstable Patients dilation and curettage. Concomitant hysteros-
copy, when possible, is an important adjuvant
Women can present with AUB-related acute to diagnose and treat intrauterine pathology
hemorrhage significant enough to result in such as polyps or leiomyomas.
191 8
8.9.1.2 Arterial Embolization at three tablets per day will often decrease or
for Pelvic Malignancies stop bleeding quickly, although many women
Women with AUB related to cervical or experience nausea with this high-dose regi-
endometrial malignancies can present with men [67]. Alternatively, medroxyprogester-
massive arterial hemorrhage. When pelvic one acetate, at a dose of 10 mg per day for
examination reveals a tumor mass as the 10–14 days, usually improves bleeding within
bleeding source, the initial approach is vagi- 2–3 days and serves to stabilize the endome-
nal packing and intravenous resuscitation trial lining prior to withdrawal bleeding.
with fluid and blood products. When pressure Patients treated with either of these
and clotting factors do not control hemor- methods should be counseled that they may
rhage, intravascular arterial embolization by experience moderately heavy bleeding within
an interventional radiologist can be lifesav- 1–2 days of stopping their medication and
ing. Embolization has been reported to result should start oral contraceptives on the Sunday
in complete or partial hemorrhage control in following the withdrawal bleeding. A combi-
up to 90% of these patients [66]. Once these nation of oral and intramuscular medroxy-
patients are stabilized, irradiation or surgical progesterone will result in a longer period of
intervention can be utilized as indicated. amenorrhea [68]. However, this intramuscular
medroxyprogesterone should be avoided in
women wishing to conceive in the near future
8.9.2 Acute Outpatient Treatment because the median delay in conception after
of AUB the last injection has been reported as approx-
imately 9 months.
8.9.2.1 Progestin Endometrial
Synchronization
Progestin therapy is the first-line approach 8.10 Long-Term Management
to stop bleeding in hemodynamically stable of Ovulatory Dysfunction
patients. Progestins are also used for women
with chronic irregular bleeding to synchronize The most appropriate long-term manage-
the endometrium prior to the initiation of ment of chronic anovulation requires accu-
cyclic hormones. Synchronization can reduce rate diagnosis of any underlying pathology.
breakthrough bleeding encountered with sub- For anovulatory women desiring concep-
sequent therapy. tion, ovulation induction is usually the most
Approaches to synchronization use either appropriate treatment. For women not imme-
an oral contraceptive taper or a potent pro- diately desiring conception, this is followed
gestin (. Table 8.2). For women with heavy by a combination of hormonal management
vaginal bleeding, oral contraceptives starting and management of associated comorbidi-
.. Table 8.2 Effective acute outpatient therapies for anovulatory bleeding
Medication Routine Dosage Frequency and duration
Ethinyl estradiol plus Norethindrone PO 35 μg TID × 1 week, then QD × 3 week

(OCPs) 1 mg
Medroxyprogesterone PO 20 mg TID × 1 week, then QD × 3 week
Medroxyprogesterone IM 150 mg Once
Plus PO 20 mg TID × 3 days
Abbreviations: IM intramuscular injection, PO oral, QD once daily, TID three times daily, OCPs oral contra-
ceptive pills
ties including obesity, type 2 diabetes mellitus, 8.10.2.1 Oral Contraceptives

and endometrial hyperplasia and cancer. For decades, combined oral contraceptive pills
have been the first-line therapy for managing
AUB, and studies have repeatedly demonstrated
8.10.1 Ovulation Induction their utility in decreasing the duration and
amount of menstrual flow as well as dysmen-
Restoration of ovulation for women desir- orrhea [70]. In addition, extending the number
ing conception is of paramount importance. of consecutive days of active pills and decreas-
Restoration of regular ovulatory cycles may ing the annual number of menses may further
necessitate treatment of any underlying con- minimize menstrual- related symptoms [70].
dition responsible for anovulation. For exam- Extended cycle regimens increase the risk of
ple, in patients with hyperprolactinemia, spotting and breakthrough bleeding when com-
using a dopamine agonist to normalize pared with standard monthly cycle regimens,
prolactin levels will often result in ovula- but the risk generally decreases over time [71].
tion and subsequent pregnancy. In cases of
PCOS, recent studies have demonstrated that 8.10.2.2 Progestins
insulin-sensitizing agents, such as metformin, Progestin therapy, cyclic or continuous, rep-
can promote ovulation (See 7 Chaps. 5 and
8 8). It is important to note, however, that utili-
resents another option for long-term man-
agement of AUB. The administration of
zation of these agents alone may not be suffi- progestins, such as 10 mg medroxyprogesterone
cient for ovulation induction and conception. or 300 mg micronized progesterone, daily, from
A recent randomized clinical trial did not day 15 to 26 of each cycle, will regulate menses
demonstrate an improvement with live birth in anovulatory patients. Cyclic progestin ther-
rates when adding metformin to clomiphene apy represents a safe and effective approach
citrate [69]. to managing AUB and does not have the side
While waiting for systemic therapies to effects or risks associated with oral estrogen.
result in resumption of ovulation and nor- Additionally, cyclic progestin therapy provides
mal menses, monthly induction of withdrawal endometrial protection against endometrial
bleeding with an oral progestin should be con- hyperplasia and cancer. Notable side effects
sidered to avoid ongoing AUB. In women not of progestin therapy include mood changes
using combined oral contraception, the use of or depression, nausea, breast tenderness, and
micronized progesterone (200–300 mg daily bloating. Both progestin and continuous oral
for 14 days) will result in reasonable with- contraceptive therapy are equally efficacious in
drawal bleeding and will be safe should preg- the treatment of AUB; however, progestin-only
nancy occur. For patients who do not resume therapy has demonstrated superior patient sat-
ovulation with systemic therapy, induction of isfaction rates in direct comparison with com-
ovulation using clomiphene citrate, aromatase bined oral contraceptives [67].
inhibitors, or injectable gonadotropins should
be considered (See 7 Chaps. 5 and 7). 8.10.2.3 Levonorgestrel-Releasing
Intrauterine Devices
Levonorgestrel-releasing intrauterine devices
8.10.2 Hormonal Treatment (LNG-IUDs), originally developed for con-
of Anovulatory Bleeding traception, have been shown to be an effective
treatment for dysmenorrhea, AUB-H, and
Women who do not desire pregnancy may endometrial hyperplasia. These IUDs release
initiate combined oral contraception or other the potent progestin levonorgestrel (LNG)
hormonal therapies, such as cyclic proges- directly into the uterine cavity, suppressing
tins and a progestin-containing intrauterine endometrial proliferation and decreasing
device. menstrual blood loss by as much as 97% [72].
193 8
While many women will experience irregu- 8.11.1.1 Combination Oral
lar or intermenstrual bleeding in the first Contraceptives
6 months of their use, at least 50% will have Estrogen-progestin oral contraceptives (OCPs)
amenorrhea by 24 months [73]. are often used for first-line management for
LNG-IUDs have very few systemic side AUB/HMB. Significant advantages include
effects compared to oral and parenteral con- reduction of menstrual flow, amelioration of
traceptives containing progestins. However, dysmenorrhea, and providing contraception.
extremely low amounts of LNG can be detected Randomized trials have demonstrated the
in the systemic circulation among LNG- ability of OCPs to decrease menstrual blood
containing IUD users [74]. As a result, some loss in women with AUB from 35% to 69%
users will experience hirsutism, acne, weight [75]. Alternative routes of administration of
change, nausea, headache, mood changes, and/ estrogen-progestin include the transdermal
or breast tenderness. contraceptive patch and vaginal contraceptive
The first LNG-IUDs contained 52 mg of ring. The efficacy of these in treating AUB is
LNG and released 20 μg every 24 hours from likely similar to that of OCPs, and compliance
this polymer cylinder. LNG-IUDs are now may be improved. Furthermore, underscoring
available that contain and release less LNG: the impact of formulation on HMB, shorter
13.5 mg/device and 19.5 mg/device. Initial duration of hormone free- intervals may be
LNG release rates are reduced by 50% after associated with less withdrawal bleeding than
5 years. Although the initial cost of an LNG- formulations with 7 hormone-free days per
IUD is higher than other medical treatment 28-day pill pack. Indeed, the only OC approved
options, long term they provide cost-effective by the US Food and Drug Administration for
therapy of AUB-H. treatment of AUB has a short hormone-free
interval [76]. In a randomized trial, this OCP
formulation significantly reduced menstrual
8.11 Treatment of AUB blood loss compared with placebo (reduced by
in Ovulatory Patients 64% versus 8%) [77].
Similarly to patients with anovulatory
In ovulatory women, AUB can be either between AUB, OCPs may be prescribed in a myriad
menses, often postcoital, or excessive bleeding of dosing regimens: a cyclic (with a monthly
(HMB) that occurs at normal, regular intervals. withdrawal bleed), extended (withdrawal
Intermenstrual bleeding can be related to cervi- bleeding every 3 months), or continuous
cal or endometrial infections or neoplasms, as (no withdrawal bleed) regimen. Although
discussed above. Chronic HMB is most often extended or continuous OCP use may be more
related to an anatomical cause, e.g., leiomyoma efficacious in suppression of menstrual blood
or adenomyosis, but can also be related to con- loss, breakthrough bleeding is a concern with
genital or acquired bleeding disorders. this approach, limiting the utility of this strat-
Unfortunately, despite a thorough evalua- egy for some patients.
tion, approximately one-half of women with
HMB have no discernible cause. These women 8.11.1.2 Progestins
must be treated with empiric hormonal or sur- Progestin-containing hormonal preparations are
gical therapies until a treatable cause can be also effective in the treatment of HMB. High-
identified or menopause occurs. dose oral progestin formulations are generally
reserved for patients who have contraindications,
prefer to avoid estrogen, or who are trying to con-
8.11.1 Medical Treatment ceive a pregnancy. Examples of treatment regi-
mens include norethindrone 5 mg one to three
The majority of patients who present with times a day or medroxyprogesterone 5–30 mg
AUB will be medically stable and thus good daily. Norethindrone is substantially more
candidates for outpatient management. potent than medroxyprogesterone in the attenu-
ation of menstrual flow [75]. Norethindrone is tranexamic acid in the treatment of HMB,
the most-studied progestin-only regimen for and in Europe this medication has become
the treatment of AUB; however, other regimens the preferred treatment for women with
including megestrol may be equally efficacious. heavy menstrual bleeding [80]. The FDA
Blood loss with progestin therapy use has dem- has approved tranexamic acid for use in the
onstrated reductions by approximately 30% in treatment of HMB. This therapy is adminis-
some studies. High-dose progestin formulations, tered orally at a dose of 1300 mg three times
unfortunately, may instigate progestin-related daily for 5 days, initiated with onset of men-
side effects, including mood lability, bloating, ses. Studies have demonstrated the superior-
and an increased appetite. ity of this class of drugs in comparison with
Levonorgestrel-containing IUDs may be NSAIDs. Conversely, tranexamic acid is infe-
offered as a first-line treatment for patients rior to LNG 52 in the treatment of AUB [81]
with HMB wishing to defer conception in the To date, studies have not demonstrated an
near future. The 52 mg-containing IUD sys- increased risk of venous or arterial throm-
tem (LNG 52) has been approved by the FDA boembolism [82]. However, tranexamic acid
for treatment of HMB due to its efficacy and should not be concomitantly administered
compliance. Studies demonstrate superiority with combined oral contraception or in women
of LNG-containing IUDs in improving qual- with an increased risk of thromboembolism.
8 ity of life in patients with HMB by significant
menstrual suppression, with the majority of
patients experiencing amenorrhea or infre- 8.11.2 Surgical Treatment of AUB
quent bleeding [73]. After 6 months, LNG
52 IUD treatment of women with HMB has In the past, surgery was one of the most com-
been shown to increase their hemoglobin and mon treatments of AUB related to either
ferritin levels by 7.5% and 68.8%, respectively. structural or nonstructural abnormalities,
Further study is required to determine the primarily in the form of hysterectomy [5].
efficacy of IUDs containing lower LNG dos- This was likely related to both an incomplete
ages (e.g., 19.5 mg and 13.5 mg) for treatment understanding of AUB and a paucity of effec-
of HMB. tive medical treatments. Surgical treatments
are now reserved for women with coexisting
8.11.1.3 Nonsteroidal surgical indications in addition to AUB (e.g.,
Anti-inflammatory Drugs pelvic organ prolapse, infertility, possible
Prostaglandins significantly impact endome- malignancy) or those who have completed
trial hemostasis, and by inhibiting prosta- childbearing and find medical treatment inef-
glandin synthesis, NSAIDs serve to decrease fective or unacceptable because of risks or
menstrual blood loss. NSAIDs may reduce side effects.
menstrual blood loss by 30–40% [78]. While Surgical approaches can be either con-
naproxen has been the most extensively stud- servative (e.g., myomectomy, polypectomy)
ied NSAID, no member of the drug class or definitive (e.g., endometrial ablation, hys-
offers distinct advantages for AUB [79]. terectomy). The choice of surgical approach
Additionally, NSAIDs provide an effective depends on the patient’s diagnosis, therapeu-
treatment for dysmenorrhea, which is often tic goals, and desire for future fertility. For
present in those with AUB. younger women whose fertility desires might
change in the future, it should be kept in mind
8.11.1.4 Tranexamic Acid that hormonal management with a progestin-
Tranexamic acid, an antifibrinolytic agent, releasing IUD can often be as effective as a
is a nonhormonal modality utilized in the definitive surgery for controlling AUB [83].
treatment of AUB. A Cochrane analysis has The details of surgical approaches are pro-
confirmed efficacy and patient tolerance of vided in 7 Chaps. 20, 21, and 22.
195 8
8.11.2.1 Medical Pretreatment and greater cost-effectiveness (see 7 Chap.
of Uterine Leiomyomas 20). Ablation is not indicated for women who
with GnRH Analogues desire to maintain fertility, since pregnan-
Medical pretreatment with GnRH agonists cies after ablation are at markedly increased
has been shown to be useful in some cases risks of adverse pregnancy outcomes, includ-
to decrease the size of leiomyoma by up to ing preterm premature rupture of mem-
47% prior to surgical intervention [84]. This branes (PPROM) and abnormal placentation.
approach has been shown to facilitate removal Women undergoing this procedure should
using minimally invasive approaches, decrease consider permanent sterilization since endo-
blood loss during open myomectomy, and metrial ablation does not provide reliable con-
facilitate specimen removal during hysterec- traception [85].
tomy. GnRH agonist injections result in an ini-
tial increase in pituitary and ovarian hormones 8.11.2.4 Hysterectomy
(i.e., “flair”) followed by pituitary downregu- Hysterectomy remains the best option for some
lation, hypoestrogenemia, and cessation of women with AUB who fail medical or surgical
menses. The side effects of estrogen depriva- management or who have additional indications
tion include hot flashes, mood alterations, and for hysterectomy. As many as 20% of women
bone loss, which can be diminished by “add- who initially undergo endometrial ablation will
back” therapy with oral norethindrone. More require hysterectomy within 5 years. Some stud-
recently, oral GnRH antagonists have become ies have demonstrated a higher satisfaction rate
available to avoid the hormonal flare. However, in women who initially underwent hysterectomy
their clinical utility remains to be determined rather than endometrial ablation [86].
for presurgical treatment of leiomyoma.
8.11.2.2 Myomectomy 8.12 Review Questions

Surgical removal of leiomyomas in symptom-
atic women is an effective treatment, although ??1. A 36-year-old woman is having frequent
subsequent growth of addition leiomyomas and heavy menses. After pregnancy was
often necessitates the need for additional sur- excluded, sonohysterogram revealed an
gery (see 7 Chap. 22). The best approach intracavitary lesion consistent with a
depends on the size and location of the fibroids 3 cm intra cavitary (type 0) fibroid.
in addition to the level of surgical expertise of What is the next best step?
the provider. Hysteroscopic resection is the ideal A. Do nothing.
approach for all but the largest intracavitary B. Place her on oral contraceptive
and submucosal leiomyomas (FIGO stage 0, I, pills.
or II) because of the decreased morbidity and C. Order a hysterosalpingogram.
faster recovery. Myomectomy for larger fibroids D. Proceed with hysteroscopic myo-
(FIGO stage III or higher) can be performed mectomy.
laparoscopically, with or without robotic assis-
tance, or using an abdominal approach. For ??2.
At 27-year-old woman presents with
patients desiring future childbearing, caution abnormal uterine bleeding. A careful his-
must be undertaken during repair of the endo- tory reveals new-onset acne, hirsutism,
metrium to prevent intracavitary scarring in and deepening of the voice. Which test(s)
cases where the uterine cavity is entered. would be most helpful at this point?
A. Hysterosalpingogram
8.11.2.3 Endometrial Ablation B. CBC
Endometrial ablation is a minimally invasive C. Serum testosterone and dehydro-
surgical procedure that, compared to hyster- epiandrosterone
ectomy, has less morbidity, shorter recovery, D. Endometrial biopsy
??3. A 33-year-old woman with a normal- 4. Morgan DM, Kamdar NS, Swenson CW, Kobernik
appearing uterus on transvaginal ultra- EK, Sammarco AG, Nallamothu B. Nationwide
trends in the utilization of and payments for
sound has continued to bleed for 3 weeks
hysterectomy in the United States among com-
despite treatment with high-dose oral mercially insured women. Am J Obstet Gynecol.
contraceptives. What is the first adjuvant 2018;218(4):425.e1–425.e18.
therapy would you consider? 5. Carlson KJ, Nichols DH, Schiff I. Indications for
A. Sonohysterogram hysterectomy. N Engl J Med. 1993;328:856–60.
6. Bayer SR, DeCherney AH. Clinical manifestations
B. Oral antibiotics
and treatment of dysfunctional uterine bleeding.
C. Endometrial biopsy JAMA. 1993;269(14):1823–8.
D. Vaginal Hysterectomy 7. Fraser IS, Critchley HO, Munro MG, Broder M,
Writing Group for this Menstrual Agreement
??4. A 23-year-old woman taking oral con- Process. A process designed to lead to international
agreement on terminologies and definitions used to
traceptives presents with several months
describe abnormalities of menstrual bleeding. Fertil
of postcoital spotting. Which test would Steril. 2007;87(3):466–76.
be least helpful at this point? 8. Zhang J, Salamonsen LA. In vivo evidence for
A. Pelvic examination with visualiza- active matrix metalloproteinases in human endo-
tion of the cervix metrium supports their role in tissue breakdown at
menstruation. J Clin Endocrinol Metab. 2002;87(5):
B. Papanicolaou smear
8 C. Nucleic acid amplification tests for
2346–51.
9. Brenner PF. Differential diagnosis of abnormal
chlamydia and gonorrhea uterine bleeding. Am J Obstet Gynecol. 1996;175(3
D. Endometrial biopsy Pt 2):766–9.
10. Haynes PJ, Hodgson H, Anderson AB, Turnbull
AC. Measurement of menstrual blood loss in
patients complaining of menorrhagia. Br J
8.13 Answers Obstet Gynaecol. 1977;84(10):763–8. https://doi.
org/10.1111/j.1471-0528.1977.tb12490.x.
vv1. D 11. ACOG Committee on Practice Bulletins—
Gynecology. Practice bulletin no. 128: diagnosis
of abnormal uterine bleeding in reproductive-aged
vv2. C women. Obstet Gynecol. 2012;120(1):197–206.
https://doi.org/10.1097/AOG.0b013e318262e320.
vv3. B 12. Ferenczy A. Pathophysiology of endometrial bleed-
ing. Maturitas. 2003;45(1):1–14.
vv4. D 13. van Gorp EC, Suharti C, ten Cate H, Dolmans
WM, van der Meer JW, ten Cate JW, Brandjes
DP. Review: infectious diseases and coagulation dis-
orders. J Infect Dis. 1999;180(1):176–86. https://doi.
References org/10.1086/314829.
14. American Academy of Pediatrics Committee on
1. Matteson KA, Baker CA, Clark MA, Frick Adolescence, American College of Obstetricians
KD. Abnormal uterine bleeding, health status, and and Gynecologists Committee on Adolescent
usual source of medical care: analyses using the Health Care, Diaz A, Laufer MR, Breech
Medical Expenditures Panel Survey. J Women’s LL. Menstruation in girls and adolescents: using
Health (Larchmt). 2013;22:959–65. the menstrual cycle as a vital sign. Pediatrics.
2. Munro MG, Critchley HO, Broder MS, Fraser IS, 2006;118(5):2245–50.
FIGO Working Group on Menstrual Disorders. 15. O’Connor KA, Holman DJ, Wood JW. Menstrual
FIGO classification system (PALM-COEIN) for cycle variability and the perimenopause. Am J Hum
causes of abnormal uterine bleeding in nongravid Biol. 2001;13(4):465–78.
women of reproductive age. Int J Gynaecol Obstet. 16. Tsilchorozidou T, Overton C, Conway GS. The
2011;113(1):3–13. pathophysiology of polycystic ovary syndrome. Clin
3. Coulter A, Bradlow J, Agass M, Martin-Bates C, Endocrinol. 2004;60(1):1–17.
Tulloch A. Outcomes of referrals to gynaecology 17. Zawadski JK, Dunaif A. Diagnostic criteria for
outpatient clinics for menstrual problems: an audit polycystic ovary syndrome: towards a rational
of general practice records. Br J Obstet Gynaecol. approach. Polycystic ovary syndrome. Boston:
1991;98:789–96. Blackwell Scientific; 1992. p. 377–84.
197 8
18. Hoeger KM. Obesity and lifestyle management in pregnancy. Best Pract Res Clin Obstet Gynae-
polycystic ovary syndrome. Clin Obstet Gynecol. col. 2014;28(5):621–36. https://doi.org/10.1016/j.
2007;50(1):277–94. bpobgyn.2014.04.003. Epub 2014 Apr 24. PMID:
19. Hurd WW, Abdel-Rahman MY, Ismail SA, 24841987.
Abdellah MA, Schmotzer CL, Sood A. Comparison 33. Hendriks E, Rosenberg R, Prine L. Ectopic preg-
of diabetes mellitus and insulin resistance screen- nancy: diagnosis and management. Am Fam Physi-
ing methods for women with polycystic ovary syn- cian. 2020;101(10):599–606. PMID: 32412215.
drome. Fertil Steril. 2011;96(4):1043–7. 34. ACOG Committee on Practice Bulletins—Gynecol-
20. Brennan K, Huang A, Azziz R. Dehydroepian- ogy. ACOG practice bulletin no. 191: tubal ectopic
drosterone sulfate and insulin resistance in patients pregnancy. Obstet Gynecol. 2018;131(2):e65–77.
with polycystic ovary syndrome. Fertil Steril. 35. Stevens FT, Katzorke N, Tempfer C, Kreimer U,
2009;91(5):1848–52. https://doi.org/10.1016/j. Bizjak GI, Fleisch MC, Fehm TN. Gestational
fertnstert.2008.02.101. Epub 2008 Apr 25. PMID: trophoblastic disorders: an update in 2015. Geburt-
18439591; PMCID: PMC2691796. shilfe Frauenheilkd. 2015;75(10):1043–50. https://
21. Chang RJ. A practical approach to the diagnosis of doi.org/10.1055/s-0035-1558054. PMID: 26556906;
polycystic ovary syndrome. Am J Obstet Gynecol. PMCID: PMC4629994.
2004;191(3):713–7. 36. Workowski KA, Bolan GA, Centers for Disease
22. Dumanski SM, Ahmed SB. Fertility and repro- Control and Prevention. Sexually transmitted dis-
ductive care in chronic kidney disease. J Nephrol. eases treatment guidelines, 2015. MMWR Recomm
2019;32(1):39–50. https://doi.org/10.1007/s40620- Rep. 2015;64(RR-03):1–137. Erratum in: MMWR
018-00569-9. Epub 2019 Jan 2 Recomm Rep. 2015;64(33):924.
23. Shaaban MM, Ghaneimah SA, Hammad WA, El- 37. Eschenbach DA. Acute pelvic inflammatory dis-
Sharkawy MM, Elwan SI, Ahmed YA. Sex steroids ease: etiology, risk factors and pathogenesis. Clin
in women with liver cirrhosis. Int J Gynaecol Obstet. Obstet Gynecol. 1976;19(1):147–69.
1980;18(3):181–4. https://doi.org/10.1002/j.1879- 38. Bjartling C, Osser S, Johnsson A, Persson K. Clini-
3479.1980.tb00276.x. cal manifestations and epidemiology of the new
24. Holley JL. The hypothalamic-pituitary axis in genetic variant of Chlamydia trachomatis. Sex
men and women with chronic kidney disease. Adv Transm Dis. 2009;36(9):529–35. https://doi.
Chronic Kidney Dis. 2004;11(4):337–41. org/10.1097/OLQ.0b013e3181a8cef1.
25. Okeke T, Anyaehie U, Ezenyeaku C. Premature 39. Heatley MK. The association between clinical
menopause. Ann Med Health Sci Res. 2013;3(1):90– and pathological features in histologically iden-
5. https://doi.org/10.4103/2141-9248.109458. tified chronic endometritis. J Obstet Gynaecol.
PMID: 23634337; PMCID: PMC3634232. 2004;24(7):801–3.
26. Britton LE, Alspaugh A, Greene MZ, McLemore 40. Gilmore H, Fleischhacker D, Hecht JL. Diagnosis
MR. CE: an evidence-based update on of chronic endometritis in biopsies with stromal
contraception. Am J Nurs. 2020;120(2):22–33. breakdown. Hum Pathol. 2007;38(4):581–4.
27. Krettek JE, Arkin SI, Chaisilwattana P, Monif 41. Eckert LO, Thwin SS, Hillier SL, Kiviat NB,
GR. Chlamydia trachomatis in patients who used Eschenbach DA. The antimicrobial treatment of
oral contraceptives and had intermenstrual spot- subacute endometritis: a proof of concept study.
ting. Obstet Gynecol. 1993;81(5):728–31. Am J Obstet Gynecol. 2004;190(2):305–13.
28. Falcone T, Desjardins C, Bourque J, Granger 42. Davies J, Kadir RA. Endometrial haemostasis
L, Hemmings R, Quiros E. Dysfunctional uter- and menstruation. Rev Endocr Metab Disord.
ine bleeding in adolescents. J Reprod Med. 2012;13(4):289–99. https://doi.org/10.1007/s11154-
1994;39:761–4. 012-9226-4.
29. ACOG Committee on Practice Bulletins—Gyne- 43. Khan KN, Kitajima M, Hiraki K, Yamaguchi
cology. Committee ACOG. Opinion no. 451: Von N, Katamine S, Matsuyama T, Nakashima M,
Willebrand disease in women. Obstet Gynecol. Fujishita A, Ishimaru T, Masuzaki H. Escherichia
2009;114:1439–43. coli contamination of menstrual blood and effect of
30. Weaver J, Shoaibi A, Truong HQ, Larbi L, Wu S, bacterial endotoxin on endometriosis. Fertil Steril.
Wildgoose P, Rao G, Freedman A, Wang L, Yuan 2010;94(7):2860-3.e1-3.
Z, Barnathan E. Comparative risk assessment of 44. Savaris RF, Teixeira LM, Torres TG, Edelweiss MI,
severe uterine bleeding following exposure to direct Moncada J, Schachter J. Comparing ceftriaxone
oral anticoagulants: a network study across four plus azithromycin or doxycycline for pelvic inflam-
observational databases in the USA. Drug Saf. matory disease: a randomized controlled trial.
2021;44(4):479–97. Obstet Gynecol. 2007;110(1):53–60.
31. Minakuchi K, Hirai K, Kawamura N, Ishiko O, 45. Marrazzo JM, Handsfield HH, Whittington
Kanaoka Y, Ogita S. Case of hemorrhagic shock WL. Predicting chlamydial and gonococcal cervical
due to hypermenorrhea during anticoagulant ther- infection: implications for management of cervici-
apy. Arch Gynecol Obstet. 2000;264(2):99–100. tis. Obstet Gynecol. 2002;100(3):579–84.
32. Knez J, Day A, Jurkovic D. Ultrasound imaging 46. Rosenthal AN, Panoskaltsis T, Smith T, Sout-
in the management of bleeding and pain in early ter WP. The frequency of significant pathology in
women attending a general gynaecological service 62. Kouides PA. Menorrhagia from a haematologist’s
for postcoital bleeding. BJOG. 2001;108(1):103–6. point of view. Part I: initial evaluation. Haemo-
47. Telner DE, Jakubovicz D. Approach to diagnosis philia. 2002;8(3):330–8.
and management of abnormal uterine bleeding. 63. Valentine L. Hysteroscopy for abnormal uter-
Can Fam Physician. 2007;53(1):58–64. ine bleeding and fibroids. Clin Obstet Gynecol.
48. Day Baird D, Dunson DB, Hill MC, Cousins D, 2017;60(2):231–44.
Schectman JM. High cumulative incidence of 64. ACOG Committee on Practice Bulletins—Gynecol-
uterine leiomyoma in black and white women: ogy. Committee opinion number 557: management
ultrasound evidence. Am J Obstet Gynecol. of acute abnormal uterine bleeding in non preg-
2003;188:100–7. nant reproductive-aged women. Obstet Gynecol.
49. Nathani F, Clark TJ. Uterine polypectomy in 2013;120(1):891–6. Reaffirmed in 2020.
the management of abnormal uterine bleeding: 65. Schapiro L, Thorp JM. Management of leiomyoma
a systematic review. J Minim Invasive Gynecol. causing myocardial infarction. Eur J Obstet Gyne-
2006;13(4):260–8. col Reprod Biol. 1996;65(2):235–6.
50. Clevenger-Hoeft M, Syrop CH, Stovall DW, Van 66. Wu CC, Lee MH. Transcatheter arterial embolo-
Voorhis BJ. Sonohysterography in premenopausal therapy: a therapeutic alternative in obstetrics and
women with and without abnormal bleeding. Obstet gynecologic emergencies. Semin Intervent Radiol.
Gynecol. 1999;94:516. 2006;23(3):240–8.
51. Bazot M, Cortez A, Darai E, Rouger J, Chopier J, 67. Munro MG, Mainor N, Basu R, Brisinger M,
Antoine JM, et al. Ultrasonography compared with Barreda L. Oral medroxyprogesterone acetate and
magnetic resonance imaging for the diagnosis of combination oral contraceptives for acute uterine
8 adenomyosis: correlation with histopathology. Hum bleeding: a randomized controlled trial. Obstet
Reprod. 2001;16:2427–33. Gynecol. 2006;108(4):924–9.
52. Armstrong AJ, Hurd WW, Shaker ME, Elguero SB, 68. Ammerman SR, Nelson AL. A new progestogen-
Barker NG, Zanotti KM. Diagnosis and manage- only medical therapy for outpatient management of
ment of endometrial hyperplasia. J Minim Invasive acute, abnormal uterine bleeding: a pilot study. Am
Gynecol. 2012;19(5):562–71. J Obstet Gynecol. 2013;208(6):499.e1–5.
53. Sorosky J. Endometrial cancer. Obstet Gynecol. 69. Legro RS, Barnhart HX, Schlaff WD, Carr BR,
2008;112(1):186–7. Diamond MP, Carson SA, et al. Clomiphene, met-
54. Young RH, Clement PB. Pseudoneoplastic glan- formin, or both for infertility in the polycystic ovary
dular lesions of the uterine cervix. Semin Diagn syndrome. N Engl J Med. 2007;356(6):551–66.
Pathol. 1991;8(4):234–49. 70. Sulak PJ. The career woman and oral contraceptive
55. Chapman GW Jr. Management of early carcinoma use. Int J Fertil. 1991;36(Suppl 2):90–7.
of the ovary. J Natl Med Assoc. 1988;80(9):1033–7. 71. Anderson FD, Hait H. A multicenter, randomized
56. Koukourakis GV, Kouloulias VE, Koukourakis study of an extended cycle oral contraceptive. Con-
MJ, Zacharias GA, Papadimitriou C, Mystakidou traception. 2003;68:89–96.
K, Pistevou-Gompaki K, Kouvaris J, Gouliamos 72. Hurskainen R, Teperi J, Rissanen P, Aalto AM,
A. Granulosa cell tumor of the ovary: tumor review. Grenman S, Kivelä A, et al. Clinical outcomes and
Integr Cancer Ther. 2008;7(3):204–15. costs with the levonorgestrel-releasing intrauterine
57. PDQ Adult Treatment Editorial Board. Vaginal system or hysterectomy for treatment of menor-
cancer treatment (PDQ®): health professional ver- rhagia; randomized trial 5 year follow up. JAMA.
sion. 2021 Feb 22. In: PDQ cancer information 2004;291:1456–63.
summaries [Internet]. Bethesda: National Cancer 73. Hidalgo M, Bahamondes L, Perrotti M, Diaz J,
Institute (US); 2002. DantasMonteiro C, Petta C. Bleeding patterns and
58. Centers for Disease Control and Preven- clinical performance of the levonorgestrel-releasing
tion. Gynecologic Cancer Incidence, United intrauterine system (Mirena) up to two years. Con-
States—2012–2016, USCS Data Brief, no 11. traception. 2002;65(2):129–32.
Atlanta: Centers for Disease Control and Preven- 74. Nilsson CG, Lahteenmaki PL, Luukkainen T,
tion, US Department of Health and Human Ser- Robertson DN. Sustained intrauterine release
vices; 2019. of levonorgestrel over five years. Fertil Steril.
59. Kouides PA. Evaluation of abnormal bleeding in 1986;45(6):805–7.
women. Curr Hematol Rep. 2002;1(1):11–8. 75. Hillard TC, Siddle NC, Whitehead MI, Fraser
60. Woo YL, White B, Corbally R, Byrne M, O’Connell DI, Pryse-Davies J. Continuous combined conju-
N, O’Shea E, et al. Von Willebrand’s disease: an gated equine estrogen-progestogen therapy: effects
important cause of dysfunctional uterine bleeding. of medroxyprogesterone acetate and norethin-
Blood Coagul Fibrinolysis. 2002;13(2):89–93. drone acetate on bleeding patterns and endome-
61. Sahin Y, Kelestimur F. The frequency of late-onset trial histologic diagnosis. Am J Obstet Gynecol.
21-hydroxylase and 11 beta-hydroxylase deficiency 1992;167(1):1–7.
in women with polycystic ovary syndrome. Eur J 76. Rafie S, Borgelt L, Koepf ER, Temple-Cooper ME,
Endocrinol. 1997;137(6):670–4. Lehman KJ. Novel oral contraceptive for heavy
199 8
menstrual bleeding: estradiol valerate and dieno- 82. Fraser IS, Porte RJ, Kouides PA, Lukes AS. A
gest. Int J Women’s Health. 2013;5:313–21. benefit-risk review of systemic haemostatic agents:
77. Wright KP, Johnson JV. Evaluation of extended and part 2: in excessive or heavy menstrual bleeding.
continuous use oral contraceptives. Ther Clin Risk Drug Saf. 2008;31(4):275–82.
Manag. 2008;4(5):905–11. 83. Kaunitz AM, Meredith S, Inki P, Kubba A,
78. Livshits A, Seidman DS. Role of non-steroidal anti- Sanchez-Ramos L. Levonorgestrel-releasing intra-
inflammatory drugs in gynecology. Pharmaceuticals uterine system and endometrial ablation in heavy
(Basel). 2010;3(7):2082–9. menstrual bleeding: a systematic review and meta-
79. Lethaby A, Puscasiu L, Vollenhoven B. Pre- analysis. Obstet Gynecol. 2009;113(5):1104–16.
operative medical therapy before surgery for 84. Lethaby A, Augood C, Duckitt K, Farquhar
uterine fibroids. Cochrane Database Syst Rev. C. Nonsteroidal anti-inflammatory drugs for heavy
2017;11(11):CD000547. menstrual bleeding. Cochrane Database Syst Rev.
80. Cooke I, Lethaby A, Farquhar C. Antifibrinolytics 2007;4:CD000400.
for heavy menstrual bleeding. Cochrane Database 85. ACOG Committee on Practice Bulletins—Gynecol-
Syst Rev. 2000;2:CD000249. ogy. ACOG practice bulletin no. 81: endometrial
81. Matteson KA, Rahn DD, Wheeler TL 2nd, Casiano ablation. Obstet Gynecol. 2007;109:1233–48.
E, Siddiqui NY, Harvie HS, Mamik MM, Balk EM, 86. Lethaby A, Shepperd S, Cooke I, Farquhar
Sung VW, Society of Gynecologic Surgeons Sys- C. Endometrial resection and ablation versus hys-
tematic Review Group. Nonsurgical management terectomy for heavy menstrual bleeding. Cochrane
of heavy menstrual bleeding: a systematic review. Database Syst Rev. 2000;2:CD000329.
Obstet Gynecol. 2013;121(3):632–43.
201 9
Menopause
Tara K. Iyer and Holly L. Thacker
Contents
9.2 Impact of Menopause – 204
9.3 Terminology – 204
9.4 Time to Natural Menopause – 205
9.5 The Physiology of Menopause – 205

9.5.1 remenopause – 205
P
9.5.2 The Menopause Transition – 206
9.6 Premature Ovarian Insufficiency – 207
9.7 Physiological Effects of Estrogen – 208

9.7.1 reast Tissue – 208
B
9.7.2 Central Nervous System – 208
9.7.3 Cardiovascular System – 208
9.7.4 Bone – 209
9.7.5 Adipose Tissue – 209
9.7.6 Liver – 209
9.7.7 Bowel – 210
9.7.8 Pulmonary System – 210
9.7.9 Skin – 210
9.7.10 Hair – 210
9.7.11 Eyes – 211
9.7.12 Vulvovaginal Tissue – 211
9.7.13 Pelvic Floor – 211
9.7.14 Urinary Tract – 211
9.8 Symptoms of Menopause – 211

9.8.1 asomotor Symptoms (VMS) – 211
V
9.8.2 Genitourinary Syndrome of Menopause (GSM) – 214
9.8.3 Other Peri- and Menopausal Symptoms – 214

https://doi.org/10.1007/978-3-030-99596-6_9
9.9 Evaluation – 214
9.9.1 iagnosis – 214
D
9.9.2 Clinical History – 215
9.9.3 Physical Exam – 215
9.10 Treatment – 217

9.10.1 eneral Counseling and Recommendations – 217
G
9.10.2 Hormone Therapy: Treatment of Vasomotor Symptoms
and Systemic Menopausal Symptoms – 217
9.10.3 Clinical Data – 219
9.10.4 Unregulated Hormone Therapy – 224
9.10.5 Non-hormonal Therapy Options – 224
9.10.6 Neurokinin 3 Receptor (NK3R) Antagonists – 225
9.10.7 Treatment for Genitourinary Syndrome
of Menopause – 225
9.11 Learning Assessment – 228

9.11.1 eview Questions – 228
R
9.11.2 Answers – 228
References – 229
Menopause
203 9
social, and economic ramifications for women
Key Points who live long enough to experience it.
55 Natural menopause, or the permanent The average age of menopause ranges
cessation of menstruation in women from 40 to 60 years old, with a median age
due to the senescent loss of ovarian of 52 years old [1]. As female life expectancy
follicular activity, is typically clinically steadily increases, women may find themselves
diagnosed retrospectively 12 months spending up to 40% of their lives in the post-
after the last menstrual period (LMP) menopausal phase.
has occurred, and often causes signifi- Given the significant morbidity that
cant physical and mental health, social, menopause and menopausal symptoms may
and economic burdens. cause for women, it is important for health-
55 The loss of estrogen that occurs with care providers to adequately understand and
menopause has myriad physiologic counsel women about the associated health
consequences throughout the body. The risks, appropriate preventive care, and avail-
most common clinical signs and symp- able treatment options.
toms of menopause include vasomotor
symptoms (VMS), such as hot flashes
and night sweats, and the genitouri- Case Vignette
nary syndrome of menopause (GSM),
encompassing vaginal dryness, dyspa- A 48-year-old G3P2 white woman with an
reunia, and urinary symptoms. unremarkable past medical history presents
55 The gold standard of treatment for to your clinic with concern about her meno-
menopausal symptoms is hormone pausal symptoms of hot flashes and night
therapy (HT), which when initiated sweats, vaginal dryness, and dyspareunia.
in low-risk women under the age of She has not had any fractures after turning
60 years old or within 10 years of 40. She has a bone density scan done, which
menopause is associated with improved is normal. Obstetric history is remarkable
cardiovascular, metabolic, neurological, for two spontaneous vaginal deliveries with
and mortality outcomes. no pregnancy complications. She had her
55 Hormone replacement therapy (HRT) menarche at age 13. She has a history of
is the recommended standard of care regular menses without a uterine bleeding
in women who experience menopause disorder. She was on oral contraceptives for
younger than 45 years old to mitigate about 10 years and was well tolerated with-
the consequences of early estrogen loss out developing venous thromboembolism
and should be continued at least until or gallbladder problems. Her paternal
the median age of menopause (52 years grandmother was diagnosed with breast
old). cancer in her 60s and a paternal aunt
deceased in her 40s from breast cancer. She
has no known genetic mutations. She has a
personal history of abnormal mammo-
9.1 Introduction grams remarkable for fibrocystic breast but
never had breast biopsy. She had a recent
The loss of endogenous ovarian hormone pro- normal mammogram. She has no history
duction that occurs at the menopause transi- of hypertension, diabetes mellitus, stroke,
tion (MT) is perhaps the most consequential or myocardial infarction. She is a non-
physiologic event experienced by women in smoker. She has no personal or familial his-
midlife. While often overlooked as a risk fac- tory of venous thromboembolism or
tor for health consequences, menopause can prothrombotic mutations.
have serious pathological, psychological,
204 T. K. Iyer and H. L. Thacker
9.2 Impact of Menopause families, as severe symptoms and subsequent

poor work performance may make it difficult
Menopause significantly impacts the preva- for women to advance in their careers or in
lence of chronic disease and mortality among some severe cases even remain employed at all.
the female population. Several longitudi- Many postmenopausal women also expe-
nal studies have demonstrated that meno- rience female sexual dysfunction (FSD) and
pause leads to pronounced cardiometabolic changes in mood, which may have a negative
changes, making it an independent risk factor impact on relationship satisfaction in both
for cardiovascular disease (CVD) and mor- men and women [13]. The changes in appear-
tality [2–6]. The loss of estrogen that occurs ance that occur due to estrogen loss may also
with menopause has also been associated provoke lower self-esteem and body image
with increased risk of dementia [7]. Several issues in women, leading to lower confidence
population-based studies have found that the levels. It is not uncommon for women and
use of estrogen therapy results in reduced their spouses or partners to endorse rela-
prevalence and incidence of dementia and tionship problems as a consequence of their
Alzheimer’s disease [7–10]. Additionally, menopausal symptoms.
menopause is a known risk factor for osteo-
porosis and has been associated with declin-
ing pulmonary function and worsening of 9.3 Terminology
chronic lung disease [11, 12].
9 Perhaps more consequential than the The stages of menopause have been classi-
physiologic impact of menopause are the psy- fied and defined by a group of menopause
chosocial ramifications, which are often over- experts in a model known as STRAW+10
looked. Several studies have demonstrated (Stages of Reproductive Aging Workshop),
a negative association with menopause and which breaks down reproductive aging into
quality of life (QOL) [13–15]. In addition seven stages throughout a woman’s life [20].
to the health-related burden experienced by This is generally accepted as the gold stan-
women, menopause may also significantly dard for the characterization of reproductive
impact mental health, social life, relation- aging in women.
ships, and career. There are several different terms used both
The US Bureau of Labor Statistics proj- in STRAW+10 and, generally, to describe the
ects that the percentage of women in the work- different types and phases of menopause (see
force from 2014 to 2024 is expected to grow below):
by 5.8%, with the largest increase occurring in 55 Menarche: The first occurrence of men-
postmenopausal women [16]. The number of struation.
women in the civilian labor force aged 65–74 55 Premenopause: The period of time in a
and aged 75+ is expected to increase by 59.2% woman’s life prior to menopause.
(~1,846,000) and 94.5% (~618,000), respec- 55 Premature menopause/premature ovarian
tively [16]. insufficiency (POI): The permanent or
Research has shown that menopausal symp- transient cessation of ovarian function
toms negatively impact work performance and before age 40. Premature ovarian failure
may increase absence from work [17, 18]. Hot (POF) is to be avoided as it implies no
flashes, mood swings, and “brain fog” (difficul- chance of ovulation (which cannot be
ties with memory and concentration) are all ruled out), so POI is a more helpful diag-
commonly reported symptoms in postmeno- nostic construct.
pausal women that may interrupt work ability. 55 Perimenopause: The highly symptomatic
Working may be correlated with improved self- time frame that exists from the first occur-
esteem and decreased psychological stress in rence of menopause-related symptoms to
some women [19]. Menopause may also pose one full year after the final menstrual
significant financial burdens to women and period (FMP).
Menopause
205 9
55 Menopause transition (MT): This term is
.. Table 9.1 Factors associated with earlier or
often interchanged with perimenopause, later onset of menopause [1]
though the MT by definition ends at the
time of the FMP. Factors associated with Factors associated with
55 Climacteric: This term is the period of earlier onset of later onset of
physiologic and psychologic changes that menopause menopause
occurs during the menopausal transition.
Active smoking Increased body mass
55 Menopause: index (BMI)
–– Natural menopause: The cessation of
Nulliparity/low parity Multiparity
menstruation due to complete or near-
complete follicular exhaustion, result- Medically treated Higher cognitive scores
ing in the end of ovarian hormone depression/seizure in childhood
disorder
production.
–– Early menopause: Menopause occurring Hereditary/familial Hereditary/familial
before the age of 45. influence influence
–– Late menopause: Menopause occurring Chemotherapy
after the age of 55.
Pelvic radiation
55 Induced menopause:
–– Surgical menopause: Cessation of ovar- Gynecologic surgery
ian function due to gynecologic surgical Lower socioeconomic
intervention. status
–– Iatrogenic menopause: Cessation of No previous use of oral
ovarian function due to an iatrogenic contraceptive pills
cause, such as chemotherapy or pelvic
radiation.
55 Postmenopause: The period of time follow-
ing menopause, starting 1 year after the 9.5 The Physiology of Menopause
final menstrual period and lasting through
the end of life. Early postmenopause is Menopause occurs as a result of the progres-
typically a more symptomatic period than sive depletion of a woman’s ovarian reserve,
late postmenopause: leading to complete or near-complete fol-
–– Early postmenopause: Period of time licular exhaustion, which is accompanied by
when women are 5–10 years or less from a reduction in quality and capability of the
FMP. aging oocytes. The subsequent disruption in
–– Late postmenopause: Period of time ovarian steroid hormone production results in
when women are greater than 10 years the cessation of ovulation and menstruation,
from FMP. as well as several physiologic consequences
throughout the body that lead to increased
risk of chronic disease and significant symp-
9.4 Time to Natural Menopause tom burden in many women.
There are several factors that have been consis-

tently identified as influencing the age at which 9.5.1 Premenopause
natural menopause occurs (see . Table 9.1).
Race/ethnicity, dietary habits, and physical At 20 weeks of gestation, a female fetus pos-
activity have been inconsistently associated sesses approximately 6–7 million eggs, the
with influencing menopause onset [1]. most ovarian follicles of its reproductive life
[21]. In utero, a female fetus begins to lose fol- increased time spent in the luteal phase of
licles through granulosa cell-mediated apop- the menstrual cycle. Luteal phase progester-
tosis in a process known as follicular atresia. one levels also decline. This leads to increased
At birth a female has about 1–2 million menstrual frequency and subsequently more
oocytes, and follicular loss continues, but at a premenstrual symptoms.
slower pace [21].
In reproductive-aged women, follicle-
stimulating hormone (FSH) stimulates ovar- 9.5.2 The Menopause Transition
ian folliculogenesis. Anti-Mullerian hormone
(AMH) and inhibin B, peptide hormones pri- Follicular depletion continues into the early
marily produced by granulosa cells in growing stages of the menopause transition, where
antral follicles, act in a negative feedback loop there is a period of compensated failure of
with FSH, functioning to restrain follicular the HPO axis. The growing pool of oocytes
growth. This negative feedback is necessary to decreases, leading to less granulosa cell pro-
moderate FSH and ensure only one dominant duction of inhibin B and AMH. As inhibin
follicle reaches the preovulatory stage. As B and AMH secretion declines, there is less
levels of inhibin B rise, negative feedback is restraint of ovarian negative feedback on
provided to the pituitary gland to indicate the FSH, resulting in increasing FSH levels [22,
maturation of oocytes has started to occur, 23]. Elevated FSH levels prompt the recruit-
which signals the pituitary gland to stop pro- ment and maturation of a new cohort of
9 ducing FSH. The FSH negative feedback follicles at the beginning of each cycle, main-
loop is also influenced by the ovarian steroid taining the drive necessary for continued ovu-
hormone estradiol (E2) and corpus luteum- lation. While there are more follicles available
secreted progesterone. Developing follicles for recruitment, there is also accelerated fol-
secrete E2, which acts on the hypothalamic- licular atresia [21]. Levels of estradiol and
pituitary-ovarian (HPO) axis to suppress FSH regular menstrual cyclicity typically remain
secretion. Each time ovulation occurs, several preserved throughout this time [22, 23].
antral follicles are recruited, though typically There are often fluctuating patterns of
only one follicle undergoes ovulation, while hormones as the menopausal transition con-
the rest undergo apoptosis. tinues. While FSH elevations accompanied
E2 secretion from developing follicles also by low inhibin B and estradiol levels are com-
causes proliferation of the endometrium. mon, they may be followed by subsequent
Following ovulation, the corpus luteum elevations in estradiol and declining FSH lev-
secretes progesterone which, in combination els [22, 23]. A woman may experience elevated
with estradiol, causes the endometrial secre- estrogen levels through increasing androgen
tory changes necessary for implantation to aromatization incurred as a result of increas-
occur. If fertilization does not occur, the cor- ing age and body weight or by increased
pus luteum regresses and progesterone secre- estradiol production by an enlarged oocyte
tion ceases, resulting in menstruation. cohort [22, 23]. These intermittently high lev-
Throughout a female’s reproductive life, els of estradiol lead to endometrial prolifera-
she continues to experience a progressive tion with subsequent heavier periods. These
loss of ovarian follicles through the natural expansive hormonal fluctuations account for
processes of ovulation and follicular atresia. why this period is so highly symptomatic.
Ovarian reserve most sharply declines in the The significant loss in ovarian follicles that
late reproductive period. As a woman ages, occurs in this period due to accelerated follicu-
there is also a concurrent reduction in the lar atresia also leads to a decreased amount of
quality and function of the remaining oocytes. receptors available to respond to FSH [21]. This
In the late reproductive phase, menstrual decreased sensitivity to FSH can in turn lead to
cycles remain predominantly ovulatory. inhibition of the typical luteinizing hormone
However, the follicular phase shortens due (LH) surge required for ovulation to occur [22,
to hastened follicular growth, resulting in 23]. As a result, there is increased anovulation
Menopause
207 9
with subsequent menstrual irregularity and a and low AMH [22, 23]. The menopausal ovary
reduction in estrogen secretion and circulation no longer produces sufficient E2. The result-
throughout the body. The decline in estrogen ing low level of endogenous estrogen is what
levels that occur lead to a disruption of HPO causes menopausal symptoms, though sever-
axis and a subsequent failure of endometrial ity varies between each individual woman.
development, causing further menstrual irregu- Some postmenopausal women may still pro-
larities [22, 23]. Anovulation may occur due to duce small amounts of estrogen through the
LH surge failure secondary to HPO axis dys- aromatization of adrenally secreted testoster-
function or an absence of corpus luteum forma- one, which may lessen symptoms.
tion despite the occurrence of an LH surge [22,
23]. Decreased corpus luteum production due
to anovulation leads to decreased progesterone 9.6 Premature Ovarian
secretion. Consequently, estrogen is often unop- Insufficiency
posed leading to endometrial proliferation and
thus a possible increased risk for endometrial Premature ovarian insufficiency (POI) occurs
hyperplasia and endometrial cancer. The endo- when there is a loss of ovarian function prior
metrium often outgrows its own blood supply to the age of 40 years old. There are several
in this case, provoking tissue necrosis and shed- possible etiologies of POI, the most common
ding, which contributes to irregular bleeding of which is idiopathic, which accounts for
patterns [22, 23]. Oocyte quality and capability more than 90% of cases [25] (7 Box 9.1).
also decline during this time, leading to further
increasing anovulatory cycles, decreased rates
of conception, and increased risk of spontane- Box 9.1 Etiologies of primary ovarian
ous abortion. The decreased oocyte quality and insufficiency (POI) [25, 115]
proficiency may be due to several mechanisms, Genetic
including impaired dominant follicle recruit- Autoimmune
ment and the age-dependent decrease in integ- Metabolic
rity and function of granulosa cells and meiotic Iatrogenic
spindles [24]. 55 Surgery
The late menopause transition is marked 55 Chemotherapy
by increasing hormone fluctuation, decreas- 55 Radiation
ing frequency of ovulatory cycles, and an
increasing number of days of consecutive Infectious
amenorrhea. At this point in the MT, the Idiopathic
persistently diminishing ovarian follicle quan-
tity decreases to a level which can no longer
be compensated for. When follicular growth Surgical menopause has the most significant
and recruitment does occur, ovulation is more physiologic consequences among the causes
likely to fail. However, given the intermittent of premature menopause. When the ovaries
ovulatory cycles that may occur throughout are removed, women experience a sudden loss
the late menopause transition, it is important of estrogen, testosterone, and progesterone,
to note that women can experience pregnancy resulting in significant disruption of the HPO
at any point up to their final menstrual period axis [26]. Subsequently, menopausal symp-
(FMP). Eventually, the follicular numbers toms typically occur more acutely and more
reach a nadir at which folliculogenesis can no severely than with the gradual hormonal loss
longer occur and E2 and progesterone pro- that occurs with natural menopause. Gyne-
duction effectively cease, leading to persistent cologic malignancies, such as cervical can-
amenorrhea. This near-complete follicular cer, endometrial cancer, ovarian cancer, and
exhaustion results in the characteristic hor- borderline ovarian tumors, may necessitate
mone profile of postmenopausal women, con- bilateral salpingo-oophorectomies (BSO).
sisting of high FSH, low E2, low inhibin B, If there is a significant disruption in ovarian
blood flow as a result of surgery, it is possible the modulation of catecholamine release, and
for early or premature menopause to occur the regulation of intracellular calcium [30].
in some women with a history of unilateral While it is widely known that estrogen plays
oophorectomy, or even hysterectomy alone. an important role in the female reproductive
Nonmalignant gynecologic disorders, such system, estrogen is also responsible for several
as endometriosis, chronic pelvic pain, bilat- critical physiologic processes throughout the
eral or recurrent ovarian cysts, tubo-ovarian body. Both ER-α and ER-β are concentrated
abscesses, ovarian torsions, and prophylactic in the central nervous system (CNS) and car-
or risk-reducing salpingo-oophorectomy, are diovascular (CV) system. ER-α predominates
other possible causes of surgical menopause. in the uterus, mammary glands, bone, vagina,
There is an accelerated aging curve that occurs cervix, liver, and adipose tissue [31–34]. ER-β
with premature and early menopause, whether is primarily located in the lung, skin, thyroid,
from surgery or other causes, which leads to spleen, thymus, bladder, and colon [31–34].
associated increases in coronary heart disease,
early bone loss, dementia, Parkinson’s disease,
mental health disorders, cancer admissions, 9.7.1 Breast Tissue
cancer deaths, and all-cause mortality [27, 28].
Estrogens stimulate blood flow to breast tissue
through vascular-mediated mechanisms [30].
9.7 Physiological Effects They play a pivotal role in the growth of duc-
9 of Estrogen tal epithelium and connective tissue within the
breast [35]. Research has also demonstrated
There are three naturally occurring estrogens that estrogen can advance the production of
in the human body, estrone (E1), 17β-estradiol breast cancer cells [36]. Later age to natural
or estradiol (E2), and estriol (E3). E2 is the menopause, specifically greater than 55 years
strongest biologically active form of natural old, has been associated with increased risk of
estrogen. E2 is predominantly produced by breast cancer.
the dominant ovarian follicle and is the most
potent and prevalent form of natural estrogen
during a woman’s reproductive years [29]. E1 9.7.2 Central Nervous System
is primarily synthesized in the skin and adi-
pose tissue through the peripheral conversion Estrogen has myriad functions in the brain. It
of androstenedione [29]. Following the cessa- is known to play a role in the regulation of
tion of ovarian steroid hormone production mood, memory, and cognition. It may also
that occurs with menopause, estrone becomes exert neuroprotective and neurotrophic effects
the predominant form of endogenous estrogen [37, 38]. The loss of ovarian hormones that
in the postmenopausal woman [29]. In post- occurs during menopause is associated with
menopausal women, serum estradiol is formed mitochondrial dysfunction, oxidative stress,
by the extragonadal aromatization of testos- neuroinflammation, synaptic deficits, cogni-
terone. It is not uncommon for levels of estra- tive impairment, and an increased risk of age-
diol in postmenopausal women to be less than related disorders, such as dementia [37, 38].
20 pg/mL, which is lower than a normal male Postmenopausal women often experience new
level of estradiol (~40 pg/mL). Extragonadal or worsening mood symptoms, cognition dif-
estradiol synthesis may increase with age and ficulties, and/or memory problems.
an increasing amount of adipose tissue.
Estrogens are cholesterol-derived steroid
hormones that exert both genomic and non- 9.7.3 Cardiovascular System
genomic effects. They bind to estrogen recep-
tors (ERs), ER-α and ER-β, throughout the Estrogen mediates a myriad of important reg-
body to perform myriad biochemical pro- ulatory functions in the cardiovascular system.
cesses, such as the induction of nitric oxide, The activation of estrogen receptors, ER-α and
Menopause
209 9
ER-β, throughout the CV system positively 9.7.4 Bone
affects vascular function, insulin sensitivity,
metabolic processes, lipid and lipoprotein lev- Estrogen plays a critical role in the regula-
els, body fat distribution, inflammation, and tion of bone metabolism. Estrogen exhibits
cardiac myocyte structure and activity [39]. an antiresorptive effect through the inhibi-
Estrogens exhibit vasoprotective effects. tion of osteoclasts by suppressing the expres-
The estrogen-mediated vasodilation and sion of receptor activator of NF-kB ligand
inhibition of platelet activation through the (RANKL), a cytokine essential for osteoclast
synthesis of nitric oxide, as well as estrogen’s stimulation, differentiation, and longevity
role in the suppression of inflammation and [43]. The bone loss that occurs after meno-
vasoconstrictive mechanisms, improve overall pause due to the loss of estrogen may be most
arterial function [30]. pronounced in the first 2 years after the FMP.
Estrogen plays an important role in the
functional activity of cardiac myocytes through
the regulation of ion channels. Through this 9.7.5 Adipose Tissue
mechanism, estrogen can influence cardiac
contractility and modulate cardiac repolar- The MT is associated with increases in both
ization [40]. Estrogen may also play a part total and visceral adiposity. Estrogen regu-
in delaying cardiac hypertrophy and creating lates metabolism and deposition of adipose
more favorable myocardial remodeling, thus tissue in the female body [44]. Estrogens work
positively influencing the structure of cardiac directly on adipocytes to inhibit lipogenesis,
myocytes [40]. Additionally, animal models and play a pivotal role in adipogenesis and
have suggested that in vivo estrogen delivery adipocyte proliferation [44]. The accumula-
immediately prior to ischemia can reduce the tion of central body fat, a known risk factor
size of myocardial infarct [40]. for type 2 diabetes (T2DM), can be attenu-
The loss of estrogen that occurs during ated with the use of estrogen therapy in post-
the MT not only increases CV risk directly menopausal women [45]. Studies have shown
through the loss of estrogen’s cardioprotective that the early loss of estrogen in women who
mechanisms but indirectly as well. Hot flashes experience premature menopause is associ-
have been associated with a multitude of ated with a clear increased risk of T2DM [46].
pathologic CV markers, including an increase Coinciding with these findings, large random-
in carotid intimal thickness, increased carotid ized controlled trials (RCTs) have suggested
and aortic calcifications, increased heart rate that the use of HT in postmenopausal women
variability, increased sympathetic tone, endo- can reduce the risk of developing T2DM [46].
thelial dysfunction, and insulin resistance [41]. While the exact mechanisms are not com-
Furthermore, many women going through pletely clear, HT has been shown to decrease
the MT experience novel or worsening mood visceral adiposity and improve β-cell insulin
symptoms, especially of depression and sleep secretion, insulin sensitivity, and glucose effi-
disturbance, which have been associated with cacy [46].
greater risk of CVD [42].
The American Heart Association (AHA)
released a scientific statement in 2020 acknowl- 9.7.6 Liver
edging menopause as an independent risk factor
for cardiovascular disease [39]. This statement Within the liver, estrogen inhibits fibrogen-
stands in agreement with the guidelines and rec- esis and cellular senescence, promotes innate
ommendations of several other prominent spe- immunity and antioxidant effects, and pro-
cialist organizations, such as the North American tects mitochondrial function [47]. Estrogen
Menopause Society (NAMS), the American also increases hemostasis through the activa-
College of Obstetricians and Gynecologists tion of gene transcription of clotting factors
(ACOG), and the American Association of (VII, VIII, X, fibrinogen) and plasminogen,
Clinical Endocrinologists (AACE). decreasing antithrombin III and protein S lev-
els, and modifying activated protein C (APC) preservation of skin moisture [54]. Estrogen
resistance [48]. may also play a role in promoting cutaneous
Estrogen affects levels of circulating lip- wound healing through the regulation of cel-
ids. Estrogens lead to increased production lular growth factors and repair enzymes [55].
of hepatic lipoprotein receptors leading to a The loss of estrogen that occurs during the
decrease in serum LDL [49]. Premenopausal MT causes several significant changes in skin
women have a more favorable lipid pro- quality and function. The disruption of elas-
file, with higher serum HDL levels and tin, cellular growth factor, and repair enzyme
lower serum LDL levels, compared to age- production leads to decreased skin elasticity
matched men and postmenopausal women and increased skin fragility [55]. Changes in
[49]. Following the MT, plasma LDL levels blood flow and cellular oxygenation effects on
increase, and HDL levels decrease [49]. keratinocytes lead to epidermal thinning [55].
Following menopause, there is also a Women can experience impaired wound heal-
reduction in liver volume, blood flow, func- ing as a result of these changes.
tion, and capacity for regeneration [47]. Many women find the changes to their skin
distressing. It is not uncommon for women to
complain of their appearance, often in vague
9.7.7 Bowel terms. Accelerated lipoatrophy, fat distribution
changes, and increased bone resorption can
Estrogen is known to affect bowel motility. It lead to facial hollowing, eyelid sagging, jowl-
9 also plays a protective role in cancer prevention ing, contour deformities, and shadow creation.
in the colonic mucosa through the modulation The decreased fibroblast activity and glycos-
of apoptotic signaling, tumor microenviron- aminoglycan production cause decreased skin
ment, and immune mechanisms, and the inhi- hydration, increasing skin dullness, and more
bition of inflammatory markers [50]. pronounced appearance of lines and wrinkles
[54]. Estrogen loss may also lead to a testoster-
one imbalance that can cause or worsen acne.
9.7.8 Pulmonary System
Estrogen plays a role in the development and 9.7.10 Hair

maintenance of healthy lung tissue. It has been
suggested that estrogen is involved in lung tis- Many women in midlife experience hair thin-
sue elastic recoil and in the production of alve- ning or loss on the scalp and eyebrows and/or
oli, extracellular matrix, and surfactant [51]. increased growth of facial hair, and accurately
Menopause is associated with lower lung associate these changes with menopause.
function and increasing respiratory symptoms Estrogen increases levels of sex hormone-
in midlife women [52, 53]. This is an especially binding globulin (SHBG), which is respon-
important consideration in women with pre- sible for binding and carrying testosterone
existing respiratory disease, such as asthma, in its inactive state [56]. When estrogen levels
COPD, or restrictive lung disease. drop during menopause, levels of SHBG also
decrease, which increases the amount of free
testosterone available in the circulation [56].
9.7.9 Skin This increase in active testosterone may lead
to symptoms such as hirsutism and female
Estrogen also appears to play a significant pattern hair loss in women.
role in the maintenance of skin elasticity and It is also important to note, however, that
the prevention of skin aging. It regulates elas- there are many other factors which may influ-
tic fiber and collagen content in the skin, help- ence the thinning or loss of hair in midlife
ing to maintain its thickness [54]. Estrogen women, including genetic predisposition,
also increases hyaluronic acid and other acid stress, other hormones, medications, vitamin
mucopolysaccharides in the skin, aiding in the deficiencies, and chronic illness.
Menopause
211 9
9.7.11 Eyes sacral ligaments, pubocervical fascia, and pel-
vic floor musculature [65, 66]. Through the
Estrogen may affect corneal elasticity, which in regulation of collagen metabolism, estrogen
turn affects clarity of vision [57]. Estrogen also functions to support the strength of the pel-
functions to reduce intraocular pressure [57]. vic floor [65, 66]. The loss of these support-
Hormone therapy has been associated with ive mechanisms in postmenopausal women
decreased incidence of glaucoma, age-related may contribute to increasing the risk of pelvic
macular degeneration, and cataracts [58]. organ prolapse [66].
9.7.12 Vulvovaginal Tissue 9.7.14 Urinary Tract
There are an abundance of estrogen receptors Estrogen and androgen receptors in the ure-
throughout the vagina and vulva [59]. Estrogen thra and the bladder contribute to numerous
has several functions in the vulvovaginal tissue, important functions, including protection
including preserving adequate blood supply, against infection and aiding in the prevention
maintaining the integrity and moisture of the of urogenital prolapse [60, 67]. Estrogen recep-
tissue, and supporting the local microbiome tors located in the urethra and bladder also
[59–63]. Androgens have also been shown to directly affect urethral smooth muscle, detru-
help support nerve fibers and maintain mois- sor muscle contraction, and urethral pres-
ture and tissue integrity [60]. Premenopausal sure to help maintain urinary continence [67].
women typically have well-estrogenized, mul- The loss of estrogen and androgen support
tilayered vaginal tissue with substantial blood in the urogenital tissue of postmenopausal
supply and glycogen-rich superficial cell lay- women leads to reduced collagen and epi-
ers [62]. In contrast, p ostmenopausal women thelial thinning with subsequent tissue atro-
typically have atrophic vulvovaginal tissue with phy (. Fig. 9.2). This atrophy increases the
marked epithelial thinning and reduced blood risk of urogenital prolapse [67]. Interestingly,
supply [59–61]. The tissue atrophy and reduc- despite the function of estrogen in these tis-
tion of tissue collagen can lead to narrowing of sues, data has shown that there is no associa-
the vaginal canal and loss of elasticity, which tion between low serum estradiol levels and
may contribute to the dyspareunia experienced increased risk of urinary incontinence [68].
by some postmenopausal women [59–61]. Menopause additionally puts women at
Estrogen also functions to help maintain an risk for recurrent urinary tract infections
acidic intraluminal vaginal pH by supporting the (UTIs). The atrophy and shriveling of uro-
growth of lactic acid-secreting lactobacillus [64]. genital tissue also leaves the urethra more
Glycogen acts as a substrate facilitating lactoba- prominent and brings it closer to the introitus,
cillus production of lactic acid [64]. The reduction leading to higher rates of UTIs. The change in
in the glycogen content of the postmenopausal vaginal microflora and decreased production
epithelium leads to decreased lactic acid produc- of urogenital antimicrobial substances also
tion and resulting increased intraluminal vaginal increase the risk of urinary infections [69].
pH [63, 64]. The change in local microbiome and
more basic pH leads to unfavorable changes in
the concentration of protective inflammatory 9.8 Symptoms of Menopause
cells, leaving the vulvovaginal tissue more vulner-
able to infectious pathogens [63, 64] (. Fig. 9.1). 9.8.1 Vasomotor Symptoms (VMS)
Vasomotor symptoms (i.e., hot flashes and

9.7.13 Pelvic Floor night sweats) are experienced by up to 80%
of women during the menopause [70]. Hot
Estrogen receptors are located throughout the flashes are typically described as a sud-
pelvic floor, and have been found in the utero- den intense feeling of warmth throughout
.. Fig. 9.1 Normal vs. postmenopausal vaginal environ- [59–64]. The right half of the figure demonstrates the
ments. From left to right, the left half of the figure dem- pathological changes that may occur in the vaginal envi-
onstrates the ideal vaginal environment typically found ronment of an untreated postmenopausal woman [59–64]
in a healthy, premenopausal woman of reproductive age
the upper body, typically most severe over Estrogen is known to play an important
the chest, neck, and face. If redness can be role in the regulation of body temperature.
seen on the skin, these episodes are typi- Estrogen deficiency results in a disruption
cally termed hot flushes. This feeling may be of the thermoregulatory center of the hypo-
accompanied by several symptoms women thalamus, triggering the occurrence of hot
find bothersome or even concerning, such flashes [73]. During a hot flash, blood flows
as diaphoresis (this may range from mild to to the periphery leading to a decrease in core
severe perspiration), flushing or reddening of body temperature and cutaneous vasodila-
the skin, chills, anxiety, and/or heart palpi- tion with the associated sensation of extreme
tations [71]. When a hot flash occurs during warmth [71].
sleep, it is termed a night sweat. Night sweats Research has increasingly shown that hot
can cause significant sleeping disruption for flashes are not physiologically benign symp-
some women. toms. Hot flashes have been associated with
A single hot flash episode typically lasts increased carotid intima thickness, increased
between 1 and 6 minutes [70–72]. The fre- carotid and aortic calcifications, increased
quency and severity of hot flashes vary from endothelial dysfunction, decreased nitric
woman to woman, though typical triggers oxide production, increased insulin resistance/
that can provoke or worsen an episode include elevated blood glucose levels, increased sym-
stress, heat, caffeine, alcohol, cigarette smoke, pathetic tone, increased heart rate variability,
spicy foods, and tight clothing. white matter hyperintensity, and increase in
Menopause
213 9
.. Fig. 9.2 Physiologic changes with menopause. The aminoglycans, LDL-C low-density lipoprotein choles-
physiological changes of various organs and organ sys- terol, UTI urinary tract infection, RANKL receptor
tems that occur due to the estrogen deficiency associated activator of NF-kB ligand, GI gastrointestinal, CVD
with menopause [30–69]. Abbreviations: GAG glucos- cardiovascular disease
N-telopeptide (NTx), which is a marker of aches, palpitations, formications (tactile hallu-

bone turnover (increased bone loss) [74–84]. cinations), and hair thinning, for example, are
often missed or misdiagnosed (. Table 9.2).
9.8.2 Genitourinary Syndrome

of Menopause (GSM) 9.9 Evaluation
Genitourinary syndrome of menopause describes 9.9.1 Diagnosis

the signs and symptoms resulting from estrogen
deficiency of the female genitourinary system. Menopause is typically diagnosed retrospec-
There has been a change in vocabulary from the tively following 12 months of amenorrhea
previous term vulvovaginal atrophy (VVA). This after the last menstrual period in a woman
change was made to create more accurate and over the age of 45, though there remains a
all-encompassing terminology, as vulvovaginal small possibility of continued cycles even after
atrophy is only a component of GSM and does these characteristics are met. In women under
not encapsulate the entire syndrome. 45 years old without any other known cause
GSM symptoms will affect at least 50–70% of early or premature menopause, an evalua-
of postmenopausal women at some point in tion for underlying causes of secondary amen-
their lives [85]. The most bothersome symptoms orrhea and premature ovarian insufficiency
of GSM as recognized by the US Food and Drug should be pursued. The European Society
9 Administration (FDA) are vaginal dryness, dys- of Human Reproduction and Embryology
pareunia (painful intercourse), vulvovaginal irri- (ESHRE) guidelines suggest that POI may
tation, vaginal soreness, dysuria, and bleeding be diagnosed in women with absence of men-
associated with sexual activity [86]. Many women struation for at least 4 months, and elevated
may also experience vulvovaginal burning and/ FSH levels on two separate occasions, at least
or abnormal vaginal discharge. These symptoms 4 weeks apart, in a women under the age of
are chronic and progressive, and will not improve 40 years old [88]. While this guideline allows
without treatment. Women with surgical meno- for diagnosis to be reached at 4 months after
pause tend to have more severe symptoms than LMP, 12 months of amenorrhea is preferable
those who go through menopause naturally [87]. for a more accurate diagnosis.
Many postmenopausal women are unaware While obtaining FSH levels is not nec-
of or embarrassed by the vulvar, vaginal, and essary for diagnosis, they can be clinically
urinary changes that result from estrogen loss. useful in some patients. A clinician can be
Additionally, symptoms do not always correlate more confident in the diagnosis of meno-
to physical exam findings. As a result, GSM is pause when it is supported by two elevated
typically underdiagnosed and/or treated with FSH levels (>30 mIU/mL) 12 months apart,
significant delay. The goals of GSM treatment especially in women with concurrent meno-
are to relieve symptoms, reverse any anatomic pausal symptoms. In women with abnormal
changes that may have occurred, improve sexual or absent menstrual cycles, such as women
dysfunction, and prevent infection. with PCOS, women with a hormonal levo-
norgestrel intrauterine system (IUS) in place
or on continuous combined hormonal contra-
9.8.3 ther Peri- and Menopausal
O ceptive (CHC) therapy, and women with a his-
Symptoms tory of hysterectomy or endometrial ablation,
the menstrual cycle criteria cannot accurately
There are myriad recognized symptoms of the be applied. Endocrinological evaluation with
menopause transition. While VMS, GSM, sleep FSH and 17β-estradiol levels can be especially
disturbances, and mood changes are commonly helpful in the diagnosis of these patients. FSH
thought of as menopausal, there are also many should always be interpreted with a simulta-
symptoms that are often overlooked. Joint neous serum estradiol level, as elevated estra-
Menopause
215 9
diol levels may suppress FSH, allowing for
.. Table 9.2 Peri- and menopausal symptoms [91]
the momentary appearance of a normal FSH
Body system Symptom value. Of note, endocrine evaluation should
not be completed until at least 3 months fol-
Genitourinary Irregular periods/bleeding lowing hysterectomy or ablation, as FSH lev-
Vaginal dryness els may be transiently elevated immediately
Changes in libido
after gynecologic surgery [89].
Urinary urgency and
incontinence In 2018, the FDA approved an AMH
Recurrent UTIs enzyme-linked immunosorbent assay (ELISA)
test, known as the pico AMH diagnostic
CNS Headaches
Paresthesias/electric shocks ELISA test, for the determination of meno-
Difficulty with concentration pausal status. Research in the last few decades
Memory lapse has shown that serum AMH levels may be
Dizziness the most accurate blood test reflecting ovar-
Formications (tactile
ian follicular reserve [90]. Given that AMH is
hallucinations)
not affected by the menstrual cycle, it may be
Gastrointestinal Digestive issues (constipa- a more useful test than FSH and 17β-estradiol.
tion, flatulence, cramps,
However, given that this test remains expensive
abdominal bloating)
and is relatively new, it is not commonly used in
Psychological Mood swings practice to diagnose menopause (. Table 9.3).
Sleeping difficulty
New-onset or worsening
anxiety/depression
Panic disorder 9.9.2 Clinical History
Formications
Breast Breast tenderness or soreness Full obstetric and gynecological history
Loss of breast fullness should be taken of all women who present
Breast sagging with menopausal concerns. Women should
Musculoskeletal Joint aches and pains also be assessed for full family history and
Muscle tightness/soreness past medical history, with special attention
Decreased skeletal muscle toward cancer history, neurological history,
mass cardiovascular history, mental health history,
Oral Burning tongue and bone health history (. Table 9.4).
Gum health issues
Integumentary Dry, itchy skin
Brittle nails 9.9.3 Physical Exam
Hair thinning or loss
Change in body odor Clinical exam of the perimenopausal and
Bone Osteoporosis/bone loss menopausal patient should be focused on the
possible physical changes that can occur dur-
Cardiovascular Hot flashes and hot flushes
(redness seen) ing menopause. Vital signs should be taken at
Night sweats each office visit. Heart rate and cardiac exam
Palpitations should be recorded, as women undergoing
Immunologic Worsening allergies hot flashes may experience tachycardia or pal-
pitations. Weight, BMI, and blood pressure
General Fatigue
should also be trended, as these levels increase
Weight gain
Bloating/water retention in the postmenopausal woman. While often
overlooked, height is a valuable measurement
.. Table 9.3 Hormone changes in menopause [21–24, 90]
Hormone Source Change in Notes

menopause
Estrogen Ovaries, adrenal glands, ↓ E1 (estrone) is the dominant estrogen during

peripheral conversion by menopause
adipose tissue
Progesterone Corpus luteum ↓ Often co-administered with estrogen for
endometrial protection in the treatment of
menopausal women with an intact uterus
Testosterone Ovaries, adrenal glands, ↓ White ethnicity, lower BMI, oral estrogen, and
peripheral tissues corticosteroid use are each associated with
lower testosterone in women 65 and older
Surgical menopause often results in lower
testosterone than other types of menopause
Follicle- Anterior pituitary gland ↑ FSH should be interpreted with estradiol
stimulating because elevated estradiol can suppress FSH
hormone leading to “falsely” normal FSH levels
(FSH) Cycle day 3 FSH is commonly used as a test of
ovarian reserve
9 Anti-Mullerian Antral follicle granulosa ↓ AMH levels are reflective with ovarian follicular
hormone cells reserve
(AMH)
in postmenopausal women, as decreasing nal canal. Bimanual pelvic and rectal exam
height may be indicative of osteoporotic ver- should also be performed to assess for ade-
tebral fractures, especially more than or equal quate pelvic floor tonicity (7 Box 9.2).
to 1.5 inches of height loss from maximum
adult height in women (and 2 inches in men).
Physical appearance may display increased Box 9.2 Possible pelvic exam findings
visceral adiposity. Women should also be eval- [85–87]
uated for signs of testosterone excess, such as Labial atrophy
hirsutism, hair thinning or sparseness, adult Vaginal dryness
acne, and deepening of the voice (especially Introital stenosis
important to evaluate if changes are career Clitoral atrophy
significant for women, as with Opera singers). Phimosis of the prepuce
Mental status should be assessed for clini- Reduced mons pubis and labia majora
cal signs of mental health issues and abnor- bulk
malities in memory and cognition. A mini Reduced labia minora tissue and pigmen-
cognitive evaluation or mini-mental status tation
exam (MMSE) may be appropriate in some Prominence and erythema of the urethral
patients. meatus
Pelvic examination should be completed Urethral caruncle
to assess for signs of estrogen deficiency, such Vaginal pallor
as vulvovaginal atrophy, vaginal dryness, pal- Lack of vaginal rugae
lor, lack of rugae, and narrowing of the vagi-
Menopause
217 9
Patients should have annual vision and hear-
.. Table 9.4 Important history points in
menopausal evaluation
ing screening after the age of 65. It should
also be recommended that patients stay up to
History Specific questions date with regular dental care, which is a reflec-
tion of bone status.
Gynecologic Age at menarche
history Menstrual history
Last menstrual period
Total number of years of oral 9.10 Treatment
contraceptive use
Obstetrics Gravidity and parity 9.10.1 General Counseling
history Breastfeeding history and Recommendations
Age at first full-term pregnancy
Pregnancy and postpartum-
associated medical conditions
Women should be educated about the health
risks associated with menopause due to the
Breast history Personal history of breast deleterious effects of estrogen loss. Midlife
cancer
Family history of breast cancer
women should be routinely counseled on life-
Personal history of breast style interventions aimed at reducing triglyc-
biopsy or surgery erides, weight gain, blood pressure, insulin
Menopausal Age at menopause onset
resistance, and atherosclerosis. There is also
history Date of last menstrual period a need for individualized counseling on the
Menopausal symptom indications and benefits of hormone therapy
assessment for treatment among menopausal women.
Vasomotor symptoms. When discussing treatment options, it is
GSM symptoms
Sexual function
important to counsel that the beneficial effects
of HT often supersede the risks when initiated
Cardiovascu- Tobacco use history within 10 years from LMP in symptomatic
lar history History of hypertension
History of hyperlipidemia
women under the age of 60 and that HT is
History of diabetes the standard of care in women with meno-
History of myocardial infarction pause prior to age 45 and should be continued
History of: until at least 52 years old. There is no time
Deep vein thrombosis (DVT) limit to HT; rather, there should be yearly re-
Pulmonary embolism (PE)
Cerebrovascular accident
evaluation of the woman’s medical status, her
(CVA) preferences, and shared treatment goals.
Family history of early CAD
Other History of gallbladder disease
medical or surgery 9.10.2 Hormone Therapy:
history History of autoimmune disorder Treatment of Vasomotor
Bone history History of previous bone mineral Symptoms and Systemic
density/DXA scan Menopausal Symptoms
History of fractures over the age
of 40
Family history of osteoporosis 9.10.2.1 Treatment
and/or hip fracture of Perimenopause
History of disorders that affect
calcium absorption or regulation
Women in perimenopause often experience
Vitamin D status more severe symptoms than postmenopausal
women, due to the extreme fluctuation in
estrogen levels that can occur. Hormone ther- 10 years of menopause and under the age
apy is the most effective medication currently of 60 years old can shift the aging curve of
available to treat menopausal symptoms. women and provide significant cardiovascu-
Combined hormonal contraceptives are often lar, neurological, and mortality benefits. This
utilized to achieve symptom relief in women is the gold standard of therapy for treatment
who are still ovulating, as these medications for vasomotor symptoms. Hormone replace-
will relieve symptoms and are potent enough ment therapy (HRT) is also the gold stan-
to prevent pregnancy. The greatest major dard of treatment for women who experience
health risk associated with the use of CHCs early or premature menopause and should
in midlife-aged women is the risk of blood be continued at least until the median age
clot/stroke. It is important to assess women of menopause (52 years old) to mitigate the
for contraindications and other vascular risk consequences of early estrogen loss. Estrogen
factors prior to initiation of therapy. monotherapy may be used in hysterectomized
Another option for treatment of women women. In women who possess an intact
in perimenopause is cycled or continuous uterus, a progestogen (bioidentical or syn-
progesterone, with or without concurrent thetic progesterone) must be co-administered
estrogen therapy. Many women in perimeno- with estrogen for endometrial protection. Co-
pause may experience periods of high levels administration of estrogen and progestogen
of unopposed estrogen due to lack of corpus may also be necessary in women who have a
luteum formation and subsequent lack of history of endometriosis, even when hysterec-
9 progesterone production. Progesterone treat- tomized, if there is any concern for remnant
ment can offset this balance and help to regu- endometrial tissue. Certain selective estrogen
late bleeding patterns. Low-dose estradiol receptor modulators (SERMs), such as baze-
therapy can be added in women with contin- doxifene, also offer sufficient endometrial
ued symptoms of estrogen deficiency. Some protection when administered with estrogen.
women in perimenopause, especially if in late
perimenopause, may achieve symptom relief 9.10.2.3 Indications for Treatment
with menopausal estrogen therapy, which with Hormone Therapy
contains a much lower dose of estrogen than Treatment of menopausal symptoms is
found in CHCs. It is important to note that indicated in any woman for symptom relief
menopausal hormone therapy (MHT) is not (VMS or GSM) and/or to improve or main-
potent enough to suppress ovulation and tain quality of life. For patients who undergo
thus does not prevent ovulation or resultant premature or early menopause without con-
pregnancy from a fertilized egg. Therefore, if traindications (including surgical/radiation-
using MHT in a perimenopausal woman who induced menopausal patients and POI
is still ovulating, it is of paramount impor- patients), HRT is the gold standard of treat-
tance that clinicians counsel patients on using ment and should be continued at least until
some form of contraception if a pregnancy the age of natural menopause. Hormone ther-
is not desired, as women can become preg- apy is also indicated and FDA-approved for
nant up until the time of their final menstrual the prevention of osteoporosis in postmeno-
period. pausal women. While there are no absolute
contraindications to hormone therapy use,
9.10.2.2 Treatment of Menopause: there are several relative contraindications
Menopausal Hormone that necessitate further risk stratification.
Therapy The decision to use HT for treatment should
Hormone therapy treatment for 5–10 years occur on an individualized basis, through
when used in appropriate candidates within shared decision-making between patient and
Menopause
219 9
medical provider after appropriate counsel- Points to consider when prescribing hor-
ing has occurred (7 Box 9.3). mone therapy:
55 Is she menopausal? Yes or no
55 Does she have a uterus? Yes or no
Box 9.3 Relative contraindications to 55 Does she have indications for HT? Yes or
hormone therapy [91] no (VMS, GU, bone, QOL)
Severe active liver disease 55 Is she within 10 years of menopause and/
History of endometrial cancer or under 65? Yes or no
History of estrogen-sensitive malignancy 55 What type of therapy is indicated: oral,
Porphyria cutanea tarda transdermal, topical, or vaginal ring?
History of deep vein thrombosis
History of pulmonary embolism If patients are postmenopausal and do not
History of stroke report systemic symptoms, providers must be
Dementia sure to also assess for silent changes, such as
Coronary heart disease bone loss and any genitourinary symptoms.
Unexplained vaginal bleeding that has not
been evaluated 9.10.2.5 Estrogen (E) Therapy
Formulations (. Tables 9.5,
9.6, and 9.7)
9.10.2.4 Selecting a Route
9.10.2.6 Equivalencies of Estrogen
of Therapy
Formulations
While conjugated and synthetic estrogen
0.625 mg CEE/esterified estrogen = 5 ug ethi-
formulations are only available for oral
nyl estradiol = 1 mg 17β-estradiol = 50 ug
administration, bioidentical estradiol can be
transdermal estradiol [93].
administered orally, transdermally, or vagi-
nally [92, 93]. Oral estrogens undergo first-pass 9.10.2.7 Progestogen (P) Therapy
metabolism through the liver, a process which (. Table 9.8)
is avoided through transdermal or vaginal
estrogen delivery [92, 93]. Subsequently, oral 9.10.2.8 strogen + Progestogen
E
estrogens need to be given in higher dosages
(E+P) Therapy (. Tables 9.9,
and have a more pronounced effect on liver
protein production [93]. Oral estrogen therapy
9.10, and 9.11)
only has also been associated with increased
triglycerides, slightly increased risk of VTE,
gallbladder disease, and stroke [94]. Stroke 9.10.3 Clinical Data
risk with oral estrogen is increased 1 extra case
9.10.3.1 Women’s Health Initiative
per 1000 women in women over age 65, not
under age 65 [94, 95]. These risks are not seen The confusion over the safety of hormone
with transdermal or vaginal hormone therapy therapy first arose in July 2002, when the
[91]. The advantages of oral HT include ease Women’s Health Initiative (WHI) published
of use, and typically improved symptomatic its initial results suggesting hormone therapy
control on skin, hair, and mood. Additionally, posed significant health risks to menopausal
some women may have issues with skin adher- women while offering insufficient benefits [96].
ence and skin irritability with the transdermal The WHI was a National Institutes of Health
patch that can be avoided with oral therapy. (NIH)-sponsored multi-outcome study con-
Cost and insurance coverage, which may vary ducted in part to evaluate the risks and ben-
among treatment options between patients, are efits of the use of HT for primary prevention
also considerations that clinicians must keep of heart disease [96]. Postmenopausal women
in mind when deciding between medication (average age 63 years old) were stratified to
routes (. Fig. 9.3). conjugated estrogen (CE) alone in hysterec-
.. Fig. 9.3 Oral vs. transdermal hormone therapy. Distinctions in the pharmacology and result physiological effects
of oral vs. transdermal hormone therapy administration [92, 93]
.. Table 9.5 Oral estrogens [93, 116, 117]
Estrogen Brand name Dosage Notes
17β-Estradiol Generic available 0.5 mg total daily Total daily dose divided into two doses
(bioidentical) Estrace 1 mg total daily for BID (every 12 hours) dosing
2 mg total daily
Esterified estrogen Generic available 0.3 mg daily
Menest 0.625 mg daily
1.25 mg daily
2.5 mg daily
Conjugated equine Premarin 0.3 mg daily Composed of ten different types of
estrogen (CEE) 0.45 mg daily sulfated estrogens extracted from the
0.625 mg daily urine of mares (female horses)
0.9 mg daily
1.25 mg daily
Menopause
221 9
.. Table 9.6 Transdermal estrogens [93, 116, 117]
Generic Route Brand name Dosages Notes
17β-Estradiol Transdermal Climara 0.025, 0.0375, 0.05, 0.06, Sufficient skin

(bioidentical) patch/film Menostar 0.075 mg 1×/week permeability required
Alora 0.014 weekly only for for adequate absorp-
Estraderm bone protection tion
Minivelle 0.025, 0.05, 0.075, 0.1 mg Typically applied to
Vivelle-Dot now 2×/week (every 84h) buttocks, lower
generic available 0.05, 0.1 mg 2x/week abdomen, lower back,
0.025, 0.0375, 0.05, 0.075, or groin
0.1 mg 2x/week
0.025, 0.0375, 0.05, 0.075,
0.1 mg 2x/week
0.025, 0.0375, 0.05, 0.075,
0.1 mg 2x/week
Gel Divigel 0.25, 0.5, 0.75, 1.0, 1.25
EstroGel mg E/g gel
Elestrin 0.75 mg E in 1.25 g gel/
pump actuation
0.52 mg E in 0.87g gel/
pump actuation
Spray Evamist 1.53 mg E/spray (1–3
sprays per day)
.. Table 9.7 Other formulations [93, 116, 117]
Generic Brand name Dosage Administration
Estradiol acetate Femring 0.05 mg/d, 0.10 mg/d Replace ring every 90 days
.. Table 9.8 Oral progestogens [93, 116, 117]
Generic Brand Dosage Administration notes

name
Medroxyprogesterone acetate Provera 2.5, 5, Cyclic administration 12–14 days/

10 mg/d month with 200 mg or 100 mg nightly
Micronized progesterone (bioidenti- Prome- 200 mg P Cyclic administration 12 days/month
cal) trium or 100 mg P Use at night given relaxing properties
Bioidentical
tomized women and conjugated estrogen plus alone arm was terminated due to concern over
medroxyprogesterone acetate (CE + MPA) increased stroke risk [97]. Post hoc analysis of
in women with an intact uterus [96]. The the data subsequently showed a reduction in
CE + MPA arm was terminated after 5.6 years CV risk in women using HT when initiated
due to concern over increased risk of inva- at or before the age of 60, or within 10 years
sive breast cancer and no apparent coronary of their last menstrual period (LMP) [97, 98].
benefit [96]. Less than 2 years later, the CE- Two subsequent landmark studies, the Kronos
.. Table 9.9 Oral estrogen + progestogen therapy [93, 116, 117]
Generic Brand Dosage

name
Conjugated estrogens + medroxypro- Prem- 0.625 mg CE + 5.0 mg MPA (2 tablets: E daily and
gesterone acetate phase MPA days 15–28)
Conjugated estrogens + medroxypro- Prempro 0.3, 0.45 mg CE + 1.5 mg MPA daily
gesterone acetate 0.625 mg CE + 2.5, 5 mg MPA daily
Ethinyl estradiol + norethindrone FemHRT 0.025 mg EE + 0.5 mg NA daily
acetate Generic 0.05 mg EE + 1 mg NA daily
17β-Estradiol + norethindrone acetate Activella 0.5 mg E + 0.1 mg NA daily

Mimvey 1 mg E + 0.5 mg NA daily
Lo
Mimvey
(generic)
17β-Estradiol + drospirenone Angelic 0.5 mg E + 0.25 mg DRSP daily

1 mg E + 0.5 mg DRSP daily
In Europe 1 mg E/2 mg DRSP daily
17β-Estradiol + progesterone (bioidenti- Bijuva 1 mg E + 100 mg P daily

9 cal)
.. Table 9.10 Transdermal estrogen + progestogen therapy [93, 116, 117]
Generic Brand Dosage Administration

name
17β-Estradiol + norethindrone Combi- 0.05 mg E + 0.14 mg Replace patch every 84 h (2×/

acetate Patch NA week patch)
0.05 mg + 0.25 mg NA
17β-estradiol + levonorgestrel Climara- 0.045 mg Replace patch weekly

Pro E + 0.015 mg L
.. Table 9.11 Other formulations [93, 116, 117]
Generic Brand name Dosage Notes
Conjugated estrogens Duavee 0.045 mg CE + 20 mg Previously produced by Pfizer,

+ bazedoxifene Bazedoxifene daily currently post COVID not in
production
Esterified estrogens + Previously 0.625 mg EE + 1.25 mg MT
methyltestosterone Estratest daily
Previously 1.25 mg EE + 2.5 mg MT
Covaryx daily
Early Estrogen Prevention Study (KEEPS) 10 years after their LMP [99, 100]. Despite
and the Early Versus Late Intervention Trial these critical trials and many others, the con-
with Estradiol (ELITE), supported these fusion around the safety of HT has remained
findings in women who started HT less than prevalent throughout the medical community,
Menopause
223 9
resulting in a sharp decline in the number of mulations, conjugated equine estrogen seems
HT prescriptions written since 2003 [101]. to have a higher risk of VTE than bioidenti-
Presently, the FDA continues to mandate cal 17β-estradiol. The WHI demonstrated a
a package insert boxed warning indicating slightly increased risk of VTE with both CE
increased risk of endometrial cancer, breast and CE + MPA oral therapy compared to
cancer, CVD, and dementia to appear on all placebo [96–98]. A subsequent two-nested
estrogen-containing MHT products. case-control study that looked at the use of
HT and VTE risk in the UK found that over
9.10.3.2 Breast Cancer 80,000 women aged 40–79 years old who had
Breast cancer risk associated with the use of a primary diagnosis of VTE over the span of
hormone therapy has been a source of confu- 19 years and who were matched by age, index
sion for decades. The CE + MPA arm of the date to almost 400,000 female controls, had a
WHI initially demonstrated an increased risk dose-dependent increased risk of VTE for all
of breast cancer diagnosis [96–98, 102]. Later oral hormone therapy agents (E + P > E alone)
review of the data, however, suggested that [105]. Importantly, this study also found that
this increased risk was more likely due to the transdermal hormone therapy was not associ-
unexpectedly lower incidence of breast cancer ated with any increased risk of VTE [105].
in a subgroup of women with a history of HT
use who were randomized to the compara- 9.10.3.4 lzheimer’s Disease (AD) or
A
tive placebo arm, rather than a true increase Senile Dementia of the
in breast cancer risk [103]. The CE-alone arm Alzheimer’s Type (SDAT)
of the WHI initially demonstrated a nonsig- There has been increasing research in the influ-
nificant reduction in breast cancer risk, with ence of hormone therapy on dementia out-
the 18-year follow-up results showing a sta- comes. In one multi-institutional case control
tistically significant decrease in breast cancer study, women aged 50–63 years old who used
mortality compared to placebo [102]. hormone therapy were found to have a reduced
Since the WHI, there have been sev- risk for AD (odds ratio [OR] 0.35, 95% CI 0.2–
eral other studies examining the association 0.7) [7]. In this study, no significant associa-
between hormone therapy use and breast can- tions were found in women older than 63 using
cer. It is important to note that these studies hormone therapy and Alzheimer’s risk [7].
are often plagued by confounders and biases There have been several other observational
and that they do not provide cause and effect studies that support this notion that HT, when
conclusions. Several decades of observational initiated in younger postmenopausal women,
studies suggest that HT does not increase is associated with a reduced risk of AD [8–10].
breast cancer death. The data also appears to When menopausal symptoms of VMS and
demonstrate that hormone therapy does not sleep disturbance are treated, many women
increase breast cancer risk in women with high report resolution of their “brain fog.” The
risk of breast cancer (i.e., genetic mutations, effects of endogenous hormones, menopause,
family history, etc.). The Danish Osteoporosis and hormone therapy remain critical areas in
Study (DOPS) was a prospective study that need of further research, as there are still many
did not show any increase in breast cancer unanswered questions.
or mortality with prolonged HT treatment,
rather a reduction in all-cause mortality [104]. 9.10.3.5 Cardiovascular Disease
The ELITE trial showed less progression of
9.10.3.3 Venous Thromboembolism atherosclerosis, as measured by carotid intima
(VTE) thickness levels, in women treated with oral
Several decades of research have shown an estradiol within 6 years of menopause [100].
association between oral hormone therapy Oral estrogen therapy has been shown to
and rare increased risk of venous thrombo- reduce LDL levels, increase HDL levels, and
embolism. Among specific oral estrogen for- increase VLDL levels in postmenopausal
women [49]. HT has been shown to decrease such as testosterone pellets or unchecked
serum levels of lipoprotein (a), which is compounded hormone regimens. If patients
considered an independent risk factor for present on this type of therapy, detailed
developing cardiovascular disease due to its history of medication use and symptoms
athero-thrombogenic properties [106]. should be assessed. Serum hormone levels
Oral, not transdermal or vaginal, estrogen for 17β-estradiol, free and total testoster-
has been associated with 1 additional case one, and dehydroepiandrosterone (DHEA)
of stroke per 1000 women over the age of 65 should be assessed if indicated. Progesterone
[94, 95]. However, after 10 years of random- levels are more accurately assessed through
ized treatment, younger women on HT had a evaluation of the endometrial lining than
significantly reduced risk of heart failure, MI, through hormonal blood levels. If women
VTE, and stroke, as well as reduced risk of have been on estrogen therapy with unreg-
mortality [107]. In women less than 10 years ulated compounded progesterone creams,
from menopause and under the age of which may not absorb adequately enough to
60 years old, the data consistently shows sta- protect the uterus sufficiently, they may have
tistically significant reductions in cardiovas- been receiving unopposed estrogen which
cular mortality, coronary heart disease, and puts them at risk for endometrial cancer. If
all-cause mortality, which strongly affects the postmenopausal women have had any vagi-
risk benefit equation for younger and symp- nal bleeding or spotting, they should undergo
tomatic menopausal women. pelvic ultrasound to assess the endometrial
9 stripe or thickness, which should be 4 mm or
9.10.3.6 Mortality Data less, and ideally also undergo an endometrial
A historical perspective shows that in the biopsy.
USA, female mortality rates from 1992 to
1996 vs. 2002 to 2006 increased in 42.8% of
counties, while male mortality rates in com- 9.10.5 Non-hormonal Therapy
parison increased in only 3.4% of counties Options
[108]. Menopause experts postulate one of
the reasons for this dramatic change was the Non-hormonal therapeutic options should be
publication of the 2002 WHI study, which considered based on patient preference or if
resulted in the decline of prescriptions for a woman has contraindications to hormone
HT nationally [101]. A nationwide study in therapy. While lifestyle modification and non-
Finland examining mortality in postmeno- hormonal medications exist for the treatment
pausal women (average age 52.2 years old) of vasomotor symptoms, women should be
showed a 12–38% reduction in the risk of counseled that they are not as effective as hor-
all-cause mortality, an 18–54% reduction in mone therapy.
cardiovascular mortality, and an 18–39% Non-pharmacologic treatment strategies
reduction in stroke mortality in HT users should focus on patient education and lifestyle
vs. age-matched controls [109]. Research has modification. Women should dress in layers,
also shown that women who have undergone keep a lower temperature in the bedroom, and
bilateral oophorectomy have an increased risk use fans/cooling devices, as needed. Women
of cardiovascular mortality when not treated should be advised to avoid triggers and limit
with E + P or estrogen-alone therapy [110]. caffeine and alcohol intake. Smoking cessa-
tion should be encouraged in any tobacco
users. Weight loss, meditation, deep breathing
9.10.4 Unregulated Hormone exercises, and yoga can be helpful in control-
Therapy ling symptoms. There is limited evidence that
cognitive behavioral therapy (CBT), hypnosis,
Women should be counseled about the dan- and acupuncture can also be helpful in the
gers of unregulated hormonal therapies, treatment of hot flashes.
Menopause
225 9
9.10.5.1 Non-hormonal Fezolinetant, a novel neurokinin 3 recep-
Pharmacologic Therapy tor antagonist, is currently in phase 3 tri-
Options (. Table 9.12) als with promising results [112, 113]. Several
clinical trials have demonstrated that use of
9.10.5.2 Herbal Remedies NK3R antagonists is not only safe but asso-
There is insufficient evidence to support the ciated with improved hot flash severity and
use of any herbal remedies for the treatment frequency [112, 113]. This groundbreaking
of menopausal symptoms. Women should medication will likely become the treatment
especially be counseled about the commonly of choice for relief of vasomotor symptoms
used supplement black cohosh. There is not in women with contraindications to hormone
sufficient evidence that black cohosh improves therapy, who previously had very limited
menopausal symptoms and persistent use may options for relief.
lead to hepatotoxicity.
9.10.7 Treatment for Genitourinary

9.10.6 eurokinin 3 Receptor
N Syndrome of Menopause
(NK3R) Antagonists
9.10.7.1 Hormone Therapy for GSM
Emerging research regarding the physiology Treatment
behind hot flashes has demonstrated that Treatment of GSM can be most effectively
the thermoregulatory center in the brain is achieved through both systemic and local
affected by several neuroendocrine influences, hormone therapies. Local hormone therapy
including the HPO axis and the hypothalamic can provide sufficient hormonal supplemen-
expression of kisspeptin and neurokinin B tation to relieve GSM with minimal systemic
(NKB) [111]. The loss of estrogen that occurs absorption. When systemic HT is needed,
with menopause has been found to disrupt the women may have resolution of GSM, though
thermoregulatory center in the hypothalamus some may require additional low-dose vaginal
through removal of negative feedback of neu- hormone therapy to achieve adequate symp-
rokinin 3 receptor (NK3R) activation [111]. tom relief (. Fig. 9.4).
.. Table 9.12 Non-hormonal medication options [118]
Generic Brand Dosage Notes

names
SSRI/SNRI Brisdelle 7.5 mg po daily Brisdelle is the only FDA-approved non-hormonal

Paroxetine Effexor 37.5, 75 mg po treatment for VMS
Venlafaxine Pristiq daily Cannot use paroxetine in patients using tamoxifen
Desvenlafaxine Lexapro 50 mg po daily because of cross-reaction between the drugs
Escitalopram Celexa 5, 10 mg po daily Lower dosages are more effective for hot flashes;
Citalopram 10, 20 mg po daily higher doses may worsen VMS
Fluoxetine and sertraline have not been shown to be
as effective as the other SSRIs
Antihypertensive Catapres 0.1 mg daily po or Can be useful in patients with high BP; however,
Clonidine patch use caution as these patients can get rebound HTN
Anticonvulsants Neurontin 300–900 mg total Can cause significant drowsiness in some women
Gabapentin Lyrica daily dose po
Pregabalin 75–300 mg po daily
Anticholinergic Ditropan 5 mg BID po Can cause dry mouth, constipation, and worsening
Oxybutynin of acute angle glaucoma
Reassess annually
Is she Is she
NO NO or if symptoms
menopausal?* permenopausal?
change
YES
YES
Obtain DXA Does she have Does she have

Unknown What is her bone status? NO NO
scan symptoms? systemic symptoms?
YES YES
Evaluate and Treat:
Is she under 65 or within 10 - CHCs
Stable or normal Bone loss years of menopause without - Cycled
bones
contraindications to HT? progesterone + -low
dose E
Counsel on Educate on Treatment YES NO

non-hormonal NO Does she want HT? options: hormonal and
treatment options non-hormonal
Discuss na/a/se and

Bone health VMS Does she have a
YES non-hormonal
uterus?
options
- SERMs (I.e. raloxifene) -SSRI/SNRIs

- BIsphosphonates - Clonidine
- Denosumab - Gabapentin Start estrogen + Start estrogen
- Abaloparatice - Oxybutynin progestin therapy monotherapy**
- Teriparatide
- Romosozumab
Does she have

persistent GSM
symptoms? NO
YES
Start vaginal HT:

- Vaginal estrogen
- Vaginal DHEA
.. Fig. 9.4 Treatment of menopause. CHCs combined SSRI selective serotonin reuptake inhibitor, SNRI sero-
9 hormonal contraceptives, DHEA dehydroepiandros- tonin-norepinephrine reuptake inhibitor. *Defined clini-
terone, DXA dual-energy X-ray absorptiometry, E estro- cally as ≥12 months since LMP (see 10.9.1 Diagnosis for
gen, HT hormone therapy, GSM genitourinary syndrome further details). **Consider estrogen+progestogen ther-
of menopause, r/b/a/se risks, benefits, a lternatives, side apy in hysterectomized patient with a history of endome-
effects, SERM selective estrogen receptor modulator, triosis if concerned for any remnant endometrial tissue
There are two main types of local hormone ing risk of endometrial cancer, breast cancer,
therapy currently available, vaginal estrogen CVD, and dementia that appears on systemic
and vaginal DHEA. Vaginal estrogen comes estrogen products is also seen in vaginal estro-
in several forms, including creams, rings, tab- gen productions. Women must be educated
lets, and inserts [87]. Vaginal DHEA comes about the differences between vaginal ET and
in suppository form, though a ring formula- systemic ET and should be informed about
tion is currently in development. All of these this box warning before they use the product
FDA-approved products have proven efficacy so they are prepared (. Table 9.13).
in placebo-controlled trials to alleviate symp-
toms of vaginal dryness and dyspareunia [87]. 9.10.7.2 Non-hormonal Treatment
Additionally, research has shown that with for GSM
the use of both vaginal estrogen and vaginal
Non-hormonal options may be sufficient
DHEA, serum estradiol levels remain within
to relieve symptoms in some women, and
postmenopausal range [87].
would be an appropriate choice for those who
It is important for clinicians to know that
do not wish to use local hormone therapy
the package insert boxed warning regard-
(. Table 9.14).
Menopause
227 9
.. Table 9.13 Hormone therapy for the treatment of GSM [87, 116, 117]
Generic Brand name Dosage Notes
17β-Estradiol Estrace 0.1 mg E/g

(bioidentical) vaginal cream 2–4 g/d × 1–2 weeks
Generic 1 g 1–3×/week
Conjugated Premarin 0.625 mg CE/g
equine vaginal cream 0.5–2 g/d for 2 weeks then
estrogen then 0.5 g 2×/weekly
Estradiol Vagifem 0.01 mg
hemihydrate vaginal tablet Initial: 1 tablet/d × 2 weeks
Generic Maintenance: 1 tablet 2×/
Yuvafem week
vaginal tablet
Estradiol Imvexxy 4mcg, 10 mcg FDA-approved
vaginal vaginal insert Daily for 2 weeks then 2×/
week
Vaginal Intrarosa 6.5 mg insert daily Through intracrinological processes,
DHEA vaginal genitourinary tissue takes up DHEA and
(prasterone) suppository processes it into androgens and estrogens,
leading to improved dryness, urinary
symptoms, and sexual function
Ospemifene Osphena 60 mg pill daily with food FDA-approved for dyspareunia and dryness
(SERM) Not recommended for breast cancer survivors
Can worsen VMS.
.. Table 9.14 Non-hormonal treatment options for GSM [87, 114]
Type of therapy Description Mechanism of action Duration Notes

of action
Moisturizers Gel or cream Hydrophilic agents that Longer

Use regularly coat the vagina and bring duration
moisture to vaginal of action
epithelial surface to
maintain hydration and
relieve dryness
Lubricants Gel or cream Moistens vaginal Shorter Silicone lubricants are more
(water vs. epithelium to improve duration expensive, but typically last
silicone vs. oil dryness and alleviate of action longer
vs. hybrid) dyspareunia prior to Water lubricants are easier to
Use only intercourse or medical wash off
prior to examinations Not all lubricants are condom
vaginal compatible
penetration
MonaLisa Vaginal Produces new collagen Longer While women may experience
Laser Therapy fractional and elastic fibers to duration improved symptoms with this
(experimental carbon remodel atrophic vaginal of action treatment, there are no current
with FDA dioxide connective tissue well-powered studies that are
warnings (CO2) laser sham procedure-controlled to
issued) confirm efficacy
A. Menopause is typically diagnosed

Conclusion retrospectively 12 months after the
Menopause, whether premature, early, nat- final menstrual period.
ural, or surgical, offers a key opportunity B. There is a rare possibility of con-
to clinicians and patients to chart the sec- tinued cycles even after a woman
ond half of female adult life with a focus meets the criteria of the classic
on symptom control, risk assessment, and clinical definition of menopause.
disease prevention. There are a multitude C. FSH and 17β-estradiol, which should
of hormonal and non-hormonal treatment always be interpreted together, can be
options available. Women under age 65 and helpful in confirming the diagnosis
within 10 years of menopause are in the of menopause.
best situation to obtain both symptom con- D. The pico AMH diagnostic ELISA
trol and increased longevity with the use of test is the most commonly used test
hormone therapy. However, regardless of to confirm the diagnosis of meno-
time since menopause, vasomotor symp- pause.
toms, bone tissue, and the genitourinary
systems are responsive to HT. For maximal ??4.
Which of the following statements
prevention and reduced risk, starting HT regarding systemic hormone therapy is
within 6–10 years of hormonal menopause not true?
is optimal, noting one cannot just rely on A. Women without a uterus can use
9 age and/or menstrual history to make the estrogen therapy by itself. Women
diagnosis of menopause. with an intact uterus must use
E + P therapy.
B. In accordance with the FDA-
9.11 Learning Assessment mandated black box warning, vagi-
nal hormone therapy increases the
9.11.1 Review Questions risk of endometrial cancer, breast
cancer, CVD, and dementia.
??1.
Which of the following etiologies of C. There is only one FDA-approved
POI causes the most significant physi- SSRI for the treatment of vasomo-
ological consequences and the most tor symptoms, Brisdelle (parox-
severe symptoms in women? etine 7.5 mg).
A. Iatrogenic D. NK3R antagonists will likely become
B. Infectious the treatment of choice for relief of
C. Surgical vasomotor symptoms in women
D. Autoimmune with contraindications to hormone
therapy.
??2. Estrogen has a multitude of functions
in the body, including:
A. Neuroprotective and neurotrophic 9.11.2 Answers
effects on the brain
B. Preserving blood supply, maintain- vv1. C
ing integrity, and supporting the
microbiome of the vagina vv2. D
C. Bone protection through RANKL-
mediated antiresorptive effects vv3. D
D. All of the above
vv4. B
??3.
Which of the following statements
about the diagnosis of menopause is
not true?
Menopause
229 9
References 13. Nappi RE, Lachowsky M. Menopause and sexual-
ity: prevalence of symptoms and impact on quality
of life. Maturitas. 2009;63(2):138–41.
1. Gold EB. The timing of the age at which natural
14. Blumel JE, et al. Quality of life after the menopause:
menopause occurs. Obstet Gynecol Clin N Am.
a population study. Maturitas. 2000;34(1):17–23.
2011;38(3):425–40.
15. Hess R, et al. The impact of menopause on health-
2. Khan ZA, Janssen I, Mazzarelli JK, Powell LH,
related quality of life: results from the STRIDE
Dumasius A, Everson-Rose SA, Barinas-Mitchell
longitudinal study. Qual Life Res. 2012;21(3):
E, Matthews K, El Khoudary SR, Weinstock PJ,
535–44.
et al. Serial studies in subclinical atherosclerosis
16. Women at Work. United States Department of
during menopausal transition (from the Study of
Labor, Bureau of Labor Statistics, March 2017.
Women’s Health Across the Nation). Am J Car-
Available at: https://www.bls.gov/spotlight/2017/
diol. 2018;122:1161–8.
women-at-work/. Accessed 29 Apr 2021.
3. El Khoudary SR, Wildman RP, Matthews K,
17. Kleinman NL, Rohrbacker NJ, Bushmakin AG,
Thurston RC, Bromberger JT, Sutton-Tyrrell
Whiteley J, Lynch WD, Shah SN. Direct and indi-
K. Progression rates of carotid intima-media
rect costs of women diagnosed with menopause
thickness and adventitial diameter during the
symptoms. J Occup Environ Med. 2013;55(4):
menopausal transition. Menopause. 2013;20:
465–70.
8–14.
18. Sarrel PM. Women, work, and menopause. Meno-
4. Thurston RC, Bhasin S, Chang Y, Barinas-Mitchell
pause. 2012;19(3):250–2.
E, Matthews KA, Jasuja R, Santoro N. Reproduc-
19. Elavsky S, McAuley E. Physical activity, symp-
tive hormones and subclinical cardiovascular dis-
toms, esteem, and life satisfaction during meno-
ease in midlife women. J Clin Endocrinol Metab.
pause. Maturitas. 2005;52(3–4):374–85.
2018;103:3070–7.
20. Harlow SD, Gass M, Hall JE, Lobo R, Maki P,
5. El Khoudary SR, Wildman RP, Matthews K,
Rebar RW, Sherman S, Sluss PM, de Villiers TJ,
Thurston RC, Bromberger JT, Sutton-Tyrrell
STRAW+10 Collaborative Group. Executive
K. Endogenous sex hormones impact the progres-
summary of the Stages of Reproductive Aging
sion of subclinical atherosclerosis in women dur-
Workshop +10: addressing the unfinished agenda
ing the menopausal transition. Atherosclerosis.
of staging reproductive aging. Climacteric.
2012;225:180–6.
2012;15(2):105–14.
6. Matthews KA, Crawford SL, Chae CU, Everson-
21. Hansen KR, Knowlton NS, Thyer AC, Charleston
Rose SA, Sowers MF, Sternfeld B, Sutton-Tyrrell
JS, Soules MR, Klein NA. A new model of repro-
K. Are changes in cardiovascular disease risk fac-
ductive aging: the decline in ovarian non-growing
tors in midlife women due to chronological aging
follicle number from birth to menopause. Hum
or to the menopausal transition? J Am Coll Car-
Reprod. 2008;23(3):699–708.
diol. 2009;54:2366–73.
22. Burger HG, Dudley EC, Robertson DM, Denner-
7. Maki PM, Henderson VW. Hormone therapy,
stein L. Hormonal changes in the menopause tran-
dementia, and cognition: the Women's Health
sition. Recent Prog Horm Res. 2002;57:257–75.
Initiative 10 years on. Climacteric. 2012;15(3):
23. Hall JE. Endocrinology of the menopause. Endo-
256–62.
crinol Metab Clin N Am. 2015;44(3):485–96.
8. Henderson VW, Benke KS, Green RC, Cupples
24. Vollenhoven B, Hunt S. Ovarian ageing and the
LA, Farrer LA. Postmenopausal hormone therapy
impact on female fertility. F1000Res. 2018;7:F1000.
and Alzheimer's disease risk: interaction with age.
Faculty Rev-1835
J Neurol Neurosurg Psychiatry. 2005;76:103–5.
25. Nelson LM. Clinical practice. Primary ovarian
9. Hogervorst E, Williams J, Budge M, Riedel W,
insufficiency. N Engl J Med. 2009;360(6):606–14.
Jolles J. The nature of the effect of female gonadal
26. Laughlin GA, Barrett-Connor E, Kritz-Silverstein
hormone replacement therapy on cognitive func-
D, von Mühlen D. Hysterectomy, oophorectomy,
tion in post-menopausal women: a meta-analysis.
and endogenous sex hormone levels in older
Neuroscience. 2000;101:485–512.
women: the rancho Bernardo study. J Clin Endo-
10. LeBlanc ES, Janowsky J, Chan BKS, Nelson
crinol Metab. 2000;85(2):645–51.
HD. Hormone replacement therapy and cogni-
27. Faubion SS, Kuhle CL, Shuster LT, Rocca
tion: systematic review and meta-analysis. JAMA.
WA. Long-term health consequences of premature
2001;285:1489–99.
or early menopause and considerations for man-
11. Songür N, Aydin ZD, Oztürk Ö, Sahin Ü, Khayri
agement. Climacteric. 2015;18(4):483–91.
U, Bircan A, Akkaya A. Respiratory symptoms,
28. Shuster LT, Rhodes DJ, Gostout BS, Grossardt
pulmonary function, and reproductive history:
BR, Rocca WA. Premature menopause or early
Isparta Menopause and Health Study. J Women’s
menopause: long-term health consequences.
Health. 2010;19(6):1145–54.
Maturitas. 2010;65(2):161–6.
12. Memoalia J, Anjum B, Singh N, Gupta M. Decline
29. Cui J, Shen Y, Li R. Estrogen synthesis and sig-
in pulmonary function tests after menopause. J
naling pathways during aging: from periphery to
Menopausal Med. 2018;24(1):34.
brain. Trends Mol Med. 2013;19(3):197–209.
30. Miller VM, Duckles SP. Vascular actions of estro- 46. Mauvais-Jarvis F, Manson JE, Stevenson JC,
gens: functional implications. Pharmacol Rev. Fonseca VA. Menopausal hormone therapy and
2008;60(2):210–41. type 2 diabetes prevention: evidence, mechanisms,
31. Koike S, Sakai M, Muramatsu M. Molecular clon- and clinical implications. Endocr Rev. 2017;38(3):
ing and characterization of rat estrogen receptor 173–88.
cDNA. Nucleic Acids Res. 1987;15(6):2499–513. 47. Brady CW. Liver disease in menopause. World J
32. Mosselman S, Polman J, Dijkema R. ER beta: iden- Gastroenterol. 2015;21(25):7613–20.
tification and characterization of a novel human 48. Tchaikovski SN, Rosing J. Mechanisms of
estrogen receptor. FEBS Lett. 1996;392:49–53. estrogen-induced venous thromboembolism.
33. Deroo BJ, Korach KS. Estrogen receptors and Thromb Res. 2010;126(1):5–11.
human disease. J Clin Invest. 2006;116(3):561–70. 49. Guetta V, Cannon RO 3rd. Cardiovascular
34. Gruber CJ, Tschugguel W, Schneeberger C, Huber effects of estrogen and lipid-lowering thera-
JC. Production and actions of estrogens. N Engl J pies in postmenopausal women. Circulation.
Med. 2002;346(5):340–52. 1996;93(10):1928–37.
35. Arendt LM, Kuperwasser C. Form and function: 50. Caiazza F, Ryan EJ, Doherty G, Winter DC,
how estrogen and progesterone regulate the mam- Sheahan K. Estrogen receptors and their impli-
mary epithelial hierarchy. J Mammary Gland Biol cations in colorectal carcinogenesis. Front Oncol.
Neoplasia. 2015;20(1–2):9–25. 2015;5:19.
36. Yue W, Wang JP, Li Y, Fan P, Liu G, Zhang N, 51. Hsu LH, Chu NM, Kao SH. Estrogen, Estro-
Conaway M, Wang H, Korach KS, Bocchinfuso gen Receptor and Lung Cancer. Int J Mol Sci.
W, Santen R. Effects of estrogen on breast can- 2017;18(8):1713.
cer development: role of estrogen receptor inde- 52. Real FG, Svanes C, Omenaas ER, Antò JM,
pendent mechanisms. Int J Cancer. 2010;127(8): Plana E, Jarvis D, Janson C, Neukirch F, Zemp E,
1748–57. Dratva J, Wjst M, Svanes K, Leynaert B, Sunyer
9 37. Zárate S, Stevnsner T, Gredilla R. Role of estrogen J. Lung function, respiratory symptoms, and the
and other sex hormones in brain aging. Neuropro- menopausal transition. J Allergy Clin Immunol.
tection and DNA repair. Front Aging Neurosci. 2008;121(1):72–80.e3.
2017;9:430. 53. Campbell B, Davis SR, Abramson MJ, Mishra G,
38. Lejri I, Grimm A, Eckert A. Mitochondria, estro- Handelsman DJ, Perret JL, Dharmage SC. Meno-
gen and female brain aging. Front Aging Neurosci. pause, lung function and obstructive lung dis-
2018;10:124. ease outcomes: a systematic review. Climacteric.
39. El Khoudary SR, Aggarwal B, Beckie TM, et al. 2018;21(1):3–12.
American Heart Association prevention science 54. Shah MG, Maibach HI. Estrogen and skin. An
Committee of the Council on epidemiology and overview. Am J Clin Dermatol. 2001;2(3):143–50.
prevention; and council on cardiovascular and 55. Wilkinson HN, Hardman MJ. The role of estro-
stroke nursing. Menopause transition and car- gen in cutaneous ageing and repair. Maturitas.
diovascular disease risk: implications for timing 2017;103:60–4.
of early prevention: a scientific statement from 56. Markopoulos MC, Kassi E, Alexandraki KI, Mas-
the American Heart Association. Circulation. torakos G, Kaltsas G. Hyperandrogenism after
2020;142(25):e506–32. menopause. Eur J Endocrinol. 2015;172(2):R79–91.
40. Murphy E, Kelly D. Estrogen signaling and cardio- 57. Ogueta SB, Schwartz SD, Yamashita CK, Farber
vascular disease. Circ Res. 2011;109(6):687–96. DB. Estrogen receptor in the human eye: influence
41. Thurston RC, Sutton-Tyrrell K, Everson-Rose SA, of gender and age on gene expression. Invest Oph-
Hess R, Matthews KA. Hot flashes and subclinical thalmol Vis Sci. 1999;40(9):1906–11.
cardiovascular disease: findings from the study of 58. Nuzzi R, Scalabrin S, Becco A, Panzica G. Gonadal
Women's health across the nation heart study. Cir- hormones and retinal disorders: a review. Front
culation. 2008;118(12):1234–40. Endocrinol (Lausanne). 2018;9:66.
42. Khan MS, Aouad R. The effects of insomnia and 59. Kelley C. Estrogen and its effect on vaginal atro-
sleep loss on cardiovascular disease. Sleep Med phy in postmenopausal women. Urol Nurs.
Clin. 2017;12(2):167–77. 2007;27(1):40–5.
43. Streicher C, Heyny A, Andrukhova O, et al. 60. Labrie F, Martel C, Pelletier G. Is vulvovaginal
Estrogen regulates bone turnover by targeting atrophy due to a lack of both estrogens and andro-
RANKL expression in bone lining cells. Sci Rep. gens? Menopause. 2017;24(4):452–61.
2017;7:6460. 61. Lev-Sagie A. Vulvar and vaginal atrophy: physiol-
44. Cooke PS, Naaz A. Role of estrogens in adipocyte ogy, clinical presentation, and treatment consider-
development and function. Exp Biol Med (May- ations. Clin Obstet Gynecol. 2015;58(3):476–91.
wood). 2004;229(11):1127–35. 62. Shynlova O, Bortolini MA, Alarab M. Genes
45. Tchernof A, Calles-Escandon J, Sites CK, Poehl- responsible for vaginal extracellular matrix metab-
man ET. Menopause, central body fatness, and olism are modulated by women’s reproductive
insulin resistance: effects of hormone-replacement cycle and menopause. Int Braz J Urol. 2013;39(2):
therapy. Coron Artery Dis. 1998;9(8):503–11. 257–67.
Menopause
231 9
63. Muhleisen AL, Herbst-Kralovetz MM. Meno- 77. Chung HF, Pandeya N, Dobson AJ, et al. The role
pause and the vaginal microbiome. Maturitas. of sleep difficulties in the vasomotor menopausal
2016;91:42–50. symptoms and depressed mood relationships:
64. Chee WJY, Chew SY, Than LTL. Vaginal microbi- an international pooled analysis of eight stud-
ota and the potential of lactobacillus derivatives in ies in the InterLACE consortium. Psychol Med.
maintaining vaginal health. Microb Cell Factories. 2018;12:1–12.
2020;19(1):203. 78. Franco OH, Muka T, Colpani V, et al. Vasomo-
65. Cardenas-Trowers O, Meyer I, Markland AD, tor symptoms in women and cardiovascular risk
Richter HE, Addis I. A review of phytoestrogens markers: systematic review and meta- analysis.
and their association with pelvic floor conditions. Maturitas. 2015;81(3):353–61.
Female Pelvic Med Reconstr Surg. 2018;24(3): 79. Thurston RC, El Khoudary SR, Sutton-Tyrrell K,
193–202. et al. Vasomotor symptoms and insulin resistance
66. Ismail SI, Bain C, Hagen S. Oestrogens for treat- in the Study of Women’s Health Across the Nation.
ment or prevention of pelvic organ prolapse in J Clin Endocrinol Metab. 2012;97(10):3487–94.
postmenopausal women. Cochrane Database Syst 80. Thurston RC, El Khoudary SR, Sutton-Tyrrell K,
Rev. 2010;9:CD007063. et al. Vasomotor symptoms and lipid profiles in
67. Blakeman PJ, Hilton P, Bulmer JN. Oestrogen and women transitioning through menopause. Obstet
progesterone receptor expression in the female Gynecol. 2012;119(4):753–61.
lower urinary tract, with reference to oestrogen 81. Jackson EA, El Khoudary SR, Crawford SL, et al.
status. BJU Int. 2000;86(1):32–8. Hot flash frequency and blood pressure: data from
68. Waetjen LE, Johnson WO, Xing G, Feng WY, the Study of Women’s Health Across the Nation. J
Greendale GA, Gold EB, Study of Women’s Womens Health (Larchmt). 2016;25(12):1204–9.
Health Across the Nation. Serum estradiol levels 82. Thurston RC, Chang Y, Barinas-Mitchell E,
are not associated with urinary incontinence in et al. Menopausal hot flashes and carotid intima
midlife women transitioning through menopause. media thickness among midlife women. Stroke.
Menopause. 2011;18(12):1283–90. 2016;47(12):2910–5.
69. Jung C, Brubaker L. The etiology and management 83. Gast GC, Grobbee DE, Pop VJ, et al. Vasomotor
of recurrent urinary tract infections in postmeno- symptoms are associated with a lower bone min-
pausal women. Climacteric. 2019;22(3):242–9. eral density. Menopause. 2009;16(2):231–8.
70. Freeman EW, Sammel MD, Sanders RJ. Risk of 84. Crandall CJ, Aragaki A, Cauley JA, et al. Associa-
long-term hot flashes after natural menopause: evi- tions of menopausal VMS with fracture incidence.
dence from the Penn ovarian aging study cohort. J Clin Endocrinol Metab. 2015;100(2):524–34.
Menopause. 2014;21(9):924. 85. Moral E, Delgado JL, Carmona F, et al. Genito-
71. Low DA, Davis SL, Keller DM, Shibasaki M, urinary syndrome of menopause. Prevalence and
Crandall CG. Cutaneous and hemodynamic quality of life in Spanish postmenopausal women.
responses during hot flashes in symptomatic The GENISSE study. Climacteric. 2018;21:
postmenopausal women. Menopause. 2008;15(2): 167–73.
290–5. 86. US Food and Drug Administration. Guidance for
72. Politi MC, Schleinitz MD, Col NF. Revisiting the industry: estrogen and estrogen/progestin drug
duration of vasomotor symptoms of menopause: products to treat vasomotor symptoms and vulvar
a meta-analysis. J Gen Intern Med. 2008;23(9): and vaginal atrophy symptoms: recommendations
1507–13. for clinical evaluation. 2003. http://www.fda.gov/
73. Rance NE, Dacks PA, Mittelman-Smith MA, downloads/drugs/guidancecomplianceregulatory-
Romanovsky AA, Krajewski-Hall SJ. Modulation information/guidances/ucm071643.pdf. Accessed
of body temperature and LH secretion by hypo- 9 Dec 2020.
thalamic KNDy (kisspeptin, neurokinin B and 87. The 2020 genitourinary syndrome of menopause
dynorphin) neurons: a novel hypothesis on the position statement of The North American Meno-
mechanism of hot flushes. Front Neuroendocrinol. pause Society. Menopause. 2020;27(9):976–92.
2013;34(3):211–27. 88. European Society for Human Reproduction
74. Thurston RC, Joffe H. Vasomotor symptoms and and Embryology (ESHRE) Guideline Group
menopause: findings from the Study of Women’s on POI, Webber L, Davies M, Anderson R,
Health Across the Nation. Obstet Gynecol Clin N Bartlett J, Braat D, Cartwright B, Cifkova R, de
Am. 2011;38(3):489–501. Muinck Keizer-Schrama S, Hogervorst E, Janse
75. Kravitz HM, Zhao X, Bromberger JT, et al. Sleep F, Liao L, Vlaisavljevic V, Zillikens C, Vermeulen
disturbance during the menopausal transition in a N. ESHRE guideline: management of women with
multi-ethnic community sample of women. Sleep. premature ovarian insufficiency. Hum Reprod.
2008;31(7):979–90. 2016;31(5):926–37.
76. Mishra GD, Chung HF, Pandeya N, et al. The 89. Qu X, Cheng Z, Yang W, Xu L, Dai H, Hu L. Con-
InterLACE study: design, data harmonization trolled clinical trial assessing the effect of laparo-
and characteristics across 20 studies on women’s scopic uterine arterial occlusion on ovarian reserve.
health. Maturitas. 2016;92:176–85. J Minim Invasive Gynecol. 2010;17(1):47–52.
90. Moolhuijsen LME, Visser JA. Anti-Müllerian 102. Manson JE, Aragaki AK, Rossouw JE, et al.
hormone and ovarian reserve: update on assess- Menopausal hormone therapy and long-term all-
ing ovarian function. J Clin Endocrinol Metab. cause and cause-specific mortality. Obstet Gyne-
2020;105(11):3361–73. col Surv. 2018;73(1):22–4.
91. The NAMS 2017 Hormone Therapy Posi- 103. Hodis HN, Sarrel PM. Menopausal hormone
tion Statement Advisory Panel. The 2017 hor- therapy and breast cancer: what is the evi-
mone therapy position statement of The North dence from randomized trials? Climacteric.
American Menopause Society. Menopause. 2018;21(6):521–8.
2017;24(7):728–53. 104. Mosekilde L, Hermann AP, Beck-Nielsen H,
92. Mashchak CA, Lobo RA, Dozono-Takano R, Charles P, Nielsen SP, Sørensen OH. The Danish
et al. Comparison of pharmacodynamic prop- Osteoporosis Prevention Study (DOPS): project
erties of various estrogen formulations. Am J design and inclusion of 2000 normal perimeno-
Obstet Gynecol. 1982;144(5):511–8. pausal women. Maturitas. 1999;31(3):207–19.
93. Smith T, Sahni S, Thacker HL. Postmeno- 105. Vinogradova Y, Coupland C, Hippisley-Cox
pausal hormone therapy-local and systemic: a J. Use of hormone replacement therapy and risk
pharmacologic perspective. J Clin Pharmacol. of venous thromboembolism: nested case-control
2020;60(Suppl 2):S74–85. studies using the QResearch and CPRD data-
94. Gartlehner G, Patel SV, Feltner C, Weber RP, bases. BMJ. 2019;364:k4810.
Long R, Mullican K, Boland E, Lux L, Viswa- 106. Anagnostis P, Galanis P, Chatzistergiou V, et al.
nathan M. Hormone therapy for the primary pre- The effect of hormone replacement therapy and
vention of chronic conditions in postmenopausal tibolone on lipoprotein concentrations in post-
women: evidence report and systematic review for menopausal women: a systematic review and
the US Preventive Services Task Force. JAMA. meta-analysis. Maturitas. 2017;99:27–36.
2017;318(22):2234–49. 107. Schierbeck LL, Rejnmark L, Tofteng CL, Stilgren
9 95. Henderson VW, Lobo RA. Hormone therapy L, Eiken P, Mosekilde L, et al. Effect of hormone
and the risk of stroke: perspectives 10 years after replacement therapy on cardiovascular events in
the Women's Health Initiative trials. Climacteric. recently postmenopausal women: randomised
2012;15(3):229–34. trial. BMJ. 2012;345:e6409.
96. Rossouw JE, Anderson GL, Prentice RL, et al. 108. Sarrel PM, Njike VY, Vinante V, Katz DL. The
Risks and benefits of estrogen plus progestin in mortality toll of estrogen avoidance: an analy-
healthy postmenopausal women: principal results sis of excess deaths among hysterectomized
from the Women's Health Initiative randomized women aged 50 to 59 years. Am J Public Health.
controlled trial. JAMA. 2002;288(3):321–33. 2013;103(9):1583–8.
97. Manson JE, Chlebowski RT, Stefanick ML, 109. Mikkola TS, Tuomikoski P, Lyytinen H, et al.
et al. Menopausal hormone therapy and health Estradiol-based postmenopausal hormone ther-
outcomes during the intervention and extended apy and risk of cardiovascular and all-cause mor-
poststopping phases of the Women's Health Ini- tality. Menopause. 2015;22(9):976–83.
tiative randomized trials. JAMA. 2013;310(13): 110. Rivera CM, Grossardt BR, Rhodes DJ, et al.
1353–68. Increased cardiovascular mortality after early
98. Manson JE, Aragaki AK, Rossouw JE, et al. bilateral oophorectomy. Menopause. 2009;16(1):
Menopausal hormone therapy and Long-term 15–23.
all-cause and cause-specific mortality: the wom- 111. Modi M, Dhillo WS. Neurokinin 3 receptor
en’s health initiative randomized trials. JAMA. antagonism: a novel treatment for menopausal hot
2017;318(10):927–38. flushes. Neuroendocrinology. 2019;109(3):242–8.
99. Santoro N, Allshouse A, Neal-Perry G, et al. 112. Fraser GL, Lederman S, Waldbaum A, Kroll
Longitudinal changes in menopausal symptoms R, Santoro N, Lee M, Skillern L, Ramael S. A
comparing women randomized to low-dose oral phase 2b, randomized, placebo-controlled,
conjugated estrogens or transdermal estradiol double-blind, dose-ranging study of the neuro-
plus micronized progesterone versus placebo: the kinin 3 receptor antagonist fezolinetant for vaso-
Kronos Early Estrogen Prevention Study. Meno- motor symptoms associated with menopause.
pause. 2017;24(3):238–46. Menopause. 2020;27(4):382–92.
100. Hodis HN, Mack WJ, Henderson VW, ELITE 113. Santoro N, Waldbaum A, Lederman S, Kroll R,
Research Group, et al. Vascular effects of early Fraser GL, Lademacher C, Skillern L, Young
versus late postmenopausal treatment with estra- J, Ramael S. Effect of the neurokinin 3 recep-
diol. N Engl J Med. 2016;374(13):1221–31. tor antagonist fezolinetant on patient-reported
101. Crawford SL, Crandall CJ, Derby CA, El outcomes in postmenopausal women with vaso-
Khoudary SR, Waetjen LE, Fischer M, Joffe motor symptoms: results of a randomized,
H. Menopausal hormone therapy trends before placebo-controlled, double-blind, dose-ranging
versus after 2002: impact of the Women’s study (VESTA). Menopause. 2020;27(12):1350–6.
Health Initiative Study Results. Menopause. 114. Cruff J, Khandwala S. A double-blind random-
2018;26(6):588–97. ized sham-controlled trial to evaluate the efficacy
Menopause
233 9
of fractional carbon dioxide laser therapy on gen- fda.gov/scripts/cder/ob/search_product.cfm.
itourinary syndrome of menopause. J Sex Med. Accessed 29 Apr 2021.
2021;18(4):761–9. 117. Pinkerton JA, Estrogen therapy and estrogen-
115. Torrealday S, Pal L. Premature menopause. Endo- progestogen therapy. In: The North American
crinol Metab Clin North Am. 2015;44(3):543–57. Menopause Society. Menopause practice: a cli-
https://doi.org/10.1016/j.ecl.2015.05.004. Epub nician’s guide. 6th edn. Pepper Pike: The North
2015 Jun 22. American Menopause Society; 2019. p. 284–303.
116. U.S. Food and Drug Administration. Orange 118. Carrol D. Nonhormonal therapies for hot
Book: approved drug products with therapeutic flashes in menopause. Am Fam Physician.
equivalence evaluations. https://www.accessdata. 2006;73(3):457–64.
235 10
Osteoporosis
Tiffany M. Cochran and Holly L. Thacker
Contents
10.1 Definition and History of Osteoporosis – 237
10.2 Epidemiology – 238

10.4 enopause Transition and Its Effect

M
on Bone – 240
10.5 Premenopausal and Bone Health – 241

10.5.1 ypothalamic Amenorrhea and Bone Health – 241
H
10.5.2 Female Athlete Triad and Bone Health – 242
10.6 Classification of Osteoporosis – 243

10.6.1 rimary Osteoporosis – 243
P
10.6.2 Secondary Osteoporosis – 243
10.7 Clinical Symptoms of Osteoporosis – 244
10.8 Diagnostic Criteria for Osteoporosis – 246
10.9 Osteoporosis Treatment – 249

10.9.1 onpharmacologic Modalities for Osteoporosis
N
Prevention – 249
10.9.2 Pharmacologic Therapies for Treatment
and Prevention of Osteoporosis – 250
10.9.3 Antiresorptive Therapies – 250
10.9.4 Anabolic Therapies – 255

https://doi.org/10.1007/978-3-030-99596-6_10
10.10 Combination Therapy – 256
10.11 Monitoring Bone Health – 256
10.12 When to Consider a Drug Holiday – 257
10.13 Barriers to Effective OP Medications – 257
10.14 When to Refer to Osteoporosis Specialist – 258
10.16 Answers – 260
References – 260
Osteoporosis
237 10
has two sisters with osteopenia. Given her
Key Points family history of osteoporosis, she has a
55 Osteoporosis is a global pandemic and bone density scan done, which is normal.
a growing public health concern, signifi- She experiences mild, tolerable hot flashes
cantly affecting women as one in three occasionally during the day, one to two
women will have at least one fragility times weekly. She is amenorrheic with
fracture. Mirena IUD. Obstetric history is remark-
55 Often, women with established osteo- able for two spontaneous vaginal deliveries
porosis are underdiagnosed and under- with no pregnancy complications. She had
treated. her menarche at age 13. She has a history of
55 The diagnosis of osteoporosis can be regular menses without a uterine bleeding
made by history of fragility fracture, disorder. She was on oral contraceptives for
based on fracture risk prediction tools, about 10 years and was well-tolerated with-
or BMD testing in the appropriate set- out developing venous thromboembolism
ting. or gallbladder problems. Her paternal
55 Women who are being evaluated and grandmother was diagnosed with breast
treated for osteoporosis should have a cancer in her 60s and a paternal aunt
thorough evaluation of relevant risk deceased in her 40s from breast cancer. She
factors or other secondary causes of has no known genetic mutations. She has a
low bone mass. Then, appropriately personal history of abnormal mammo-
monitor and follow to ensure optimal grams remarkable for fibrocystic breast but
treatment. never had breast biopsy. She had a recent
55 Fragility fracture should raise suspicion normal mammogram. She has no history
for osteoporosis and warrants optimal of hypertension, diabetes mellitus, stroke,
therapeutic intervention. or myocardial infarction. She is a non-
55 There are many effective treatment smoker. She has no personal or familial his-
options, including hormonal therapy, tory of venous thromboembolism or
which is the only therapy shown to prothrombotic mutations.
reduce vertebral, hip, and non-vertebral
fractures as a preventive treatment.
55 Nonadherence is a significant barrier to 10.1 Definition and History
effective treatments, and evidence shows of Osteoporosis
good counseling and patient education
can improve the continuation of ther- Osteoporosis is the most frequent chronic dis-
apy. ease of the skeleton, characterized by a reduc-
55 Consider referring to an osteoporosis tion in the quantity and quality of bone, and
specialist for women with unusual fea- altered microarchitecture, resulting in
tures or difficult-to-treat disease for decreased bone strength and increased risk of
appropriate evaluation. fracture [1–4]. These fractures, often occur-
ring with little or no trauma, are diagnostic of
skeletal fragility, which in conjunction with
Case Vignette classification by the bone mineral density
(BMD) criteria form the basis for this diagno-
A 48-year-old G3P2 white woman with sis in clinical practice. The burden of illness
unremarkable past medical history presents associated with fragility fractures for children,
to your clinic concern about her bone men, and women worldwide is enormous,
health. She has not had any fractures after growing, and similar or greater to other non-
turning 40. Her mother has osteoporosis communicable diseases such as cardiovascular
treated previously with ibandronate. She disease and cancer [1–8]. The remainder of
238 T. M. Cochran and H. L. Thacker
this chapter will focus primarily on this illness US [13, 14]. In Europe, approximately four
in women. million major osteoporotic fractures occur
In 1833, German-born French pathologist each year at a cost of almost €60 billion [1, 4].
and surgeon Dr. Jean Lobstein coined the All clinical fractures result in some burden
term osteoporosis following his description of of illness, can be life-threatening and costly,
pathologic diseased bones with holes in the and represent a leading cause of pain, disabil-
bone microarchitectural structure causing ity, and loss of independence [1–4, 15–18].
increased bone weakness [9]. As far back as Clinical vertebral and hip fractures are among
the 1880s, women were noted to have a greater the most devastating, whose impact on
tendency for osteoporosis than men, possibly patients’ quality of life and independence may
due to greater longevity and earlier onset [9]. persist long after the fracture [11, 15, 18]. The
At that time, the link to the postmenopausal impact of radial and other major fractures is
state was unknown. In the 1940s, American less dramatic and associated with a greater
endocrinologist Dr. Fuller Albright’s observa- recovery [19]. These fractures are sentinel
tions linked estrogen’s role in regulating bone events, multifactorial in origin and associated
metabolism for both women and men [9]. Dr. with a severalfold risk of subsequent fracture
Albright treated these women that had hypo- in the next few years [20–22]. Fractures are
calcemia and bone disease with estrogen, associated with increased mortality, though
demonstrating significant improved calcium the attributable portion may be small and var-
metabolism and bone health [9]. Osteoporosis ies between people and fracture location
existence in antiquity has been established [16–17, 23–27]. Hip and clinical vertebral
using analyses of archaeological skeletal fractures have the worst prognosis [26], with
10 remains. These remains show similar age- up to one in three individuals dying in the year
matched femoral neck bone mineral density following these events in population studies
(BMD), rates of decline in bone strength indi- [17, 23, 24]. Clinical trial populations are
ces, and differential BMD values between younger, with fewer comorbidities, and have
those with and without fractures to modern much lower rates [27].
populations [10]. Despite the immense advances in osteopo-
rosis treatment, a treatment gap exists for
patients at high risk for osteoporosis [11].
10.2 Epidemiology Osteoporosis affects postmenopausal women
more than the diagnosis of stroke, myocardial
Osteoporosis is a global pandemic, represent- infarction, or breast cancer combined [28].
ing an enormous growing public health con- An estimated one in two postmenopausal
cern worldwide. This disease affects people women will experience a fragility osteoporo-
across race, gender, and regions, in part due to sis-related fracture during their lifetime [13].
the aging of the world’s population [2, 11]. Limited opportunity is given for patients to
Affected people remain asymptomatic until a discuss the risk of fracture or bone health.
fracture happens [2, 3, 11]. Although most Even now, for postmenopausal women,
fractures occur in postmenopausal women, osteoporotic fractures are underdiagnosed
males and females of all ages may suffer a and undertreated despite multiple known and
broken bone. Today, one in three women and efficacious therapies and treatment strategies
one in six men will sustain at least one fragility for osteoporosis treatment [28]. Clinicians
fracture before they die [4]. Although the need to identify and treat patients at high risk
entire skeleton is at risk, the vertebrae repre- for fracture for effective utilization of these
sent the most frequently injured site [12]. This treatments, thus emphasizing the need for
disease results in more than two million peo- continued education for clinicians to become
ple with a fragility fracture requiring hospital- competent in identifying, managing, and
ization per year at a cost of $70 billion monitoring osteoporosis.
Osteoporosis
239 10
10.3 Pathophysiology than premenopausal women, and this produc-
tion decreased with estrogen therapy [32].
Specialized cells and a mineralized matrix of Whether through direct or indirect effects,
salts form skeletal bone. Cortical bone makes estrogen deficiency increases RANKL pro-
up about 80% of the skeleton, including long duction, and thus fuel increased bone resorp-
bones such as femur, tibia, vertebral shell, and tion. Denosumab, one of the treatments for
flat bones’ surfaces. Trabecular bone makes osteoporosis, acts at this level by acting as an
up the axial skeleton and has a distinct honey- antibody to RANKL and will be discussed
combed appearance. later in this chapter.
Skeletal bone is continually being turnover The Wnt/B catenin signaling pathway is
with bone destruction by osteoclast and for- now known to have a prominent role in regu-
mation of new bone by osteoblast. This highly lating bone formation and a possible mediator
dynamic process occurs throughout life at dif- of skeletal remodeling. Sclerostin, an
ferent skeletal sites in response to changes in osteocyte- s pecific protein, decreases bone for-
systemic signaling. Osteoblast, osteoclast, mation by blocking Wnt signaling [33]. The
and osteocytes assemble into anatomic struc- drug romosozumab acts by blocking scleros-
tures called basic multicellular units (BMUs). tin, leading to increased bone mass, and is dis-
Osteoclasts migrate to various sites in the cussed later in this chapter.
skeleton from the circulation and erode into Estrogen and androgens influence skeletal
the bone surface, creating deep cavities named development, maturation, and maintenance
“resorption pits.” This process happens over for both females and males. Androgen pro-
several weeks. Following the formation of duction for women happens primarily via
resorption pits, osteoblasts replace osteoclasts conversion in peripheral tissues with smaller
to build new bone to restore the eroded bone amounts from the ovaries and adrenal
surface over a few months steadily. Naturally, glands [32]. Skeletal differences between men
this bone remodeling process occurs synchro- and women are related to differences in estro-
nously to sustain a healthy, intact skeleton. gen and testosterone serum levels and tissue
Various factors (such as regulatory genes, response to these hormones. Testosterone is
several cytokines, and hormones including known to act directly on osteoclast progeni-
estrogen, testosterone, vitamin D, and para- tors and mature osteoclasts to decrease osteo-
thyroid) can influence the systemic signaling, clast production along with bolstering
possibly uncoupling this remodeling process osteoclast apoptosis [32]. Testosterone also
[29, 30]. It is unknown the exact sequence of stimulates osteoblast proliferation. Studies in
events caused by estrogen deficiency. However, mice with androgen receptor deletion resulted
various studies established that estrogen medi- in decreased trabecular bone mass without
ates the production of specific cytokines affecting cortical bone mass, with a milder
blocking the action of tumor necrosis factor- effect in female mice [32]. Overall, androgens
alpha (TNFa) and, to a lesser extent, interleu- increase bone formation and less bone resorp-
kin-1 beta (IL-1B). This effect leads to tion through less known mechanisms, even
increased osteoprotegerin (OPG), resulting in though it plays a minimal role compared to
less bone resorption and reduced osteoclast estrogen.
differentiation. 1,25-Hydroxyvitamin D Furthermore, peak bone mass (PBM)
potentiates the action of OPG [31]. The recep- determines bone mineral density (BMD) and
tor activator of nuclear factor kappa beta strongly correlates with fracturing risk at any
(RANK) binds to the RANK ligand. Thus, given age. Bone mass is the total bone gained
TNFa, OPG, RANK, and RANKL all influ- during childhood and adolescence minus
ence skeletal remodeling [29, 32]. Khosla and bone loss with advanced aging. Maximal bone
Monroe designed a study showing RANKL mass accrual is considered reached by age
production increased by two- to threefold in 18 in many or young adulthood, with rapid
estrogen-deficient postmenopausal women bone mass obtained during puberty [34, 35]. It
is suggested that about 94% of BMD is gained cal porosity, increased trabecular thickness,
at age 16 [30]. PBM is deemed as being higher cortical thickness, and appreciable
achieved during the second and third decades bone strength [37]. For that reason, black
of life [35]. However, timing is controversial as women have lower hip fractures after adjust-
it is gender- and site-dependent, one study ing for BMI and DXA BMD [37]. Lower
suggesting PBM occurs in the hip for women BMD was observed in Chinese and Malaysian
between ages 16 and 19 [35, 36]. Various fac- women compared to Indian women [37].
tors can influence PBM attained, including Intriguingly enough, Asian women still had
genetics and race, endocrine disorders, nutri- lower hip fracture rates compared to white
tion (calcium and vitamin D), physical activ- women. BMD variation results from genetic
ity, exposure to risk factors (e.g., smoking and differences among racial groups, local envi-
alcohol intake while rare), specific medical ronmental factors, individual body weight,
diseases, and medications [35, 36]. Conditions skeletal size, and microarchitecture [37].
affecting bone growth and mineralization
during childhood, puberty, or adolescence
will result in less PBM than expected for an 10.4 Menopause Transition
individual. Hence, a 6.4% loss of bone mass and Its Effect on Bone
during childhood has an associated twofold
fracture risk in adulthood [35]. Osteoporosis Estrogen maintains bone mass by decreasing
is delayed by 13 years with a ten percent gain bone turnover and sustaining the coupling of
in bone mass [35]. Women with low PBM pos- bone remodeling through stimulation of
sibly failed to reach peak genetic potential osteoclast apoptosis. After menopause and
10 bone mass by the mid-30s due to processes with aging, the bone remodeling process
causing bone loss at an earlier age than usu- favors more bone resorption causing more
ally seen [36]. For that reason, puberty and bone loss. This decrease in BMD happens at
adolescence are crucial periods for attaining an expeditious rate in women with a higher
optimal PBM. Any interruption of normal prevalence in older, inactive women. There is
physiology by illness or other factors may about a 2% bone loss annually, starting
result in lower PBM reached, affecting future 1–3 years preceding menopause and continu-
bone strength and risk for osteoporosis. ing for 5–10 years [38]. Nearly 20% of bone
Optimal PBM achievement is usually a loss occurs during the menopause transition,
multifactorial process. Heredity greatly influ- with an average loss of BMD of 10%–12% in
ences acquired PBM, accounting for most the spine and hip across the menopause tran-
BMD variability and the most influential sition [38, 39]. Higher rates of bone loss hap-
determinant of PBM in adulthood. Various pen in postmenopausal women who are thin
genetic polymorphisms and syndromes have weight compared to overweight. Following
been identified to play an essential role in the this period of accelerated bone loss, the rate
variance of PBM. A genome-wide association plateaus to an annual 0.5% loss in bone den-
study (GWAS) identified several genes and sity and continues even into advanced age.
variants in children and young adults. For Women aged 80 years have lost roughly 30%
example, the CPED1-WNT16-FAM3C gene of their peak bone mass consequence of this
locus is linked to wrist BMD, bone strength, remodeling imbalance [3].
cortical thickness, and forearm fracture risk in The Study of Women’s Health Across the
adults, and PBM in premenopausal women, Nation (SWAN) is one of the largest racially
and accrued bone mass and fracture risk in and ethnically diverse cohorts, following more
elderly patients in Europe [30]. Genetic vari- than 2000 women over 20 years across 5 clini-
ances can influence BMD throughout a per- cal centers in the United States and observed
son’s entire lifetime. changes in women’s bone health throughout
PBM differs among ethnic groups. menopause transition [34]. The SWAN study
Compared to white women, black women showed increased bone resorption 2 years
have the highest areal BMD, decreased corti- before the final menstrual period (FMP),
Osteoporosis
241 10
peaking at about 1.5 years after the FMP, fol- increased demands from the fetus and later
lowed by a plateau of bone loss [34]. from lactation. The mainstay treatment is cal-
Simultaneously, there is an acceleration of cium and vitamin D supplementation. The
bone loss occurring 3 years before FMP [34]. safety of certain anti-osteoporotic drugs dur-
A gradual decline in bone loss occurs around 2 ing pregnancy is not fully known.
years following FMP [34]. During the 3 years Bisphosphonates can impact fetal bone for-
of rapid bone loss occurring in the early part mation based on a few studies observing
of the menopause transition, the BMD decline mothers receiving various bisphosphonates
rate occurred in white women at an estimated for secondary osteoporosis before or through-
annual rate of 2.5% in the lumbar spine and out pregnancy without witnessing adverse
1.8% in the femoral neck [34]. Chinese women effects [41]. Bisphosphonate use in pregnancy
and Japanese women had a substantially has to be balanced against risks. Raloxifene is
increased bone loss at the femoral neck at not recommended in premenopausal women.
about an annual rate of 2.2% and 2.1%, Denosumab can cause fetal harm, so it is
respectively [34]. After adjusting for body important to avoid use in pregnancy [41].
mass index (BMI), black women had a small- Teriparatide cannot be used during pregnancy
scale BMD loss at both spine (2.2% per year) as it can affect open epiphyseal bone forma-
and femoral neck (1.4% per year) [34]. As tion [41]. Primary hyperparathyroidism during
expected, changes in estrogen and testosterone pregnancy is managed conservatively by
serum levels drive these changes in bone mass. observing unless significantly elevated cal-
In the SWAN study, every doubling of FSH cium. Then, surgery is preferably done in the
during menopause transition equated to an second trimester [41].
additional 0.3% decline in BMD at both femo- Lactation may cause temporary bone loss
ral neck and lumbar spine [34]. Women with and elevated bone turnover markers, especially
vasomotor symptoms (such as hot flashes and during the exclusive breastfeeding stage. It
night sweats) had lower BMD correlating with occurs within the first few weeks of lactation
a steeper decline in estrogen. with longitudinal studies demonstrating
decrease in the femoral neck and lumbar spine
bone mass of two to six percent within the first
10.5 Premenopausal months of lactations [43, 44]. It is suggested
and Bone Health that the elevation of prolactin prolonged sup-
pression of the hypothalamic-pituitary-ovar-
Pregnancy may cause three to five percent loss ian axis results in amenorrhea due to a
of bone mass [40]. Pregnancy-induced osteo- generated hypoestrogenic state [43]. The lactat-
porosis happens very infrequently, causing ing mammary glands also secrete PTHrP,
substantial trabecular bone loss and fragility decreasing the efficiency of intestinal calcium
fractures, particularly of the spine. It usually absorption.
spares the cortical bone. Advanced maternal
age heightens the risk for osteoporosis with
pregnancy. Rare observational studies 10.5.1 Hypothalamic Amenorrhea
suggested physiological changes related to
and Bone Health
pregnancy alter serum calcium and phosphate
levels, leading to increased calcium metabo- Hypothalamic amenorrhea impacts bone
lism [41, 42]. The placenta, lactating mam- health due to estrogen deficiency, causing a
mary glands, and fetal parathyroid gland cascade of hormonal signaling resulting in an
produce parathyroid hormone-related protein upsurge in bone resorption. Hypothalamic
(PTHrP), which mobilizes calcium from the amenorrhea frequently causes amenorrhea in
skeleton through resorption activity by osteo- young women besides pregnancy. Multiple
clasts [41, 42]. This mechanism allows the factors can contribute to hypothalamic amen-
body to maintain calcium levels despite orrhea, such as ovarian dysfunction, pituitary
disorders, hypothalamic disorders, polycystic nents: amenorrhea, low energy availability, and
ovarian syndrome, and endocrine disorders osteoporosis. Women participants of esthetic
[45]. Iatrogenic causes stem from a created and weight-dependent sports (e.g., ice skating,
hypoestrogenic state seen with depot medroxy- weight lifting, gymnastics, and endurance run-
progesterone acetate (DMPA) and ning) were thought to be the most often
gonadotropin- releasing hormone (GnRH) affected [48]. Over time, this Triad became
agonist. Exogenous use of androgens can also more of a spectrum as athletes do not always
lead to hypothalamic amenorrhea. The next present with all three clinical features.
following sections will delve into these factors Excessive exercise generates an energy def-
mentioned earlier. icit limiting fuel availability. Then, energy is
Hormonal contraception that suppresses shunted from bodily growth and reproduction
normal ovulatory cycles potentially has a neg- to metabolic processes for survival and
ative bone effect as it creates a hypoestrogenic homeostasis for energy conservation [48, 49].
state, a clinical risk factor for bone loss or Consequently, there is a decrease in the meta-
osteoporotic fracture. A recent Cochrane bolic rate of total triiodothyronine (TT3),
review highlighted certain hormonal contra- insulin-like growth factor 1 (IGF-1), leptin,
ceptives which posed a higher risk of nega- and insulin [49]. This process leads to a
tively impacting bone health, particularly hypoestrogenic state inducing amenorrhea.
depot medroxyprogesterone acetate (DMPA) As discussed earlier, estrogen deficiency brings
and etonogestrel implant [46]. Its effect about more bone resorption due to the indi-
appears reversibly primarily with discontinua- rect effect on hormonal signaling and influ-
tion. A retrospective cohort study found encing bone remodeling.
10 higher fracture risk associated with recent use Eating disorders are suggested as another
of DMPA for less than 2 years or exceeding 2 plausible explanation for low energy availabil-
years of cumulative use [47]. There was no ity [48, 49]. Athletes have a higher prevalence
increased fracture risk in women with past of eating disorders than the general popula-
DMPA usage [47]. There is a lower fracture tion, especially sports preferring lean body
risk using combined oral contraceptive pills image such as figure skating and gymnastics
[47]. If choosing a hormonal contraceptive, or ballerina dancers [48]. The eating disorder
select an option that will allow for some ovu- behaviors may not limit to just restrictive or
latory activity if possible. For combined oral purging eating patterns. It is imperative to
contraceptive pills, better to choose an estro- identify at-risk individuals for eating disorder
gen dose between 30 and 35 mcg as it is less behaviors as the outcome results in decreased
likely to result in a hypoestrogenic state [46, energy availability affecting the hypothalamic-
47]. There is a boxed warning on DMPA that, pituitary-gonadal axis and ultimately bone
if administered for over 2 years, a baseline health [48].
evaluation of BMD should be obtained. If the Experimental studies conducted by Dr.
BMD test is low for age-matched peers, then a Loucks, Dr. Bullen, and Dr. Williams
secondary evaluation should be done with showed evidence of menstrual disruption
add-back estradiol, and repeat BMD in caused by changes in energy availability. The
2 years if the woman continues on that mode random controlled trials of Bullen et al. and
of contraception [47]. Williams et al. observed a mild to a modest
reduction in energy availability equated to
markedly suppression of metabolic hor-
10.5.2 emale Athlete Triad
F mones, suppressive luteinizing hormone
and Bone Health (LH) pulse frequency, and the onset of
abnormal menstrual cycles [49]. Early stud-
The female athlete triad (Triad) was first coined ies performed by Dr. Loucks showed signifi-
by the American College of Sports Medicine cant hormonal dysfunction if energy
in 1992 [48]. It is a disorder with three compo- availability was less than 30 kcal/kg/fat-free
Osteoporosis
243 10
mass (FFM), with minimal dysfunction seen
.. Table 10.1 Summary of clinical risk factors
at 45 kcal/kg/FFM [48, 49]. The minimum for osteoporosis
energy availability needed is 30 kcal/kg/
FFM, with 45 kcal/kg/FFM being ideal [48]. Non-modifiable Modifiable risks
In fact, it varies per individual based on their risks
energy needs and availability.
Age Tobacco use
With the considerable rise in female par-
ticipation in sports, clinicians must be aware Gender Excessive alcohol use
of the Triad due to short-term and long-term (>2 drinks per day for women)
health consequences. One associated short- Race/Ethnicity Caffeine intake
term consequence is stress-related fractures (>3 cups coffee per day)
due to weakening bone [48, 50, 51]. A long- Family history Glucocorticoid use (>5 mg
term aftereffect is the higher risk for osteopo- of osteo prednisone daily or equivalent
rosis due to decreased bone mass related to porosis ≥ 3 months)
delayed menarche with recommended hor- Lower peak Vitamin D deficiency
monal therapy to mitigate this risk [51, 52]. bone mass
The goal is to have an athlete with optimal
Lower body Low body weight
bone health, optimal energy availability, and mass index (BMI <21 kg/m2)
regular menstrual cycles with menarche at an
History of Inadequate calcium intake
appropriate time [48].
prior fracture
Hypogonadism
10.6 Classification of Osteoporosis Hypoestrogenism
10.6.1 Primary Osteoporosis Refs. [11, 33, 34]
It is classically known as a condition affecting

mainly the aging population. As discussed in compared to those in their age group, mean-
early sections, the underlying mechanism is ing age-matched Z-score − 1.5 or less and cer-
multifactorial and includes poor nutrition tainly if Z-score of −2 or less and additional
and vitamin D deficiency, diminished peak risk factors [40, 54]. Premenopausal women
bone mass, accelerated bone loss during the with osteoporosis need to have a workup for
initial menopause transition, and hypogo- secondary disease, and earlier sections dis-
nadal states. Clinical risk factors for primary cussed several common etiologies. Those indi-
osteoporosis are listed in . Table 10.1. viduals with a failed response to optimal
therapy for osteoporosis should raise suspi-
cions for secondary cause and warrant a cur-
10.6.2 Secondary Osteoporosis sory medical workup.
Secondary osteoporosis should also be
Secondary osteoporosis is defined by bone considered whenever there is any clinical sus-
mass loss explainable by an identifiable cause. picion of a disorder known to affect bone or
Approximately 5–48% of evaluated persons calcium metabolism. There are well-
with osteoporosis have identified etiology, established medications and conditions
with an estimated 17–30% prevalence in known to affect bone mass and possibly bone
women [53, 54]. Certain conditions should quality, thus increasing fracture risk. A care-
prompt investigation for secondary causes of ful history, including a review of past and
loss BMD. Based on the International Society present medications, is essential given the
for Clinical Densitometry (ISCD) recommen- extensive list of diseases known to cause a low
dation, reversible causes need to be searched bone mass or bone loss (see . Tables 10.2
for in any person with a severe bone disease and 10.3).
.. Table 10.2 Medications that cause bone lossa
Anticonvulsants Carbamazepine (Tegretol)

Phenytoin (Dilantin)
Anticoagulants Unfractionated heparin

LMWHb
Antiretroviral Tenofovir
Zidovudine
Antacids containing aluminum Maalox, Mylanta, and Rolaids
Glucose-lowering agents such Rosiglitazone and Pioglitazone
as thiazolidinediones
Chemotherapy drugs Aromatase inhibitors such as exemestane (Aromasin),
anastrozole (Arimidex), and letrozole (Femara)
Immunosuppressive drugs Calcineurin inhibitors such as tacrolimus, cyclosporine,
and pimecrolimus
Loop diuretics Furosemide
Torsemide
Proton pump inhibitors (PPI) Esomeprazole (Nexium)
Pantoprazole (Protonix)
Selective serotonin reuptake inhibitors (SSRI) Citalopram (Celexa)
10 Fluoxetine (Prozac)
Sertraline (Zoloft)
Progestin-containing contraceptives Medroxyprogesterone acetate (Depo-Provera)
Gonadotrophin-releasing hormone agonist Leuprorelin (Lupron)
Chronic Steroids (>5 mg prednisone daily or Cortisone, prednisone, and methylprednisolone
equivalent ≥ 3 months)
Thyroid supplementation Levothyroxine (Synthroid)
Pain medications Opioids (oxycodone and hydrocodone)
Nonsteroidal anti-inflammatory (NSAIDs)
Refs. [51, 52]

aNot an exhaustive list of medications
bLow molecular weight heparin (LMWH)
Obtain at minimal a complete comprehen- testing should be based upon the clinical
sive metabolic panel, total blood count, impression.
thyroid-stimulating hormone (TSH), 24-hour
calcium urine collection for calcium excre-
tion, and a 25-hydroxyvitamin D level in all
patients (54–55). Whether radiographic imag- 10.7 Clinical Symptoms
ing or other laboratory studies, such as serum of Osteoporosis
and urine protein electrophoresis, parathy-
roid hormone, or cortisol levels, should be Individuals with osteoporosis routinely pres-
undertaken is a decision that needs to be ent first with fracture as it is most often a
taken by the individual physician, as ancillary symptom-free and painless condition. Over
Osteoporosis
245 10
.. Table 10.3 Common causes of secondary osteoporosis
Laboratory evaluation
Drug- For example, aromatase Medication reconciliation – revisit . Table 10.1

induced inhibitors, anticonvulsants,
and chronic steroids
Nutritional Anorexia Comprehensive metabolic panel
disorders Malnutrition 25-Hydroxyvitamin D serum level
24-hour calcium urine
Genetic Turner’s syndrome Appropriate genetic testing
Gaucher’s disease
Cystic fibrosis
Muscular dystrophy
Marfan syndrome
Osteogenesis imperfecta
Ehlers-Danlos syndrome
Endocrine/ Hyperparathyroidism Parathyroid hormone, phosphorus serum level,
Hormonal Hypophosphatemia 25-hydroxyvitamin D serum level, FSHa, estradiol level,
Vitamin D deficiency prolactin, anti-Müllerian hormone, 24-hour urinary free
Hypothalamic dysfunctions cortisol, dexamethasone suppression test, Hgb A1c,
Hypercortisolism (Cushing’s syndrome) fasting glucose, glucose intolerance test, 24-hour calcium
Hypogonadism urine, TSH, free T4, total T3
Type 1 and 2 Diabetes Mellitus
Pregnancy
Lactation
Amenorrhea
Hypercalciuria
Hypothyroidism
Gastroin- Malabsorption Endomysial IgA antibody, anti-tissue transglutaminase,
testinal Inflammatory bowel disease anti-deamidated gliadin peptide IgG antibodies, serum
(Crohn’s disease and Ulcerative total iron binding capacity, transferrin, serum ferritin
colitis) level, comprehensive metabolic panel, 25-hydroxyvitamin
Celiac disease D serum level, 24-hour calcium urine, sweat chloride
testing or genetic testing
Hemato- Hemochromatosis Serum total iron binding capacity, transferrin, serum ferritin
logic Thalassemia major level, comprehensive metabolic panel, hemoglobin
disorders Multiple myeloma electrophoresis, protein electrophoresis, serum electrophoresis
Inflamma- SLEb Antinuclear antibodies, anti-double-stranded DNA,
tory Rheumatoid arthritis anti-Smith antigens, anti-cyclic citrullinated antibodies,
disorders Chronic obstructive lung disease rheumatoid factor
Connective Marfan syndrome
Tissue Osteoporosis imperfecta
disorders Ehlers-Danlos Syndrome
Organ
transplant
Renal disease Chronic renal failure Renal function test
(continued)
Laboratory evaluation
Immobility Multiple sclerosis

Muscular dystrophy
Bedbound individuals
Stroke
Quadriplegia
Space Flight
Refs. [51, 52]

aFollicle-stimulating hormone (FSH)
bSystemic lupus erythematosus (SLE)
two-thirds of vertebral fractures are clinically fracture, and family history of osteoporosis,
silent and incidentally detected on imaging, and inspect for medications predisposing for
not once capturing medical attention [55, 56]. bone loss. Obtain an accurate weight and
Often sites for fractures involve the spine, hip, height to calculate BMI and analyze for dras-
distal forearm, or proximal humerus. A clini- tic weight or height loss.
cian may palpate a collapsed vertebrae on The gold standard for diagnosing osteopo-
physical exam, discern a stooped posture rosis is the standard measuring of BMD with
(kyphosis or dowager’s hump), notice a bluish a central dual-energy X-ray absorptiometry
10 tint to sclerae (hallmark for osteogenesis (DXA) of the spine and hip as noninvasive
imperfecta), the clinical manifestation of and quickly performed. The forearm is only
adrenal insufficiency (e.g., abdomen with useable when the spine or hip is unmeasurable
striae, buffalo hump of posterior neck, moon or BMD data uninterpretable. DXA calcu-
facies), or conclude an unremarkable physical lates T- and Z-scores, expressions of BMD in
exam. Women with osteoporosis frequently standard deviations to a distributed reference
lose a significant amount of height, deemed as population compared to a population
height loss greater than 4 cm or more than 1.5 matched by age, gender, and race. T-score
inches. compares BMD to young, healthy Caucasian
Clinicians should ask about back pain, women at peak bone mass. Z-score compares
height loss, dietary calcium intake, dental persons to age, gender, and racially matched
health, age of menarche and age of meno- control populations. Specific BMD and
pause, history of eating disorder, menstrual T-score criteria by the World Health
cycle history, smoking history, alcohol con- Organization (WHO) for diagnosis of osteo-
sumption, and caffeine intake and screen for penia and osteoporosis are outlined in
medications. It is also practical to screen for . Table 10.4 [57, 58]. DXA studies have
fracture risk such as poor vision, history of shown a substantial correlation to biome-
falls, or complete fall risk assessment. chanical bone strength through finite element
analysis and a clinical predictor of fracture
risk, all with low- radiation exposure [59].
10.8 Diagnostic Criteria DXA and clinical risk tools used conjointly
for Osteoporosis can remarkably identify persons at high frac-
ture risk. Nevertheless, DXA is limited in
A thorough history and physical exam are assessing bone microarchitecture. Although
invaluable in diagnosing osteoporosis. Assess not commonly obtained in clinical practice,
for risk factors for bone loss (see . Table 10.1), other modalities are obtainable to evaluate
including female gender, small body frame or bone quality, such as high-resolution quanti-
low body mass index (BMI), prior fragility tative computed tomography (QCT), high-
Osteoporosis
247 10
resolution magnetic resonance imaging (ISCD) and the American Association of
(MRI), or double tetracycline-labeled transil- Clinical Endocrinology (AACE)) recommend
iac bone biopsy histomorphometry [59–61]. BMD evaluation for the following individuals
Trabecular bone score (TBS) and vertebral [64–66]:
fracture assessment (VFA) are possible tools 55 All women 65 and older
used conjunctly with DXA to provide data on 55 Younger postmenopausal women with
bone quality. TBS is an analytical tool calcu- risk factors for osteoporosis (e.g., smoker,
lator that uses lumbar spine images from fragility fracture, family history of osteo-
DXA to estimate bone microarchitecture, porosis or hip fracture, BMI 21 or <)
expressed as a score quantifying variation 55 All adults with a fragility fracture
among pixels and not an exact dimensional 55 All individuals with a predisposition to
measurement [59, 62]. VFA utilizes DXA to bone loss, whether due to a disease, condi-
detect vertebral fractures owning to persons tion, or taking medication
not meeting criteria for osteoporosis based on 55 To monitor patients on bone therapy
BMD alone [59, 63]. This additional data 55 Men aged 70 years of age or older
from TBS and VFA can influence an individu-
al’s decision on starting and adhering to treat- (Picture of normal lumbar spine near here –
ment. . Fig. 10.1 Normal lumbar spine on DXA)
Various organizations (such as the
International Society for Clinical Densitometry
.. Table 10.4 WHO BMD and T-score criteria

for diagnosis of osteopenia and osteoporosis
BMD measurement T-score
Normal BMD within 1.0 SDa +2.5 to −1.0

of the mean value
for young, healthy
women (reference
population)
Osteo- BMD between 1.0 −1.1 to −2.4
penia and 2.5 SD below
the mean value for
young, healthy
women (reference
population)
Osteo- BMD equal to 2.5 Less than or
porosis SD or below the equal to −2.5
mean value for
young, healthy
women (reference
population)
Severe BMD equal to 2.5 Less than or
Osteo- SD or below the equal to −2.5
porosis mean value for and fragility
young, healthy fracture (s)
women (reference
population)
Refs. [55, 56]

aStandard deviation (SD)
.. Fig. 10.1 Normal lumbar spine on dual-energy
X-ray absorptiometry (DXA)
Z-scores instead of T-scores should deter- mal BMD T-scores [59]. These fracture risk
mine a diagnosis for osteoporosis for children tools meld the clinical risk factors and femo-
and premenopausal women [64–67]. ral neck BMD. FRAX takes into account the
Peripheral BMD is valuable for fracture risk following clinical parameters: age, sex, weight,
assessment only and should not be used to height, previous fracture history, parental hip
diagnosis osteoporosis. Abnormal peripheral fracture, current smoking status, glucocorti-
BMD prompts further evaluation with central coid use, presence of rheumatoid arthritis,
DXA of the spine and hip, i.e., the gold stan- secondary causes of osteoporosis, alcohol
dard for osteoporosis screening. consumption, and femoral neck BMD (which
The presence of fragility fracture (i.e., excluded in under-resourced settings) [59].
fractures occurring from a fall at standing FRAX tool calculates absolute 10-year frac-
height or minimal trauma) diagnoses osteo- ture risk. Persons need treatment if they have
porosis regardless of BMD. These fractures a 10-year risk of hip fracture of 3% or greater
should raise suspicion for pathology and not or if the 10-year risk of any major osteopo-
dismissed consequence of fall or expected rotic fracture is 20% or more [59]. The tool is
trauma (see . Fig. 10.2). A T-score of −2.5 freely available to quickly calculate risk on the
or less in the lumbar spine, femoral neck, total FRAX website [7 http://www.shef.ac.uk/
hip, or 1/3 distal radius even if no known frac- FRAX].
ture history also diagnoses osteoporosis based FRAX tool should be used only to guide
on criteria from the WHO and AACE [57, 58, to clinical decision-making on needed treat-
65]. Individuals with T-score between −1.0 ment as there are several limits to its use [59].
and − 2.5 with increased fracture risk using FRAX calculation only accounts for femoral
10 the FRAX tool may equally be diagnosed neck BMD for both individual and family
with osteoporosis [58, 59, 65]. fracture history, as follows would underesti-
Fracture risk calculator tools, such as the mate risk for patients with low BMD of the
widely accepted Fracture Risk Assessment lumbar spine but normal hip BMD as com-
Tool (FRAX), were created due to persons monly seen in the early menopause transition.
who developed a fracture despite having nor- Further, only allowing binary yes-no responses
.. Fig. 10.2 Vertebral fractures depicted on various imaging modalities

Osteoporosis
249 10
for smoking, alcohol, and steroid use also rich in calcium is essential, starting at a young
would lessen the estimated risk for which age for bone health. Premenopausal women
dose-related and chronicity have an immense should aim for 1000 mg of dietary calcium
impact on bone health [59]. Omission of TBS, daily and 1200 mg daily for postmenopausal
hip axis length, and fall history additionally women [65, 68]. Supplemental calcium is only
limit the FRAX tool [59]. The Garvan frac- suggested for those unable to obtain adequate
ture prediction tool includes various fractures nutritional calcium given the risk of athero-
from age 50 and fall history within the previ- sclerosis from blood vessels’ microcalcifica-
ous year [59]. tions [69, 70]. It is also imperative to maintain
a normalized serum vitamin D level. Many
adults are vitamin D deficit in part to working
inside more and less often outside than in the
10.9 Osteoporosis Treatment
past. Risk factors for vitamin D deficiency
include [68]:
10.9.1 Nonpharmacologic 55 Increased melanin skin tone acting as an
Modalities for Osteoporosis ultraviolet sunlight blocker which some-
Prevention what decreases the conversion of vitamin
D to an active form in the skin
A suggested practice to prevent osteoporosis 55 Conditions that cause malabsorption
is for clinicians to screen for risk factors pre- 55 Specific medications
disposing to bone loss. Treating clinicians 55 Lack of sun exposure (those homebound,
should also advocate for a baseline evaluation chronically ill, or living in areas with less
with BMD and bone turnover markers for sunlight)
women a few years within reach of meno- 55 Obesity
pause, considering that rapid bone loss hap-
pens prior, during, and immediately following There is no recommended guideline for ade-
menopause [34, 39]. Timely administer risk- quate daily vitamin D supplementation. A suf-
reducing treatments for women with second- ficient level of vitamin D would be >20 ng/mL
ary medical conditions that increase the risk per the ISCD. A Korean study found that a
for rapid or substantial bone loss, such as daily dose of 1000–2000 international units of
hyperparathyroidism, hyperthyroidism, vita- vitamin D is needed to maintain a serum
min D deficiency, and hypercalciuria. level > 50 ng/mL [71]. Further, vitamin
Parathyroidectomy done to treat hyperpara- D3 is better absorbed compared to ergo-
thyroidism restores normal calcium metabo- cholecalciferol, vitamin D2. The best recom-
lism and possibly improves bone mass. mendation is a daily vitamin D3 supplementation
Hydrochlorothiazide can be initiated to to maintain serum level > 30 ng/mL, which
inhibit renal calcium excretion and maintain would be for the majority about 2000 interna-
bone mass for women with idiopathic hyper- tional units daily of vitamin D3.
calciuria. Exercise plays an influential role in the
Clinicians should implement strategies to bone remodeling process by stimulating osteo-
help preserve bone health and delay the onset blast production, pivoting toward bone for-
of osteoporosis. These preventative steps mation. Progressive resistance training (weight
would need early initiation before menopause lifting or resistance bands) is an extensively
transition to maintain bone mass effectively. researched exercise technique in preserving
Clinicians can alert women about fall risk and BMD. One Australian prospective study
safe footwear. Adopting a healthy lifestyle is showed improved BMD in the femoral neck
preventive for most chronic medical condi- (2.8%) and lumbar spine (3.3%) [72]. Other
tions, especially for osteoporosis. Smoking studies have shown similar results with
and excessive alcohol (two alcoholic drinks or increased BMD with progressive resistance
more daily for women) negatively impact bone training [72]. Weight-bearing exercise (activity
health. Eating a healthy, well-balanced diet moving against gravity) is the physical activity
also known to impact bone health and reduce 55 Have a T-score of −1.0 and − 2.5 and
fall risk. Such exercises include walking, run- FRAX 10-year probability for major
ning, jogging, dancing, golf, tennis, high- osteoporotic fracture is ≥20%, or the
impact aerobics, and stairs. A study found a 10-year probability of hip fracture is ≥3%
positive association with walking steps daily in the United States or above the country-
and improved hip BMD, with a 25% increase specific threshold in other countries or
in walking steps associated with a 1.4% regions.
increase in hip BMD [73]. Evidential data 55 Failed therapy on approved osteoporosis
shows that high-impact exercise (exercise therapy.
bands, weight lifting, tai chi, yoga, or Pilates) 55 Have a fracture while on drugs known to
positively impacts BMD without increasing cause bone loss, such as chronic glucocor-
musculoskeletal injury risk [74]. If warranted, ticoids or aromatase inhibitors.
physical therapy and balance training are 55 Have a high risk for falls or history of inju-
promising modalities for bone health and fall rious falls, and a very high FRAX 10-year
risk prevention. probability for major osteoporotic frac-
ture is ≥30%, or the 10-year probability of
hip fracture is ≥4.5% in the United States
10.9.2 Pharmacologic Therapies or above the country-specific threshold in
other countries or regions.
for Treatment
and Prevention
of Osteoporosis 10.9.3 Antiresorptive Therapies
10
Pharmacologic therapies are usually neces- Antiresorptive therapies increase BMD by
sary for a patient at high risk for fracture. A reducing bone loss via decreased osteoclast
crucial goal for treating clinicians is to iden- activity. There is no new bone formation as
tify persons with established osteoporosis for antiresorptives do not affect osteoblast activ-
appropriate treatment to improve bone health ity. Agents labeled as antiresorptive are estro-
and, more importantly, prevent future osteo- gen therapy, bisphosphonates, and denosumab.
porotic fractures. Individuals with osteoporo-
sis need periodic evaluation with initiation of Estrogen Therapy Estrogen reduces osteoclast
optimal treatment and adjustments as war- activity and promotes osteoclast apoptosis. It
ranted. Choosing the ideal osteoporotic treat- also functions to suppress TNF-alpha, which
ment calls for a thorough assessment of blocks the action of RANKL activity, further
modifiable and non-modifiable risk factors restricting osteoclast activity. The
(see . Table 10.1) and risk stratifying for Postmenopausal Estrogen/Progestin Interven
available osteoporotic therapies and then fol- tion trial showed lumbar spine BMD increased
lowed by ensuring that the treatment is afford- by 3.5–5.0% and total hip by 1.7% after 3 years
able and convenient for patients’ adherence. of HT [75]. Furthermore, spine and hip bone
Several proven effective pharmacologic thera- density substantially improved to 4.5% and
pies are available and grouped based on being 3.7%, respectively, with standard daily EPT
antiresorptive or osteoanabolic agents, listed doses (0.625 mg conjugated estrogen (CE) plus
in . Table 10.5. 2.5 mg MPA) compared to placebo [76]. Daily
Pharmacologic treatment is highly advised doses of oral 17-β estradiol at 0.25 mg, 0.5 mg,
for the following patients [65]: and 1.0 mg boost the spine density by 0.4%,
55 Have osteopenia and a history of fragility 2.3%, and 2.7% after 2 years of use [77].
fracture. Combining therapy with norethindrone acetate
55 Have a T-score of −2.5 or less in the spine, 0.5 mg resulted in more sizeable gains in bone
femoral neck, total hip, or 1/3 radius. density. In the Women’s Health Initiative (WHI)
55 Have a very low T-score (for instance, 5-year trial, a 5.2-year follow-up of 16,608
T-score < −3.0).
Osteoporosis
251 10
.. Table 10.5 FDA-approved drugs for preventing and treating osteoporosis
Generic Brand Dosing Dosing Postmenopausal Glucocorticoid- Osteoporosis

Name Name Method Interval Osteoporosis Induced In Men
Osteoporosis
Preven- Treat- Preven- Treat- Treatment
tion ment tion ment
Estro- Many Various Various Yes No No No No

gen (oral,
transder-
mal)
Alen- Fosa- Pill, liquid Daily, Yes Yes No Yes Yes
dronate max Weekly
Iban- Boniva Pill Monthly Yes Yes No No No
dronate
Iban- Boniva Intrave- 3-Monthly No Yes No No No
dronate nous
injection
Rise- Actonel Pill Daily, Yes Yes Yes Yes Yes
dronate Atelvia Weekly,
Monthly
Zole- Raclast Intrave- Yearly (or Yes Yes Yes Yes Yes
dronate nous every Other
injectton year-
Prevention)
Raloxi- Evista Pill Daily Yes Yes No No No
fene
Denu- Prolia Subcuta- Every 6 No Yes No Yes Yes
somab neous month by
injection HCP
Teripa- Forteo Subcuta- Daily for up No Yes No Yes Yes
ratide (ana- neous to 2 years
bolic) injection (self)
women aged 50–79 years with intact uterus ran- Further, clinical evidence shows that the
domized to EPT showed a decreased combined estrogen effect on bones is dose-dependent
risk of hip fractures, vertebral fractures, and [11, 76]. Younger women may need higher
total fractures by 34% compared to placebo in doses of MHT to protect against bone loss in
the low-fracture risk population [11, 76, 78]. younger women, especially those aged 40 or
There was 50% risk reduction of hip fractures younger [80]. Rapid loss of BMD can happen
(hazard ratio [HR], 0.7; unadjusted 95% confi- with the discontinuation of MHT, with loss of
dence interval [CI], 0.4–1.0), 30% for vertebral 3–6% occurring within the first year after ces-
fractures (HR, 0.7; unadjusted 95% CI, 0.4– sation and bone turnover markers return to
1.0), and 20% for other osteoporotic fractures pretreatment values within a few months
(HR, 0.8; 95% CI, 0.7–0.9). MHT use for at [81–83]. BMD gains fall to levels observed in
least 5–7 years markedly reduced hip fractures, women who never took hormones within 2
vertebral fractures, and non-vertebral [78, 79]. years of cessation of MHT [84]. Moreover, in
the WHI trial, fracture risk returned to levels ment of postmenopausal osteoporosis and
seen in women who had received placebo and reduced invasive estrogen receptor (ER)-
without increased fracture risk [85]. One large positive breast cancer in those at high risk. This
study found no increase in fracture rates agent has an agonistic effect on the bone while
among postmenopausal women who discon- acting antagonistically on the uterus and breast
tinued MHT, although the lack of BMD and tissue. Several studies have shown that vertebral
BTM data limits the study findings [86]. fracture risk decreases by 30–50% in postmeno-
Hormonal therapy is not an approved pausal women with low BMD and known
treatment for postmenopausal osteoporosis osteoporosis and with or without a history of
as no studies have analyzed its effects on frac- prior vertebral fracture due to averting post-
ture risk in women with osteoporosis. There menopausal bone loss [68, 85]. However, it has
is no known fracture data on lower doses of not been shown to effectively reduce the risk for
ET or EPT than studied in the WHI trial. hip or non-vertebral fractures in clinical trial
Menopausal hormone therapy (MHT) bene- endpoints [68, 85]. It can increase hot flashes in
fits, including preservation of bone health, recently menopausal women and cause muscle
are achievable if initiated in women under 65. pain or cramps, including arms and legs. Risk
This MHT effect is termed the timing hypoth- for VTE is about 1–1.6%, and warrants risk
esis discussed in the chapter on menopause stratifying before initiation of ERAAs
[11]. Historically, hormonal therapy was the (. Table 10.6).
first line for preventing and treating post- A third-generation ERAA named baze-
menopausal osteoporosis [35]. In 2002, the doxifene is favorable as it increased BMD,
Women’s Health Initiative (WHI) publication lowered BTMs, and improved lipids [11]. It
10 led to trickle-down effects, resulting in less has also been effective in decreasing the risk
hormonal therapy treatment due to an over- for non-vertebral fractures for certain women
inflated concern regarding breast cancer and at high risk for fracture. It has the same
cardiovascular risks that were not age and adverse effect profile as raloxifene. In 2013,
time stratified. Data showed estrogen-alone the FDA approved using Duavee (20 mg of
therapy in women with a hysterectomy bazedoxifene/conjugated esterified estrogen
reduced breast cancer risk. Risks with MHT 0.45 mg), forming a tissue-selective estrogen
are discussed in the menopause chapter in therapy for vasomotor symptoms and man-
full detail. Mitigation of VTE risk, cardio- agement of postmenopausal bone loss. It is no
vascular risk, and cerebrovascular risk is pos- longer available on the current 2020–2021
sible using a transdermal route of estrogen. market due to problems initially with packag-
For instance, ultra-low-dose transdermal ing without a known exact date for returning
estradiol (Menostar) can be used to prevent to the market.
osteoporosis in postmenopausal women aged Bisphosphonates are a commonly used
60–80 who have osteopenia without other treatment for osteoporosis. It comprises ana-
menopausal symptoms, even though there is logs of pyrophosphates with a strong affinity
no fracture data to provide. Women with a for hydroxyapatite, inhibiting osteoclast abil-
uterus would only need a biannual dose of ity to bind to the bone. Thus, there is less
progestin due to the relatively low estrogen activity from osteoclast, impeding bone
level. resorption. Their strength is influenced by the
length and structure of side chains, which
Estrogen Receptor Agonist/Antagonists (ERAAs), impacts the chemical affinity for bone. This
Previously Known as Selective Estrogen Receptor potency differs among the various bisphos-
Modulators (SERMs) This drug class is a non- phonates. About 1% of oral bisphosphonates
steroidal compound binding to estrogen recep- are absorbed following ingestion and further
tors, which causes estrogen-like actions impaired by calcium, iron, caffeine, and acidic
(agonist) in specific tissues with neutral or foods [68]. Oral bisphosphonates need to be
antagonistic outcomes in other tissues. taken on an empty stomach (at least 45 min-
Raloxifene (Evista) is an FDA-approved treat- utes before food consumption) for optimal
Osteoporosis
253 10
.. Table 10.6 Cost-effectiveness of FDA-approved osteoporosis treatments
Agent Hip Verte- Non- Common adverse effects Benefits Cost

fracture bral verte-
risk fracture bral risk
reduc- risk reduc-
tion reduction
tion
Antiresorptive agents
Hormonal therapy
Estro- + + + Increased risk of VTE, MI, and Improves $-$$
gens CVA VMS and
Increased risk of estrogen- GMS
dependent cancers such as If have intact
breast cancer risk after 5 years uterus, must
in EPT combined
with progesto-
gen
Estrogen receptor agonist/antagonist (ERAA) therapy
Raloxi- NA + NA VTE, increased hot flashes, Reduce risk $
fene muscle pain, or cramps for invasive Zero
breast cancer cause if
for
preven-
tion
Baze- NA + + $$
doxifene
Bisphosphonates
Alendro- + + + Dysphagia, heartburn, Sustained $
nate esophagitis, hypocalcemia, rare effects due to
risk of atypical fracture long half-life
Ibandro- NA + NA $
Associated with kidney injury
nate
Risedro- + + + $
nate
Zole- + + NA Flu-like symptoms (fever, chills, $$$
dronic myalgia, joint pain, nausea,
acid fatigued, pain and irritation at
injection site
Rank Ligand Inhibitor
Deno- + + + Rare risk of atypical fracture $$$
sumab and jaw osteonecrosis,
hypocalcemia, hypersensitivity
skin rash, and rare risk of
infections
Anabolic agents
PTH analogs
(continued)
Agent Hip Verte- Non- Common adverse effects Benefits Cost

fracture bral verte-
risk fracture bral risk
reduc- risk reduc-
tion reduction
tion
Teripa- NA + + Hypotension (associated with $$$

ratide dizziness, palpitations,
tachycardia, or nausea),
Abalo- NA + + $$$
hypercalcemia, headaches,
paratide
theoretical risk for osteosar-
coma (recently removed by the
FDA from teriparatide
labeling)
Anti-sclerostin antibody
Romoso- NA + NA Theoretical risk for CVA or MI $$$
zumab (avoid for recent CVA or MI
within 12 months)
Hypersensitivity skin rash
Pain at injection site
10
absorption and staying upright for at least 1 tion, intravenous zoledronic acid is available
hour to prevent esophageal damage. Nearly and effectively improves BMD and reduces
50% of bisphosphonates are deposited into fracture risk.
bones with remnants excreted by kidneys, and Bisphosphonate use can cause adverse
consequently, serum creatinine needs to be effects, including hypocalcemia, renal injury,
monitored. and gastrointestinal symptoms such as esoph-
Several pivotal randomized trials demon- agitis. Vitamin D deficiency and hypocalcemia
strated the effectiveness of alendronate should be corrected, and serum creatinine
(Fosamax) and risedronate (Actonel) in using bisphosphonates should be regularly
improving BMD, decreasing bone turnover monitored [68]. Infusion of zoledronate is
markers, and sustaining bone density over associated with flu-like symptoms such as
time [68]. The risks for vertebral, wrist, and bone, joint, or muscle pain and can be less by
hip fractures decrease by about 50% by giving adequate hydration and normalized vitamin
alendronate for women at a higher predisposi- D level. A recent study demonstrated a higher
tion for vertebral fractures [68]. There are risk of AFF with prolonged bisphosphonates
approximately 40–50% reduction of vertebral usage, certainly if used 5 years or more, and
fractures and 30–36% for non-vertebral frac- was expeditiously lowered with discontinua-
tures using risedronate [68]. Risedronate is tion [87]. Asian women had a heightened risk
also FDA- approved to prevent glucocorti- for atypical fracture with bisphosphonate use,
coid-induced osteoporosis. Ibandronate although benefits outweighed the risk. There
(Boniva) is another FDA-approved bisphos- is a tremendously low risk for osteonecrosis of
phonate for postmenopausal bone loss with a the jaw and atypical fractures using bisphos-
vertebral fracture risk reduction of 50–60% phonates up to 5 years of therapy in post-
and is optimal for improved BMD of the menopausal women severely at risk for
spine [68]. If there is concern about absorp- fracture [79].
Osteoporosis
255 10
Denosumab (Prolia) This drug is a human (Evenity), a novel so-called mixed anabolic
monoclonal antibody with a strong affinity and antiresorptive medication. It is recom-
for RANK ligand receptor, directly inhibiting mended to initially use anabolic therapies for
this pathway and ultimately leading to less women with high fracture risk to help increase
osteoclast production and activity. bone strength, followed by the use of antire-
Denosumab significantly improved BMD and sorptive to prevent further bone breakdown.
decreased bone turnover markers in post-
menopausal women with osteoporosis. PTH Analogs, Teriparatide and Abalopara
Vertebral, hip, and non- vertebral fractures tide Intermittent administration of parathy-
reduced by 68%, 40%, and 20%, respectively roid hormone increases bone mass and
seen in the FREEDOM trial [79]. It is hepati- improves skeletal microarchitectural struc-
cally metabolized with no need to adjust based ture, particularly at the hip and spine.
on renal function. This way, it is an alternative Teriparatide is a recombinant 1–34 N-terminal
option for patients with renal dysfunction. PTH fragment given as a daily injectable agent
The action of denosumab does stop once dis- for at least 2 years. It reduces the risk of verte-
continued resulting in a rapid bone loss due to bral fractures by 65% and 53% of non-verte-
a transient increase in bone remodeling, an bral fractures with a 70% decrease in new
expected average bone loss at 0.25 or 0.5 stan- moderate or severe vertebral fractures over 18
dard deviation [88]. This fact must be consid- treatment months [68, 79]. The continued
ered when contemplating the discontinuation effects on the risk of non-vertebral fractures
of denosumab. A recommendation is to reach persist for up to 30 months following the use
above target treatment BMD before discon- of teriparatide [68]. Another PTH analog is
tinuation of denosumab [88]. abaloparatide, a synthetic 34-amino acid 76%
FREEDOM Extension trial extended the homologous to PTH-related peptides and
study of denosumab exposure for 10 years to 41% homologous to PTH. It is a more potent
observe safeness and efficacy. The study dem- and selective activator of the PTH signaling
onstrated that denosumab’s prolonged use con- pathway resulting in 86% relative risk reduc-
tinue the fracture risk reduction and reduced tion of vertebral fractures and 43% non-verte-
bone turnover markers with continued lumbar bral fractures following use for 18 months
spine and hip improvements [89]. It also consis- [68]. Adverse effects include injection site
tently sustained an accepting safety profile with reactions, mild transient hypercalcemia, hypo-
prolonged use [89, 90]. ONJ occurred in a small tension (associated with dizziness, palpita-
portion of study participants, with a rate of tions, tachycardia, or nausea), and headache.
one per 10,000 participants yearly [90]. Other There was an associated theoretical risk of
adverse effects include cellulitis, eczema, and osteosarcoma as witnessed in trials with rats
other severe infections and remained low dur- but rare causes in human trials [79]. Recent
ing the extended study [90]. 15-year surveillance of the use of teriparatide
found the incidence of osteosarcoma associ-
ated with its use to be no different from the
10.9.4 Anabolic Therapies expected incidence rate of osteosarcoma [91].
The FDA approved removing the osteosar-
Anabolic agents help with new bone forma- coma warning label for teriparatide in
tion. There are two classifications: remodeling November of 2020 [92].
stimulators and modeling stimulators. A recent phase 1b study was completed to
Remodeling stimulators allow mostly bone evaluate the effectiveness of the intradermal
formation to occur along with some bone route of abaloparatide-solid Microstructured
resorption. This class group includes parathy- Transdermal System (abaloparatide-sMTS) in
roid hormone analogs, teriparatide (Forteo) 22 healthy postmenopausal women aged
and abaloparatide (Tymlos). Modeling stimu- 50–85 years old with low BMD over 29 days
lators build new bone with decreased bone [93]. Results showed that the daily
resorption and includes romosozumab abaloparatide- sMTS provided consistently
the same pharmacokinetic profile as 1 month vertebral fractures (HR, 0.81; 95% CI, 0.66–
of daily subcutaneous injections of abalo- 0.99) in contrast to those solely given alendronate
paratide [93]. Most importantly, patients were [3, 94, 95]. Both FRAME and ARCH studies
satisfied with the route method, with the most showed further increases in BMD observed fol-
common adverse effect being local skin reac- lowing 24 subsequent months of alendronate or
tions that improve with continued use of the denosumab; the gains in BMD were sustained
transdermal patch [93]. for at least 2 years.
A monthly injection of romosozumab was
Romosozumab (Evenity) This agent is a mono- overall well-tolerated and safe. Side effects
clonal antibody that binds to sclerostin with include pain at the injection site and hypersen-
high infinity. Sclerostin is a glycoprotein primar- sitivity skin rash. There is a rare risk for osteo-
ily produced by osteocytes and functions to necrosis of the jaw and atypical femoral
regulate bone formation by blocking the activa- fracture with romosozumab. It still carries a
tion of the Wnt signaling pathway, leading to boxed warning label in the United States and
the stifling of new bone formation [33, 68]. In Canada, cautioning for major adverse cardio-
2019, the FDA approved it as an infusion vascular events. Thus, it is contraindicated in
administered monthly for a total of 12 months patients with recent cardiac events within
for treatment of postmenopausal osteoporosis. 12 months or with high cardiac risk [96].
Romosozumab is recommended as first-line
therapy for postmenopausal women with mul-
tiple vertebral fractures or hip fracture and 10.10 Combination Therapy
BMD in the severely osteoporotic range and
10 refractory to antiresorptive treatment. Bone The American Association of Clinical
mineral density (BMD) significantly increased Endocrinology does not recommend combi-
after 12 months of romosozumab, as evident in nation therapy due to limited data on the
two large phase 3 trials conducted. The Fracture effect on fracture risk [65]. Anabolic agents
Study in Postmenopausal Women with should not be used with bisphosphonates or
Osteoporosis (FRAME) trial demonstrated
denosumab as would hamper gains in
73% risk reduction in vertebral fractures (risk BMD. There have not been any adverse out-
ratio [RR], 0.27; 95% confidence interval [CI], comes with a combination of estrogen ther-
0.16–0.47] in postmenopausal women after apy with bisphosphonates, denosumab, or
12 months of romosozumab (n = 7180) [33, 94]. anabolic agents [65, 95]. Some data show that
No significant risk reduction was evident with anabolic agents should be used ideally first as
non-vertebral fractures. After 24 months of antiresorptive can blunt BMD gains [65, 95].
denosumab, this treatment showed a 75%
decrease in risk for new vertebral fractures (RR,
0.25; 95% CI, 0.16–0.40) [94]. The Active- 10.11 Monitoring Bone Health
Controlled Fracture Study in Postmenopausal
Women with Osteoporosis at High Risk Women with low bone density or on treat-
(ARCH) trial matched romosozumab to alen- ment for osteoporosis need appropriate
dronate in postmenopausal women at greatest sequential monitoring to assess bone disease
risk for fracture (n = 4093). BMD greatly to ensure effectiveness and adherence to treat-
improve to 13.7% (spine), 6.2% (total hip), and ment. The interval between DXA depends on
4.9% (femoral neck) with romosozumab for 1 the baseline axial (lumbar spine and hip
year [3, 95–96]. At 24 months, the romoso- including 1/3 radius in patients with primary
zumab followed by alendronate regimen had a hyperparathyroidism) DXA [65, 97, 98]. If
48% risk reduction of vertebral fractures (RR, initial axial DXA is normal, then less frequent
0.52; 95% CI, 0.40–0.66), 38% risk reduction of intervals such as follow-up DXA in 5 years
hip fractures (hazard risk [HR] 0.62; 95% CI, would be appropriate depending on clinical
0.42–0.66), and 19% risk reduction of non- factors [65, 98]. Otherwise, it is recommended
Osteoporosis
257 10
to repeat DXA at least every 1–2 years, ideally ture would benefit up to 6 years of yearly zole-
conducted on the same DXA machine to dronate infusions [65, 98].
allow for valid comparison of interval changes A drug holiday is not recommended for
of BMD [65, 97, 98]. In certain circumstances, non-bisphosphonate drugs such as deno-
bone turnover markers (BTMs) may be fol- sumab or anabolic agents. Multiple studies
lowed to assess efficacy and adherence to (i.e., FREEDOM study, ACTIVE study,
treatment. Antiresorptive therapies substan- VERO study, ARCH study, and Frame study)
tially reduce BTM, which correlates to signifi- have shown the loss of bone mass happens
cant fracture risk reduction. While with rapidly following cessation of denosumab,
romosozumab, and the PTH analogs [99,
anabolic agents, considerable increases of
100]. Sequential treatment with antiresorptive
BTM demonstrate an excellent response to
treatment is recommended after discontinua-
therapy [65]. However, the routine use of bone
tion of denosumab and anabolic therapies as
turnover markers is not generally recom-
discussed earlier.
mended by other guideline recommendations A drug holiday is also not recommended
[98]. Serum creatinine and vitamin D level for women severely at risk for fracture, multi-
may need monitoring with bisphosphonates ple fragility fractures, failed osteoporotic
and anabolic therapy. treatment, or repeatedly not improving BMD
Consider osteoporosis treatment success- or T-score less than or equal to −2.5 [65, 97,
ful when having stable or increasing BMD 98]. Women on chemotherapy agents such as
without evidence of new fracture or worsen- anastrozole or chronic steroids would not be
ing of vertebral fracture. Also, in conjunction, candidates for a drug holiday as a high risk for
BTMs are at or below target for a good fracture remains [65].
response to antiresorptive therapies or signifi- Osteoporotic treatment should be resumed
cantly increased with anabolic therapies [65]. for the following [35, 65, 98]:
Alternative therapies and reassessment for 55 Significant bone loss evident by substan-
secondary causes of bone loss should be tial decreases in BMD
considered for those women with new inci- 55 Increasing bone turnover markers
dences of fractures or significant bone losses 55 New risk factors for bone loss such as
while on current osteoporotic treatments. Two starting medications that would promote
or more fragility fractures should raise a con- bone loss
cern about treatment failure. 55 New fragility fracture
10.12 hen to Consider a Drug

W
10.13 arriers to Effective OP
B
Holiday
Medications
Women with stable or significant BMD with-
Evidence shows that despite available effective
out new incidence of fracture would be ideal
therapies to treat osteoporosis, postmeno-
candidates for a drug holiday after 6–10 years pausal women are substantially underrated,
of oral bisphosphonate if no longer at higher with only 64.3% receiving osteoporosis treat-
risk for fracture (having a T-score greater than ment within 1 year [101]. Women discontinue
−2.5 or greater or no new fractures). Treatment treatment the following rates shown to be 45,
should be continued for an additional 5 years 58, and 70% at 6, 12, or 24 months, respec-
if persistently high risk for fracture. A drug tively [101].
holiday is suggested after 3 years of intrave- A survey study showed alternative therapy
nous zoledronate in women at high risk for and fear of side effects were the main reasons
fracture. Women at severely high risk for frac- for not initiating or discontinuing treatment
[101]. Medication cost was another likely bar- der problems. Her paternal grandmother
rier to starting and adherence osteoporotic was diagnosed with breast cancer in
therapy; these findings may be limited due to her 60s and a paternal aunt deceased
generalizability as the survey population was in her 40s from breast cancer. She has
from a consumer panel [101]. However, clini- no known genetic mutations. She has a
cal evidence shows that good counseling has a personal history of abnormal mammo-
pivotal role in treatment adherence [102]. grams remarkable for fibrocystic breast
but never had breast biopsy. She had a
recent normal mammogram. She has no
10.14 When to Refer history of hypertension, diabetes mel-
to Osteoporosis Specialist litus, stroke, or myocardial infarction.
She is a nonsmoker. She has no personal
Consider referring to an osteoporosis special- or familial history of venous thrombo-
ist for women with fragility fractures with or embolism or prothrombotic mutations.
without normal DXA for optimal evaluation What can be offered to her to help pre-
and treatment, failed osteoporosis therapy, or serve her bone health?
medical conditions complicating management A. Tell her she does not need any treat-
(hyperparathyroidism, malabsorption, or ment as her bones are as healthy as
decreased kidney function). Also, refer to an a young woman.
osteoporosis specialist if low BMD at a young B. Offer her ibandronate as she has a
age, unexplained findings on bone density, predisposition for osteoporosis due
and abnormal laboratory studies such as low to her family history.
10 or high alkaline phosphatase or low C. Tell her she does not need to worry
phosphorus [65]. about her bone health.
D. Tell her to take calcium and vitamin
D3 supplementation for her bone
10.15 Review Questions health.
E. Offer her hormonal therapy to al-
??1. A 48-year-old G3P2 white woman with leviate vasomotor symptoms and
unremarkable past medical history pres- would help preserve bone health.
ents to your clinic concern about her
bone health. She has not had any frac- ??2.
A 70-year-old G3P3003 woman pres-
tures after turning 40. Her mother has ents for follow-up for postmenopausal
osteoporosis treated previously with bone loss and genitourinary syndrome
ibandronate. She has two sisters with of menopause (GSM). She is on vagi-
osteopenia. Given her family history nal DHEA suppositories for GSM with
of osteoporosis, she has a bone density improved symptoms. She does use pes-
scan done, which is normal. She experi- sary for urinary incontinence. She is
ences mild, tolerable hot flashes occa- not having any vasomotor symptoms.
sionally during the day, one to two times She has no personal history or family
weekly. She is amenorrheic with Mirena history of venous thromboembolism.
IUD. Obstetric history is remarkable for She has a history of stage 3 ER+/PR+/
two spontaneous vaginal deliveries with HER-2 gene amplified left breast cancer
no pregnancy complications. She had status post left mastectomy. She com-
her menarche at age 13. She has a his- pleted adjuvant therapy and now 7 years
tory of regular menses without a uter- of anastrozole with discontinuation. She
ine bleeding disorder. She was on oral was on zoledronic acid infusion while
contraceptives for about 10 years and taking anastrozole, with the last infu-
was well-tolerated without developing sion being about 2 years ago. She has a
venous thromboembolism or gallblad- recent stable DXA with osteopenia with
Osteoporosis
259 10
the lowest T-score − 1.5 of left forearm ing the intensity of her exercise routine
with significant improvement of the for about 1 year. The urine pregnancy
right femur neck. What treatment can be test in the clinic is negative. In addition
offered for her bones? to workup for secondary amenorrhea,
A. Offer no treatment and offer drug what additional evaluation should be
holiday given results of recent done at this visit?
DXA. A. Recommend a baseline DXA scan
B. She is a candidate now for HT as to evaluate bone health and possible
posttreatment for breast cancer. referral to a sports medicine special-
C. Discuss and counsel her on oral ral- ist.
oxifene 60 mg daily for breast can- B. Offer no additional workup besides
cer prevention and treatment for secondary amenorrhea.
postmenopausal bone loss. C. Advise to add multivitamin with
D. Tell her to continue with optimal calcium and vitamin D supplemen-
dietary calcium and vitamin D sup- tation.
plementation to treat her bones. D. Demand she decreases her physical
E. Start her on an anabolic agent such exercise.
as daily teriparatide injections or E. Recommend cognitive behavior
monthly romosozumab infusion as therapy as high risk for an eating
she is at high risk for fracture and disorder.
has been off treatment for 2 years.
??4. A 32-year-old woman with a history
??About 16 months later, she contacts of hypothyroidism and spontaneous
your office following a fall where she miscarriage 3 years ago presents for
fractured her left wrist. She has a repeat an annual visit. She has bothersome
DXA that is surprisingly stable. Since hot flashes and night sweats, disturb-
being treated for osteoporosis, FRAX ing sleep. At age 28, she was worked
was not calculated. What treatment up for amenorrhea at 18 months and
should be offered at this time? was found to have primary ovar-
A. Continue with raloxifene as recently ian insufficiency (mosaic Turner’s
started, so not possible due to failed syndrome) with FSH > 65 IU/L and
therapy. estradiol <20 pg/mL on two separate
B. Do nothing. Repeat DXA in 2 years. blood draws 6 months apart. She is
C. Resume zoledronate infusion. short stature, and her BMI is 20. A
D. Discuss anabolic treatments such as baseline DXA scan is obtained with
teriparatide, abaloparatide, or ro- the lowest T-score − 2.0 of the spine
mosozumab. (Z-score − 1.0) and at hip T-score − 0.8
E. Refer to physical therapy for fall (Z-score − 1.0). Her 25-hydroxy D
evaluation. serum level is 40 ng/ml. She is a veg-
etarian. She is informed that the DXA
??3. A 16-year-old female gymnast presents result is remarkable for osteopenia
for concern of amenorrhea for 8 months. and recommends repeating DXA in 2
She has been concerned about hair thin- years. Should hormonal replacement
ning and shedding for the past 6 months. therapy or hormonal contraception be
She is not on any hormonal contracep- prescribed?
tives as not sexually active, and menses A. Do not prescribe hormonal therapy.
were normal about a year ago. Her BMI Counsel about lifestyle modifica-
is 15. She denies any history of an eat- tions to help with vasomotor symp-
ing disorder. However, she is following toms.
a strict diet for the upcoming gymnastic B. Discuss and counsel on hormonal
competition. Also, she had been increas- replacement therapy with continu-
ous contraception or high-dose hor- thalamic amenorrhea. Baseline

monal therapy. DXA evaluation will assess bone
C. Recommend 1000 mg calcium daily health. She would benefit from hav-
and 2000 international units of vita- ing input from a sports medicine
min D3 daily. specialist to help establish a healthy
D. Advise to include isometric exercises plan for gymnastic competition.
three times weekly. The goal is to have optimal bone
E. Wait for a repeat DXA scan to de- health, optimal energy availability,
cide on the treatment needed. and regular menstrual cycles.
vv4. B. Hormonal replacement therapy is

10.16 Answers advised for women with primary or
premature ovarian insufficiency to
vv1. E. Patient was offered a low-dose reduce the risk of cardiovascular
weekly estradiol patch as she had disease, lower the risk for osteopo-
Mirena IUD placed to protect the rosis, decrease the risk for urogeni-
uterine lining. This treatment would tal atrophy, and maintain quality of
offer relief from vasomotor symp- life and sexual health. Continue
toms, maintain her bone health, hormonal replacement therapy until
decrease risk for cardiovascular dis- the average age of natural meno-
ease, lower risk for dementia, reduce pause (approximately age 50–51).
risk for diabetes mellitus, decrease
10 risk for all-cause mortality, and
References
improve life longevity.
1. Borgstrom F, et al. Fragility fractures in Europe:
vv2. C. This patient is an excellent candi- burden, management and opportunities. Arch
date for raloxifene, given a history Osteoporos. 2020;15(1):59.
of breast cancer. Studies have shown 2. Compston JE, McClung MR, Leslie
that raloxifene can decrease the risk WD. Osteoporosis. Lancet. 2019;393(10169):
364–76.
for invasive breast cancer by 38%
3. Cosman F, et al. Clinician’s guide to prevention
and improve vertebral and hip and treatment of osteoporosis. Osteoporos Int.
BMD. The most common risk is 2014;25(10):2359–81.
venous thromboembolism (risk of 4. Kanis JA, et al. SCOPE 2021: a new scorecard for
about 1–1.6%), so risk stratify and osteoporosis in Europe. Arch Osteoporos.
2021;16(1):82.
counsel patients on this risk before
5. Cauley JA, et al. Incidence of fractures compared
initiating. to cardiovascular disease and breast cancer: the
Women’s Health Initiative Observational Study.
Patient has suffered from a fragility
D. Osteoporos Int. 2008;19(12):1717–23.
fracture, so there is a high risk for 6. Piscitelli P, et al. Incidence and costs of hip frac-
tures vs strokes and acute myocardial infarction
another fracture in the future. Fracture
in Italy: comparative analysis based on national
risk could be reduced by the initiation hospitalization records. Clin Interv Aging.
of anabolic agents followed by antire- 2012;7:575–83.
sorptive agents. 7. Singer A, et al. Burden of illness for osteoporotic
fractures compared with other serious diseases
among postmenopausal women in the United
vv3. A. The likely diagnosis, in this case,
States. Mayo Clin Proc. 2015;90(1):53–62.
is functional hypothalamic amenor- 8. Williams SA, et al. Economic burden of osteopo-
rhea due to low body fat composi- rotic fractures in US managed care enrollees. Am
tion because of strenuous exercise J Manag Care. 2020;26(5):e142–9.
and dietary restriction. She is at risk 9. Brand RA. 50 years ago in CORR: the appear-
ance of osteoporosis in ambulatory institutional-
for bone loss due to hypoestrogen- ized males Paul J. Vincent MD and Marshall
ism as a result of functional hypo-
Osteoporosis
261 10
R. Urist MD CORR 1961;19:245–2. Clin Orthop 25. Mattisson L, Bojan A, Enocson A. Epidemiology,
Relat Res. 2011;469(7):2076–7. treatment and mortality of trochanteric and sub-
10. Mays SA. Osteoporosis in earlier human popula- trochanteric hip fractures: data from the Swedish
tions. J Clin Densitom. 1999;2(1):71–8. fracture register. BMC Musculoskelet Disord.
11. Khosla S, Hofbauer LC. Osteoporosis treatment: 2018;19(1):369.
recent developments and ongoing challenges. 26. Lyles KW, et al. Zoledronic acid and clinical frac-
Lancet Diabetes Endocrinol. 2017;5(11):898–907. tures and mortality after hip fracture. N Engl J
12. Ballane G, et al. Worldwide prevalence and inci- Med. 2007;357(18):1799–809.
dence of osteoporotic vertebral fractures. 27. Cauley JA, et al. Risk of mortality following clin-
Osteoporos Int. 2017;28(5):1531–42. ical fractures. Osteoporos Int. 2000;11(7):556–61.
13. Li N, Cornelissen D, Silverman S, et al. An 28. Watts NB. Postmenopausal osteoporosis: a clini-
updated systematic review of cost-effectiveness cal review. J Womens Health (Larchmt).
analysis of drugs for osteoporosis. 2018;27(9):1093–6.
PharmacoEconomics. 2021;39:181–209. 29. Rosen, Clifford J. The epidemiology and patho-
14. Hansen D, Pellizari PM, Pyenson BS. Medicare genesis of osteoporosis. Endotext, edited by
cost of osteoporotic fractures: 2021 updated Kenneth R Feingold et al., MDText.com, Inc., 21
report: the clinical and cost burden of fractures June 2020.
associated with osteoporosis. Milliman Research 30. Zhu X, Zheng H. Factors influencing peak bone
Report. Commissioned by the National mass gain. Front Med. 2021;15(1):53–69.
Osteoporosis Foundation. 2021. 31. Wiren KM. Androgen action in bone: basic cel-
15. Kanis JA, et al. A systematic review of hip frac- lular and molecular aspects. In: Orwoll ES,
ture incidence and probability of fracture world- Bliziotes M, editors. Osteoporosis: pathophysiol-
wide. Osteoporos Int. 2012;23(9):2239–56. ogy and clinical management. Totowa: Humana
16. Lau E, et al. Mortality following the diagnosis of Press; 2002. p. 349–74.
a vertebral compression fracture in the Medicare 32. Khosla S, Monroe DG. Regulation of bone
population. J Bone Joint Surg Am. metabolism by sex steroids. Cold Spring Harb
2008;90(7):1479–86. Perspect Med. 2018;8(1):a031211. Published 2018
17. LeBlanc ES, et al. Hip fracture and increased Jan 2.
short-term but not long-term mortality in healthy 33. Bandeira L, et al. Romosozumab for the treat-
older women. Arch Intern Med. ment of osteoporosis. Expert Opin Biol Ther.
2011;171(20):1831–7. 2017;17(2):255–63.
18. Leslie WD, Morin SN. Osteoporosis epidemiol- 34. Karlamangla AS, et al. Bone health during the
ogy 2013: implications for diagnosis, risk assess- menopause transition and beyond. Obstet
ment, and treatment. Curr Opin Rheumatol. Gynecol Clin N Am. 2018;45(4):695–708.
2014;26(4):440–6. 35. Rozenberg S, Al-Daghri N, Aubertin-Leheudre
19. Borgstrom F, et al. The International Costs and M, et al. Is there a role for menopausal hormone
Utilities Related to Osteoporotic Fractures Study therapy in the management of postmenopausal
(ICUROS)—quality of life during the first 4 osteoporosis? Osteoporos Int. 2020;31(12):
months after fracture. Osteoporos Int. 2271–86.
2013;24(3):811–23. 36. Chew CK, Clarke BL. Causes of low peak bone
20. Svedbom A, et al. Quality of life after hip, verte- mass in women. Maturitas. 2018;111:61–8.
bral, and distal forearm fragility fractures mea- 37. Liu J, Curtis EM, Cooper C, Harvey NC. State of
sured using the EQ-5D-3L, EQ-VAS, and the art in osteoporosis risk assessment and treat-
time-trade-off: results from the ICUROS. Qual ment. J Endocrinol Investig. 2019;42(10):
Life Res. 2018;27(3):707–16. 1149–64.
21. Johansson H, et al. Imminent risk of fracture 38. Finkelstein JS, Brockwell SE, Mehta V, Greendale
after fracture. Osteoporos Int. 2017;28(3): GA, Sowers MR, Ettinger B, Lo JC, Johnston
775–80. JM, Cauley JA, Danielson ME, Neer RM. Bone
22. Soreskog E, et al. Risk of major osteoporotic mineral density changes during the menopause
fracture after first, second and third fracture in transition in a multiethnic cohort of women. J
Swedish women aged 50years and older. Bone. Clin Endocrinol Metab. 2008;93(3):861–8.
2020;134:115286. 39. Ji MX, Yu Q. Primary osteoporosis in postmeno-
23. Lindsay R, et al. Risk of new vertebral fracture in pausal women. Chronic Dis Transl Med.
the year following a fracture. JAMA. 2015;1(1):9–13.
2001;285(3):320–3. 40. Langdahl BL. Osteoporosis in premenopausal
24. Neuburger J, et al. The impact of a national women. Curr Opin Rheumatol. 2017;29(4):
clinician-led audit initiative on care and mortality 410–5.
after hip fracture in England: an external evalua- 41. Leere JS, Vestergaard P. Calcium metabolic disor-
tion using time trends in non-audit data. Med ders in pregnancy: primary hyperparathyroidism,
Care. 2015;53(8):686–91. pregnancy-induced osteoporosis, and vitamin D
deficiency in pregnancy. Endocrinol Metab Clin women: is it cost-effective? Osteoporosis Int.

N Am. 2019;48(3):643–55. 2020;31(12):2321–35.
42. Salles JP. Bone metabolism during pregnancy. 57. Kanis JA, et al. The diagnosis of osteoporosis. J
Ann Endocrinol (Paris). 2016;77(2):163–8. Bone Miner Res. 1994;9:1137–41.
43. Grizzo FMF, Alarcão ACJ, Dell’ Agnolo CM, 58. World Health Organization. Assessment of frac-
Pedroso RB, Santos TS, JRN V, Pinheiro MM, MDB ture risk and its application to screening for post-
C, Pelloso SM. How does women’s bone health menopausal osteoporosis. Report of a WHO
recover after lactation? A systematic review and meta- study group. Geneva: World Health Organization;
analysis. Osteoporos Int. 2020;31(3):413–27. 1994. (WHO Technical Report Series, No. 843).
44. Brembeck P, Lorentzon M, Ohlsson C, Winkvist 59. Fuggle NR, et al. Fracture prediction, imaging
A, Augustin H. Changes in cortical volumetric and screening in osteoporosis. Nature reviews.
bone mineral density and thickness, and trabecu- Endocrinology. 2019;15(9):535–47.
lar thickness in lactating women postpartum. J 60. Chang G, et al. MRI assessment of bone struc-
Clin Endocrinol Metab. 2015;100(2):535–43. ture and microarchitecture. JMRI.
45. Rozenberg S, Bruyère O, Bergmann P, et al. How 2017;46(2):323–37.
to manage osteoporosis before the age of 50. 61. Ma YL, et al. Comparative effects of teriparatide
Maturitas. 2020;138:14–25. and strontium ranelate in the periosteum of iliac
46. Lopez LM, Grimes DA, Schulz KF, Curtis KM, crest biopsies in postmenopausal women with
Chen M. Steroidal contraceptives: effect on bone osteoporosis. Bone. 2011;48(5):972–8.
fractures in women. Cochrane Database Syst Rev. 62. Harvey NC, et al. Trabecular bone score (TBS) as
2014;6:CD006033. a new complementary approach for osteoporosis
47. Raine-Bennett T, Chandra M, Armstrong MA, evaluation in clinical practice. Bone. 2015;78:
Alexeeff S, Lo JC. Depot medroxyprogesterone 216–24.
acetate, oral contraceptive, intrauterine device 63. Zeytinoglu M, et al. Vertebral fracture assess-
use, and fracture risk. Obstet Gynecol. ment: enhancing the diagnosis, prevention, and
2019;134(3):581–9. treatment of osteoporosis. Bone. 2017;104:54–65.
48. Curry EJ, Logan C, Ackerman K, McInnis KC, 64. The Writing Group for the International Society
10 Matzkin EG. Female athlete triad awareness for Clinical Densitometry (ISCD) Position
among multispecialty physicians. Sports Med Development Conference. Position statement:
Open. 2015;1(1):38. introduction, methods, and participants. J Clin
49. Shufelt CL, Torbati T, Dutra E. Hypothalamic Densitom. 2004;7:13–6.
amenorrhea and the long-term health conse- 65. Camacho PM, Petak SM, Binkley N, et al.
quences. Semin Reprod Med. 2017;35(3):256–62. American Association of Clinical Endocrinologists/
50. Pepe J, Body JJ, Hadji P, et al. Osteoporosis in American College of Endocrinology Clinical
premenopausal women: a clinical narrative review Practice guidelines for the diagnosis and treatment
by the ECTS and the IOF. J Clin Endocrinol of postmenopausal osteoporosis-2020 update.
Metab. 2020;105(8):dgaa306. Endocr Pract. 2020;26(Suppl 1):1–46.
51. MacKnight JM. Osteopenia and osteoporosis in 66. Amarnath ALD, et al. Underuse and overuse of
female athletes. Clin Sports Med. 2017;36(4): osteoporosis screening in a regional health sys-
687–702. tem: a retrospective cohort study. JGIM.
52. Crofton PM, et al. Physiological versus standard 2015;30(12):1733–4.
sex steroid replacement in young women with 67. U.S. Preventive Services Task Force. Screening for
premature ovarian failure: effects on bone mass osteoporosis: U.S preventive services task force
acquisition and turnover. Clin Endocrinol. recommendation statement. Ann Intern Med.
2010;73(6):707–14. 2011;154(5):356–64.
53. Bours SP, van den Bergh JP, van Geel TA, 68. Rizzoli R. Postmenopausal osteoporosis:
Geusens PP. Secondary osteoporosis and meta- Assessment and management. Best Pract Res
bolic bone disease in patients 50 years and older Clin Endocrinol Metab. 2018;32(5):739–57.
with osteoporosis or with a recent clinical frac- 69. Anderson JJ, et al. Calcium intake from diet and
ture: a clinical perspective [published correction supplements and the risk of coronary artery cal-
appears in Curr Opin Rheumatol. 2014;26(5):604]. cification (CAC) and its progression among older
Curr Opin Rheumatol. 2014;26(4):430–9. adults: 10-year follow-up of the multi-ethnic
54. Colangelo L, Biamonte F, Pepe J, Cipriani C, study of atherosclerosis (MESA). J Am Heart
Minisola S. Understanding and managing sec- Assoc. 2016;5:e003815.
ondary osteoporosis. Expert Rev Endocrinol 70. Chung M, et al. Calcium intake and cardiovascu-
Metab. 2019;14(2):111–22. lar disease risk: an updated systematic review and
55. McCarthy J, Davis A. Diagnosis and manage- meta-analysis. Ann Intern Med. 2016;165:
ment of vertebral compression fractures. AFP. 856–66.
2016;94(1):44–50. 71. Chung YS, Chung DJ, Kang MI, et al. Vitamin D
56. Yang J, et al. Vertebral fracture assessment (VFA) repletion in Korean postmenopausal women with
for osteoporosis screening in US postmenopausal osteoporosis. Yonsei Med J. 2016;57(4):923–7.
Osteoporosis
263 10
72. McMillan LB, Zengin A, Ebeling PR, Scott Alexandersen P, Ravn P, Christiansen C, Santora
D. Prescribing physical activity for the Prevention AC 2nd, Early Postmenopausal Intervention
and treatment of osteoporosis in older adults. Cohort Study Group. Changes in bone density
Healthcare (Basel). 2017;5(4):85. and turnover after alendronate or estrogen with-
73. Foley S, Quinn S, Jones G. Pedometer determined drawal. Menopause. 2004;11(6 Pt 1):622–30.
ambulatory activity and bone mass: a population- 83. Heiss G, Wallace R, Anderson GL, Aragaki A,
based longitudinal study in older adults. Beresford SA, Brzyski R, Chlebowski RT, Gass
Osteoporos Int. 2010;21:1809–16. M, LaCroix A, Manson JE, Prentice RL,
74. Multanen J, Rantalainen T, Kautiainen H, Ahola Rossouw J, Stefanick ML, WHI Investigators.
R, Jämsä T, Nieminen MT, Lammentausta E, Health risks and benefits 3 years after stopping
Häkkinen A, Kiviranta I, Heinonen A. Effect of randomized treatment with estrogen and proges-
progressive high-impact exercise on femoral neck tin. JAMA. 2008;299(9):1036–45.
structural strength in postmenopausal women 84. Papadakis G, Hans D, Gonzalez-Rodriguez E,
with mild knee osteoarthritis: a 12-month Vollenweider P, Waeber G, Marques-Vidal PM,
RCT. Osteoporos Int. 2017;28:1323–33. Lamy O. The benefit of menopausal hormone
75. The Postmenopausal Estrogen/Progestin therapy on bone density and microarchitecture
Interventions (PEPI) Trial. Effects of hormone persists after its withdrawal. J Clin Endocrinol
replacement therapy on endometrial histology in Metab. 2016;101(12):5004–11.
postmenopausal women. The Writing Group for 85. Barrionuevo P, Kapoor E, Asi N, et al. Efficacy of
the PEPI Trial. JAMA. 1996;275(5):370–5. pharmacological therapies for the prevention of
76. Cauley JA, Robbins J, Chen Z, Cummings SR, fractures in postmenopausal women: a network
Jackson RD, LaCroix AZ, LeBoff M, Lewis CE, meta-analysis. J Clin Endocrinol Metab.
McGowan J, Neuner J, Pettinger M, Stefanick 2019;104(5):1623–30.
ML, Wactawski-Wende J, Watts NB, Women’s 86. Watts NB, et al. No increase in fractures after
Health Initiative Investigators. Effects of estrogen stopping hormone therapy: results from the
plus progestin on risk of fracture and bone min- Women’s Health Initiative. J Clin Endocrinol
eral density: the Women’s Health Initiative ran- Metab. 2017;102:302–8.
domized trial. JAMA. 2003;290(13):1729–38. 87. Black DM, et al. Atypical femur fracture risk ver-
77. Greenwald MW, Gluck OS, Lang E, Rakov sus fragility fracture prevention with bisphospho-
V. Oral hormone therapy with 17beta-estradiol nates. N Engl J Med. 2020;383(8):743–53.
and 17beta-estradiol in combination with noreth- 88. Sølling AS, et al. Treatment with zoledronate sub-
indrone acetate in the prevention of bone loss in sequent to denosumab in osteoporosis: a random-
early postmenopausal women: dose-dependent ized trial. J Bone Miner Res. 2020;35(10):
effects. Menopause. 2005;12(6):741–8. Jiang 1858–70.
XD. Hormone therapy for the treatment of post- 89. Bilezikian JP, Lin CJF, Brown JP, et al. Long-
menopausal osteoporosis: will it soon become a term denosumab treatment restores cortical bone
lost art in medicine? Menopause. 2018;25(7): loss and reduces fracture risk at the forearm and
723–7. humerus: analyses from the FREEDOM
78. Fink HA, MacDonald R, Forte ML, Rosebush extension crossover group. Osteoporos Int.

CE, Ensrud KE, Schousboe JT, Nelson VA, 2019;30(9):1855–64.
Ullman K, Butler M, Olson CM, Taylor BC, 90. Bone HG, Wagman RB, Brandi ML, et al. 10
Brasure M, Wilt TJ. Long-term drug therapy and years of denosumab treatment in postmeno-
drug discontinuations and holidays for osteopo- pausal women with osteoporosis: results from the
rosis fracture Prevention: a systematic review. phase 3 randomised FREEDOM trial and open-
Ann Intern Med. 2019;171(1):37–50. https://doi. label extension. Lancet Diabetes Endocrinol.
org/10.7326/M19-0533. Epub 2019 Apr 23 2017;5(7):513–23.
79. Eastell R, et al. Pharmacological management of 91. Gilsenan A, Midkiff K, Harris D, Kellier-Steele
osteoporosis in postmenopausal women: an N, McSorley D, Andrews EB. Teriparatide did
endocrine society* clinical practice guideline. J not increase adult osteosarcoma incidence in a
Clin Endocrinol Metab. 2019;104(5):1595–622. 15-year US Postmarketing Surveillance Study. J
80. Lindsay R, Gallagher JC, Kleerekoper M, Pickar Bone Miner Res. 2021;36(2):244–51.
JH. Effect of lower doses of conjugated equine 92. Forteo® post-market osteosarcoma surveillance
estrogens with and without medroxyprogesterone program: real-world data contributes to label
acetate on bone in early postmenopausal women. change. RTI-health solutions website. https://www.
JAMA. 2002;287(20):2668–76. rtihs.org/news-and-events/forteo%C2%AE-post-
81. Seifert-Klauss V, Schmidmayer M, Hobmaier E, market-osteosarcoma-surveillance-program-real-
Wimmer T. Progesterone and bone: a closer link world-data-contributes.
than previously realized. Climacteric. 93. Miller PD, Troy S, Weiss RJ, et al. Phase 1b evalu-
2012;15(Suppl 1):26–31. ation of abaloparatide solid microstructured
82. Wasnich RD, Bagger YZ, Hosking DJ, McClung transdermal system (Abaloparatide-sMTS) in
MR, Wu M, Mantz AM, Yates JJ, Ross PD, postmenopausal women with low bone mineral
density. Clin Drug Investig. 2021;41(3): menopausal women: the 2021 position statement
277–85. of The North American Menopause Society.
94. Shoback D, et al. Pharmacological management Menopause. 2021;28(9):973–97.
of osteoporosis in postmenopausal women: an 99. Lewiecki EM, et al. One year of romosozumab fol-
endocrine society guideline update. J Clin lowed by two years of denosumab maintains frac-
Endocrinol Metab. 2020;105(3):587–94. ture risk reductions: results of the FRAME
95. Cosman F. Anabolic and antiresorptive therapy extension study. J Bone Miner Res. 2019;34:419–28.
for osteoporosis: combination and sequential 100. Bone HG, et al. ACTIVExtend: 24 months of
approaches. Curr Osteoporos Rep. 2014;12(4): alendronate after 18 months of abaloparatide or
385–95. placebo for postmenopausal osteoporosis. J Clin
96. Saag KG, Petersen J, Brandi ML, et al. Endocrinol Metab. 2018;103:2949–57.
Romosozumab or alendronate for fracture pre- 101. Lindsay BR, Olufade T, Bauer J, Babrowicz J,
vention in women with osteoporosis. N Engl J Hahn R. Patient-reported barriers to osteoporo-
Med. 2017;377:1417–27. sis therapy. Arch Osteoporos. 2016;11(1):19.
97. Prevention O. Screening, and diagnosis: ACOG 102. Sewerynek E, Horst-Sikorska H, Stępień-Kłos W,
clinical practice guideline no. 1. Obstet Gynecol. et al. The role of counselling and other factors in
2021;138(3):494–506. compliance of postmenopausal osteoporotic
98. The North American Menopause Society patients to alendronate 70 therapy. Arch Med Sci.
(NAMS). Management of osteoporosis in post- 2013;9(2):288–96.
10
265 11
Male Infertility
Scott Lundy and Sarah C. Vij
Contents
11.2 he Psychological Impact of Male

T
Infertility – 266
11.3 Categorization of Male Infertility – 267
11.4 Guideline-Based Approach for Diagnosis and

A
Management of Male Infertility – 268
11.5 he Importance of a Comprehensive Male Factor

T
Workup – 268
11.6 Infertility and Comorbidities – 268
11.7 Obtaining a History of the Infertile Male – 269
11.8 Physical Examination of the Infertile Male – 270
11.9 Semen Analysis – 272
11.10 Laboratory Workup – 274
11.11 Imaging – 274
11.13 Surgical Management of Male Infertility – 275
11.15 Answers – 277
References – 277

https://doi.org/10.1007/978-3-030-99596-6_11
266 S. Lundy and S. C. Vij
underlying cause [7]. Even more concerning is

Key Points the emerging data supporting a link between
55 Referral to reproductive urologist facili- male infertility and mortality [8], suggesting
tates a complete workup and holistic that early evaluation may provide not only a
care for men having difficulty conceiv- benefit for reproductive purposes but for over-
ing. all health as well.
55 Adherence to a guideline-based In the current chapter, we will briefly sum-
approach reduces unnecessary tests and marize the current state-of-the-art diagnosis
maximizes patient outcomes. and management of male infertility, with a
55 The intensity of workup and manage- particular focus on the emerging psychosocial
ment should be tailored to the repro- effects and the importance of a thorough gen-
ductive potential of the partner and the eral medical examination to assess for comor-
severity of any identifiable pathology. bidities.
55 Male infertility is associated with early
mortality, and men with infertility
should receive a thorough clinical eval- Clinical Vignette
uation with an emphasis on identifying
other comorbidities and providing lon- A 35-year-old man presents with a chief
gitudinal care. complaint of infertility with his 30-year-old
partner for 18 months. He has never caused
a pregnancy to his knowledge. He denies
any history of undescended testicles or her-
11.1 Introduction nia repair. He does report a left-sided scro-
tal fullness that worsens throughout the day
For many couples with infertility, the inability and resolves by morning. He and his wife
11 to conceive a child can be one of the most are wondering if there is any testing or
emotionally taxing events of their lives. treatment necessary to improve their
Roughly one in six couples worldwide suffer chances of having a child.
from infertility [1], and within these couples,
up to 33% of cases are due to an isolated male
factor, and an additional 20% of couples have 11.2 he Psychological Impact
T
combined male and female factors [2, 3]. of Male Infertility
Thus, roughly half of all couples with infertil-
ity may benefit from male evaluation and While the emotional toll and societal stigma
treatment. Worryingly, these statistics may be of female factor infertility have been the sub-
compounded by emerging data suggesting ject of increasingly insightful research efforts
that sperm counts may be falling globally for including the development of standardized
unknown reasons [4]. Indeed, mammalian instruments such as the FertiQoL [9] and
spermatogenesis is an exquisitely complex female infertility stigma [10] instruments,
process requiring the most diverse proteome comparatively little work has been completed
[5] of any tissue in the human body and last- on the male side. Nevertheless, it is clear that
ing nearly 3 months from spermatogonia to the inability to father a child contributes sig-
mature spermatozoa. While the physiology of nificant stress and decreases in quality of life
spermatogenesis has become increasingly well for infertile men. Men receiving a diagnosis of
understood [6], the pathology underlying male infertility experience significant increases
impaired spermatogenesis and sperm dys- in distress and rates of psychiatric comorbidi-
function in many subfertile and infertile men ties which persist even after receiving
remains elusive, and 60% of all men who pres- treatment [11]. Infertility is associated with
ent with male infertility and undergo thor- significant decreases in sexual function, which
ough workup will have no identifiable can compound challenges with conception
Male Infertility
267 11
.. Fig. 11.1 List of locations along the male genitourinary tract for obstructive azoospermia
[12]. These symptoms are often minimized, genital absence of the vas deferens, epididy-
perhaps due to the social stigma surrounding mal obstruction due to infection, prior
infertility. While only 5% of men with male vasectomy, or inguinal hernia repair causing
infertility self-reported psychiatric illness, vasal obstruction (. Fig. 11.1). Non-
testing revealed a prevalence of almost one in obstructive etiologies represent a failure of
three men [11]. Perhaps this reflects the deeply the testicle to generate sperm due to genetic,
ingrained societal stigma surrounding infertil- hormonal, environmental, or iatrogenic
ity. Even more disturbingly, one in five couples causes. Finally, it is important to distinguish
treated for infertility have experienced idiopathic male infertility, which refers to
thoughts of suicide [13]. Taken together, these men with poor semen quality for unex-
findings suggest that further research is neces- plained reasons, and unexplained male infer-
sary to better understand which men are at tility, which describes men with male factor
greatest risk for mental health deterioration infertility in the absence of aberrations in
and may benefit significantly from referral for semen analysis parameters [15].
counseling or pharmacologic therapy. Semen concentration provides another
useful tool to characterize infertile men. Men
with normal sperm counts are deemed to be
11.3 Categorization of Male within the normal range set by the World
Infertility Health Organization (WHO) in the most
recent 2009 guidelines [16]. These men are
Male infertility can be broadly categorized designated as “normospermic” if they have a
in several different ways. First, primary male semen concentration of >15 million sperm/
infertility refers to men who have never suc- mL. Men with semen concentrations between
cessfully initiated a clinical pregnancy, while 5 and 15 million/mL are labeled as oligosper-
secondary male infertility refers to men who mic, and men with <5 million/mL are termed
have previously caused a pregnancy but sub- severely oligospermic. If only rare sperm are
sequently have difficulty [14]. Next, male seen, this is called cryptospermia. Finally, if
infertility can be caused by either obstructive no sperm are identified despite extensive
or non-obstructive etiologies. Obstructive efforts, the condition is termed azoospermia.
etiologies, characterized by normal sper- Beyond merely sperm counts, semen analysis
matogenesis but impaired sperm delivery, can also provide more narrow diagnoses. Men
include ejaculatory duct obstruction, con- with abnormal sperm motility are termed
asthenospermic, and men with abnormal be performed. There are, however, some dif-
sperm morphology are termed teratospermic. ferences in treatment approaches, including
These terms can also be combined; for exam- recommendations regarding medical therapy
ple, a man with poor sperm counts, low mor- for men with male infertility. Taken together,
phology, and poor motility is deemed to have these documents represent an evidence-based
oligoasthenoteratozoospermia (OAT). strategy for the index patient with male infer-
A subset of men with male infertility can tility and should be implemented in the
be described according to their hormonal axis workup and management of most patients.
aberrations. The hypothalamic-pituitary-
gonadal (HPG axis) describes the relationship
between gonadotropin-releasing hormone 11.5 The Importance
(GnRH) and the hypothalamus providing a of a Comprehensive Male
stimulus to the pituitary to release follicle-
Factor Workup
stimulating hormone (FSH) and luteinizing
hormone (LH). FSH stimulates the Sertoli Frequently, couples begin their workup for
cells, which are required for normal spermato- infertility through reproductive endocrinol-
genesis, and LH stimulates Leydig cells to ogy, and men undergo a basic semen analysis
produce testosterone. Testosterone then feeds and are referred to urology only if this dem-
back negatively to complete the control loop. onstrates significant abnormalities. Emerging
Men with primary testicular failure usually data, however, suggests that 15% of men with
exhibit elevated FSH and LH but decreased T male factor infertility have normal semen
and low sperm counts. In contrast, men with parameters [15], underscoring the importance
decreased levels of both pituitary and testicu- of evaluation by a male reproductive special-
lar hormones are said to have hypogonado- ist even in the absence of semen analysis
tropic hypogonadism or secondary testicular abnormalities. In addition, there is a growing
11 failure. body of literature supporting the strong link
between systemic disease and male factor
infertility. There are now several reports
11.4 Guideline-Based Approach
A describing an epidemiological link between
for Diagnosis male infertility and early mortality [8, 19]. A
and Management of Male recent meta-analysis [19] showed that infertile
Infertility men have a 1.6-fold higher risk of dying than
fertile men, and this hazard ratio climbs to
Despite the complexities and nuances involved over 2 in azoospermic men. While the exact
with the management of male infertility, there cause for this linkage is unknown and likely
are two current standardized guidelines avail- multifactorial, it implies that spermatogenesis
able for clinician use. The American Urological may represent the “canary in the coalmine”
Association (AUA) and American Society for and an early harbinger for morbidity in an
Reproductive Medicine (ASRM) recently otherwise asymptomatic man.
released a joint series guideline encompassing
the basic diagnosis and management of male
infertility [17, 18]. In addition, the European 11.6 Infertility and Comorbidities
Association of Urology (EAU) released inde-
pendent guidelines for male infertility in 2012. Infertility and Hypogonadism There is a clear
Many of the statements in these two resources linkage between subfertile men and hypogo-
closely coincide. Both, for example, recom- nadism. This may be due to the fact that nor-
mend concurrent male and female evaluation. mal spermatogenesis is reliant upon high levels
Both recommend the use of the WHO stan- of intra-testicular testosterone. Similarly, con-
dards for semen analysis interpretation, and ditions such as cryptorchidism may lead to
both recommend at least two semen analyses abnormal sperm production and abnormal tes-
Male Infertility
269 11
tosterone production by Leydig cells. demonstrate prepubertal- sized firm testicles
Hypogonadism has been shown to predispose usually associated with primary testicular fail-
men to decreased libido, erectile dysfunction, ure and hypogonadism. Proper identification
decreased lean body mass, depression, and and management of men with Klinefelter syn-
poor bone health [20]. In addition, testosterone drome is important for avoiding the untoward
levels within the testicle are up to 125 times effects of hypogonadism and simultaneously
higher than in the circulation, and this elevated maximizing fertility capacity using assisted
level is key for proper spermatogenesis [21]. reproduction technology (ART). Even with
While the exact relationship between these two aggressive management and early surgical
testicular functions is difficult to fully describe, sperm retrieval, however, only 50% of men will
the two processes (spermatogenesis and hor- be found to have sperm.
mone synthesis) are clearly intimately linked
and must be addressed concurrently in men Infertility and Cystic Fibrosis While the link
with poor testicular function. between mortality and infertility remains
poorly understood, the link between infertility
Pituitary Masses Roughly 16% of men with and other comorbidities is quite strong.
erectile dysfunction and 11% of men with sub- Approximately 1 in 1000 men have congenital
fertility will be found to have elevated prolactin bilateral absence of the vas deferens (CBAVD),
[22]. Many of these men will be found to have a and this population accounts for roughly 1% of
sellar mass that may be either functional (e.g., all men presenting for infertility workup [26].
prolactin-secreting or FSH-/LH-secreting) or Mutations in the cystic fibrosis transmembrane
nonfunctional. In fact, the prevalence of prolac- region (CFTR) family of genes are found in
tinomas in men with infertility is approximately roughly 90% of men with CBAVD [27]. When
350-fold higher than the general population suspected by an experienced urologist during
[23]. As a result, it is important to consider pro- physical examination, these men should
lactin measurement in select men with infertility undergo kidney ultrasound to rule out a soli-
and screen for symptoms of sellar mass. tary kidney, CFTR gene testing, and referral to
pulmonology for further management. In addi-
Infertility and End-Stage Renal Disease tion, the partner of these men should be
(ESRD) Men suffering from renal failure are at screened, and couples should be counseled on
significant risk for infertility for a multitude of the genetic implications of their condition
reasons. Uremia itself appears to impair sper- should they choose to proceed with assisted
matogenesis and sperm function via direct and reproductive technology. In contrast, congeni-
indirect hormonal effects. Men with chronic tal unilateral absence of the vas deferens
kidney disease typically present with oligoas- (CUAVD) is less commonly associated with
thenoteratozoospermia (OAT) and a > 50% CFTR mutations but should still be evaluated
decrease in most semen parameters [24]. These using a similar algorithm.
changes appear to be directly correlated with
the duration of hemodialysis. Most of these
parameters will improve following renal trans- 11.7 Obtaining a History
plantation, though a significant proportion of of the Infertile Male
men will remain azoospermic [25].
Obtaining a thorough history is a vital step to
Klinefelter Syndrome Klinefelter syndrome identifying potential causal factors in men
(47, XXY) is a common genetic syndrome with infertility.
affecting roughly 1 in 1000 life male births and First, age is an important factor to con-
commonly presents in adulthood with primary sider as fertility diminishes over time. Despite
infertility. Physical examination may reveal this, however, roughly 80% of men in their
gynecomastia, mild cognitive dysfunction, fifth to seventh decades of life maintain nor-
sparse body and facial hair, and decreased lean mal semen parameters [28]. Assessment of
muscle mass. Genital exam will universally prior pregnancies or children with a current
or prior partner will distinguish men with pri- as a risk factor for retrograde ejaculation. As
mary from secondary infertility. many as 27% of infertile men who underwent
Men should be queried for the length of inguinal hernia repair as a child will go on to
unprotected intercourse and the use of con- develop vasal obstruction [33]. Thus, particu-
ception strategies (e.g., ovulation kits, lar focus should be given to assessing for a his-
calendar-based approaches, basal body tem- tory of hernia repair including age of
perature, etc.). While seemingly superfluous, it intervention and type of repair (e.g., with or
is also important to confirm with couples that without mesh).
they are participating in penetrative inter- A minority of men will report an onco-
course and that ejaculation occurs. logic history, most commonly testicular can-
Ideally, the female partner will be present cer and some hematologic malignancies.
at the consultation to provide an accurate Thorough documentation of malignancy type
partner history and encourage a coordinated and treatments (including specific chemother-
workup and treatment discussion. This should apeutic or radiation treatments) can elucidate
include assessment of menstrual pattern, important gonadotoxic exposures. Numerous
prior pregnancies with this or another part- agents are detrimental to spermatogenesis
ner, and consent to coordinate care with the including alkylating agents (e.g., cyclophos-
reproductive endocrinology team when phamide), cisplatin, and dactinomycin [34].
appropriate. Partner age is a critical compo- Environmental exposures can cause sig-
nent to assess, as this can directly dictates the nificant decreases in sperm counts and are pri-
intensity of therapy for men whose partners marily centered around exposure to
are nearing menopause. gonadotoxic agents such as pesticides [35] .
A developmental history including assess- Heat is also a significant environmental expo-
ment for cryptorchidism, hypospadias, poste- sure risk factor and can be applied by hot tubs
rior urethral valves, or other congenital [36] or laptops [37]. Smoking is a significant
11 genitourinary anomalies will identify key risk risk factor for subfertility and appears to
factors for poor testicular function. decrease sperm concentration, total motile
Assessment of the age of puberty is also count, and oxidative stress [38].
important. Delayed puberty can be seen in Scrotal trauma is an often-forgotten cause
men with Kallmann syndrome, Turner syn- of infertility. Men with a history of high-
drome, hypogonadism, and men with pitu- impact sport activities such as football can
itary masses and hyperprolactinemia. Aside develop hypogonadism and erectile dysfunc-
from these diagnoses, men with subjectively tion [39]. Repetitive low-impact activities such
delayed puberty appear to have worse semen as cycling may also have a detrimental effect
parameters and a 25% decrease in semen con- [40], though the literature in this area remains
centration [29]. mixed [41].
Infectious etiologies are a common cause Finally, countless medications have been
of infertility and account for up to 15% of implicated in male infertility. For a full list,
cases [30]. Recent illness is also an important the reader is referred to . Table 11.1 and to
factor to discuss, as a single febrile illness several recent reviews on the topic [42, 43].
reduces sperm concentration by one third
[31]. A discussion of sexually transmitted dis-
ease history is also indicated, as prior gonor- 11.8 Physical Examination
rhea or chlamydia infection can result in of the Infertile Male
obstruction of the epididymis and obstructive
azoospermia [32]. The physical exam remains a critical aspect in
Next, providers should strive to capture a the evaluation of the infertile or subfertile
thorough genitourinary surgical history male. Assessment of body habitus, presence
including prior scrotal surgery, urethral of secondary sex characteristics, and gyneco-
instrumentation to assess for possible stric- mastia should be performed. Abdominal
tures, and history of retroperitoneal surgery exam may reveal surgical incisions from prior
Male Infertility
271 11
.. Table 11.1 List of medications suspected or proven to cause male infertility
Category Subcategory Drugs Pattern Strength of

evidence
Alpha- Tamsulosin, Silodosin Retrograde ejaculation or Strong

blockers anejaculation
Analgesics Opioids Oxycodone Decreased libido, ED, Strong
concentration
Methadone Hypogonadism, decreased Strong
motility
Tramadol Decreased count, motility Strong
Antacids H2 blockers Cimetidine, famotidine, Decreased sperm counts Weak
ranitidine for cimetidine only
Proton pump Lansoprazole, Modestly decreased Weak
inhibitors Omeprazole, Pantopra- sperm counts
zole
Antibiotics Nitrofurantoin Macrobid, macrodantin Decreased motility Weak
Tetracycline Doxycycline, Minocy- Decreased viability and Weak
cline, tigecycline motility
Antihyperten- ACE Inhibitors Captopril, enalapril, Decreased motility Weak
sives lisinopril
Beta-Blockers Atenolol, Carvedilol, Decreased motility Weak
Metoprolol
Calcium channel Amlodipine, nifedipine, Decreased motility and Weak
Blockers Verapamil capacitation
Diuretics Spironolactone Decreased motility Weak
Anti- Colchicine Decreased concentration Weak
inflammatory
Sulfasalazine Decreased concentration, Weak
drugs
motility, morphology
Chemothera- Alkylating Cyclophosphamide, Cytotoxic to spermatogo- Strong
peutics Agents chlorambucil nia
Mitotic Vinblastine Cytotoxic to spermatogo- Strong
Inhibitors nia
Hormonal Androgens Testosterone Azoospermia Strong
Therapies
Antiandrogens Bicalutamide, flutamide Erectile dysfunction, Strong
decreased libido
5-ARIs Dutasteride, Finasteride Decreased concentration, Strong
semen volume
GnRH analogs Leuprolide, goserelin Erectile dysfunction, Strong
decreased libido
(continued)
Category Subcategory Drugs Pattern Strength of

evidence
Immunosup- Antimetabolites Azathioprine, Decreased motility, Weak

pression Mycophenolate teratogenic
mTOR Everolimus, sirolimus Decreased concentration, Weak
inhibitors motility, teratogenic
Steroids Prednisone Minimal effect on sperm Strong
Psychiatric Phenothiazines Chlorpromazine Increased prolactin, Weak
medications decreased motility
SSRIs Fluoxetine, Paroxetine Decreased counts and Weak
motility
Lithium Decreased motility Weak
Radiation Spermatogonia toxicity Strong
(pelvic)
inguinal hernia repair raising suspicion of should be performed to assess for prostate
vasal obstruction in the appropriate clinical masses.
context. Close attention is then paid to the
genital exam which is often best performed in
the standing position. Evaluation of testicular 11.9 Semen Analysis
11 size can be performed with the use of an
orchidometer or by subjective assessment by Basic Semen Analysis The cornerstone of male
an experienced provider. The consistency of fertility workup is the basic semen analysis.
the testis is important to assess, as men with According to WHO guidelines [16], men are
testicular failure may have soft testes, whereas instructed to abstain from ejaculation for
a testicular mass will be firm and irregular. between 2 but not more than 7 days prior to
The epididymis should be palpated for tender- providing a specimen. Specimens should be
ness, which may suggest epididymitis, or collected in a clean fashion without the use of
masses such as epididymal cysts (spermato- saliva or most commercially available lubri-
celes). Epididymal fullness can be appreciated cants, both of which can negatively impact
on obstructed men. The presence or absence semen parameters [44]. Men should be edu-
of the vas deferens is critical to identify men cated on the importance of a complete collec-
with vasal agenesis. The presence and grade tion, as a “split collection” where the initial or
of varicocele should then be noted, again with terminal portion of the specimen is lost can
the patient in the standing position and with a underestimate the true semen concentration
Valsalva maneuver. Varicoceles are graded on significantly.
physical exam as follows: Grade 1 varicocele Following collection, the semen sample
is palpable only with Valsalva maneuver, should be processed in a consistent manner by
Grade 2 varicocele is palpable without experienced technicians. While semen has a
Valsalva, and Grade 3 is visible. Evaluation of remarkable ability to buffer pH, a value of
meatal location, Tanner stage, and penis size less than 7.0 is often associated with obstruc-
may be important particularly in men with tion due to the loss of fructose-rich alkaline
history of hypospadias and congenital hypo- fluid from the seminal vesicles. Volume should
gonadotropic hypogonadism, respectively. If typically exceed 1.5 mL in a normal specimen,
the patient is of appropriate age, a rectal exam and volumes lower than this should raise
Male Infertility
273 11
c oncern for obstruction or retrograde ejacula- data from these assays has proved to be diffi-
tion. It is important to note that vasal obstruc- cult and is limited to specific clinical scenarios
tion does not cause decreased ejaculate such as recurrent pregnancy loss or unex-
volume, as the testicular contribution to the plained infertility. Furthermore, treatment of
ejaculate volume is only a fraction of the total elevated DNA fragmentation primarily relies
ejaculated volume. on antioxidant therapy or – in the setting of
Semen concentration is perhaps the most ART – collection of testicular sperm, which
versatile basic semen analysis parameter, as may relieve some of the accumulated DNA
this provides a key measure of fertilizing abil- damage from elevated oxidative stress expo-
ity. When combined with percentage of motile sure in ejaculated sperm.
sperm and total volume, the total motile
sperm count (TMSC) can be calculated. In Oxidative Stress It is thought that the root
subfertile men, TMSC of >5 million per mL is cause of DNA damage in sperm is the presence
sufficient for intrauterine insemination (IUI), of elevated oxidative stress. Measurement of
whereas values less than this are typically best oxidative stress can be accomplished via numer-
managed with IVF or ICSI. ous assays including reactive oxygen species
Many labs now perform computer-aided measurement using luminol chemilumines-
semen analysis (CASA) in addition to or in cence [49], total antioxidant capacity [49], and
some cases in place of manual counts. These direct measurement of the oxidation reduction
platforms use high-throughput digital imag- potential [50].
ing and analysis software to determine semen
concentration, motility, and several other Viability Testing In cases of severely compro-
parameters including linearity and velocity. mised motility and oligospermia or cryptosper-
While these systems provide relatively consis- mia, sperm viability testing provides an
tent data, most literature suggests equivocal attractive tool to confirm that sperm are alive
results to manual analysis [45, 46], and there and can be used successfully for intracytoplas-
is little evidence suggesting that these mic sperm injection (ICSI). Some of the most
expanded parameters provide additional clin- common tests used for this purpose include the
ical utility. eosin-nigrosin stain [51], the hypoosmotic
swelling test [52], and the laser-assisted detec-
Leukocytospermia Assessment Semen should tion tests [53].
be examined for the presence of round cells,
which can represent either immature sperm Antisperm Antibodies Some semen specimens
precursor cells or white blood cells. If positive, demonstrate significant sperm agglutination,
samples are typically assessed using the myelo- which can be due to the presence of antisperm
peroxidase test. Men with positive leukocyto- antibodies (ASA) from prior trauma or scrotal
spermia testing should be further assessed for surgery [54]. These can be measured using the
underlying etiologies including smoking and IgG-mixed antiglobulin reaction (MAR) test
the presence of occult infection, which can be [55]. If identified, men with ASA can be treated
empirically treated using doxycycline [47]. with a host of approaches including immuno-
suppression, sperm washes, and sperm purifi-
DNA Fragmentation The fidelity of sperm cation, and/or ICSI can be utilized depending
DNA is critical to the successful generation on the clinical scenario [56].
and propagation of a human embryo, and as
such the field of male infertility has spent con- Capacitation Assays The need for sperm to be
siderable effort into studying assays to assess able to penetrate the zona pellucida and enter
DNA fragmentation. Numerous assays have the egg, as is necessary in traditional in vitro
been developed including TUNEL, sperm fertilization, has largely been supplanted by
chromatin structure, and sperm chromatin dis- advances in ICSI. As such, the role for capaci-
persion assays [48]. Despite its theoretical tation assays has been largely diminished, and
importance, clinical implementation of the these tests are now rarely performed.
11.10 Laboratory Workup circumstances, imaging may be useful. Scrotal

ultrasonography is the most commonly uti-
Bloodwork A typical laboratory workup per- lized imaging modality in this context.
formed in conjunction with semen analysis Ultrasonography can assess testicular volume,
includes assessment of the HPG axis via mea- testicular echogenicity, presence or absence of
surement of follicle-stimulating hormone and varicocele in the setting of difficult physical
testosterone, both of which are mandatory in exam as well as testicular mass, and epididy-
men with impaired libido, erectile dysfunction, mal anatomy. Clinicians might order scrotal
oligozoospermia or azoospermia, atrophic tes- ultrasonography if the physical exam is chal-
tis, or abnormal physical exam findings such as lenging or further anatomic information
testicular atrophy [17]. If hypogonadism is about the scrotal contents is desired.
identified, prolactin and luteinizing hormone Transrectal ultrasonography can be a useful
should also be checked to assess for primary or tool in the setting of obstructive azoospermia
secondary hypogonadism [18]. to evaluate for dilated seminal vesicles and
ejaculatory ducts as well as prostatic utricle or
Genetics Genetic evaluation for the infertile Wolffian duct cysts. In patients with elevated
male is typically reserved for men with severe prolactin, cranial MRI is indicated. Lastly,
oligospermia or azoospermia, recurrent preg- vasography can be performed intra-operatively
nancy loss, or men with consanguinity or to evaluate for distal genital tract obstruction
known syndrome or other high-risk popula- in anticipation of operative repair.
tions. This involves a karyotype to assess for
additional chromosomes or macroscopic inser-
tions/deletions. Y-chromosome microdeletion 11.12 Management
(YCMD) is a special case whereby small dele-
11 tions within the long arm of chromosome Y in
one of three azoospermic factor (AZF) regions
Medical Management of Male Infertility In
many cases of oligozoospermia, medical inter-
(AZFa, AZFb, or AZFc). While men with ventions are sufficient to improve sperm param-
AZFa and AZFb have not been shown to have eters and cause a pregnancy. Men who are
sperm on surgical interrogation, up to 75% of smoking should be counseled on the impor-
men with isolated AZFc mutations will have tance of cessation, particularly if associated
foci of spermatogenesis and thus should with leukocytospermia. The importance of a
undergo surgical sperm retrieval [57]. While healthy diet and healthy body composition also
hundreds of single nucleotide polymorphisms cannot be overstated. Antioxidants and vita-
have been identified and reported in the litera- mins are also often recommended to decrease
ture [58], the clinical utility in routinely assess- oxidative stress, but the evidence for this
ing for these remains unproven. Finally, CFTR approach is weak at best. Nevertheless, the risk
mutation testing is indicated in men with sus- to this approach appears to be quite low, and
pected CBAVD or CUAVD. If positive, the for oligozoospermic men with limited options
female partners should also be tested. All for intervention, this can be considered.
patients with a genetic abnormality on testing
should be offered genetics counseling. HPG Axis Manipulation for
Hypogonadism There are several indications
for the treatment of infertile men with medica-
11.11 Imaging tions designed to modulate the HPG axis. Men
with hypogonadism but with relatively normal
Imaging can be a useful adjunctive tool in the pituitary hormone levels may benefit from
diagnostic workup of the infertile male. treatment, but prescribing these men tradi-
Physical exam along with laboratory testing tional testosterone replacement therapy is
and semen testing can often provide sufficient strictly contraindicated due to its suppression
diagnostic information; however in certain of spermatogenesis. Instead, selective estrogen
Male Infertility
275 11
receptor modulators (SERMs), aromatase element of choice (cold knife, hot knife, hot
inhibitors, or human chorionic gonadotropin loop, button, etc.) is then inserted and used to
(hCG) can be prescribed. SERMs such as clo- resect the verumontanum until blue efflux is
miphene citrate are mixed agonist/antagonists noted. Outcomes are modest but favorable,
of the estrogen receptor which exert their effects with 83% of men experienced increased semen
by increasing GnRH pulse frequency and thus volume and 63% of men demonstrating
increasing FSH and LH levels. Aromatase increased semen concentration [61].
inhibitors such as anastrozole work by limiting
the conversion of androgens to estrogen. This Varicocelectomy For men with a clinical vari-
class of medications is particularly helpful in cocele and subfertility or varicocele-related
obese men with elevated estradiol levels. Finally, pain, surgical varicocelectomy can be offered.
recombinant hCG can also provide a safe way For a detailed review on the management
to increase testosterone in men desiring fertility. options for varicocele, the reader is referred to a
recent systematic review [62] and Cochrane
HPG Axis Manipulation for Hypogonadotropic review [63] on the subject. Briefly, varicocelec-
Hypogonadism In cases of hypogonadotropic tomy can be accomplished with either surgical
hypogonadism (e.g., Kallmann syndrome), or endovascular intervention. Surgical
men desiring fertility should be referred to approaches include laparoscopic, retroperito-
endocrinologists or male infertility specialists. neal, inguinal, and subinguinal approaches.
The most common regimen used in these men Regardless of the approach used, success rates
consists of initial treatment with hCG and are high and range from 75% to 90%.
recombinant FSH to restore testicular func- Complications include hydrocele and varicocele
tion. recurrence. Testicular loss is exceedingly rare
and should be mentioned as a complication.
HPG Axis Manipulation for Idiopathic Despite its well-described role and high
Subfertility The role for hormonal manipula- prevalence in infertile men, outcomes for fer-
tion in the subfertile man with normal testos- tility purposes remain contentious. On the
terone levels remains controversial. Many one hand, Abdel-Meguid [64] conducted a
providers will consider a trial of off-label clo- randomized controlled trial and found an
miphene in these men with the intention of odds ratio for pregnancy of 3.0 for varicoce-
optimizing sperm parameters for natural con- lectomy compared to observation. This corre-
ception. Similarly, there is evidence supporting sponds to a number needed to treat of 5.3. A
medical management in patients with non- Cochrane review subsequently confirmed the
obstructive azoospermia (NOA) prior to sperm benefit of varicocelectomy, but the number
retrieval to optimize sperm yeilds [59]. needed to treat for this analysis was much
higher at 17.
11.13 Surgical Management Diagnostic Testicular Biopsy Outside of con-

of Male Infertility cern for malignancy or carcinoma in situ, the
role for diagnostic testicular biopsy in the infer-
TURED For men with ejaculatory duct tile male is limited [65]. Most men with azo-
obstruction, transurethral resection of the ejac- ospermia can usually be correctly categorized
ulatory ducts (TURED) can restore normal as obstructive or non-obstructive based upon a
ejaculation volumes and thereby improve fertil- thorough history, semen analysis, and labora-
ity. In this procedure, a transrectal ultrasound tory workup. In cases where the diagnosis for
is performed and the dilated seminal vesicles obstruction is equivocal, diagnostic testicular
aspirated for sperm preservation purposes. biopsy can be considered to ensure whether
Many providers then inject methylene blue to spermatogenesis is present prior to a more-
provide visual feedback for the subsequent involved reconstruction operation. Another
resection [60]. The cystoscope with working viable option for these patients is testicular
sperm extraction with cryopreservation for operation commonly performed by urologists

both diagnostic and therapeutic purposes. with specialty training in male infertility and
offers excellent (>90%) technical success rates
Surgical Sperm Retrieval For men with little to in most situations. Men with short interval
no sperm in their ejaculate, surgical sperm between vasectomy and reversal (<15 years)
retrieval offers the ability to retrieve sperm can commonly be reconstructed using a vaso-
directly from the epididymis or the testicle. The vasostomy, while men with longer intervals or
specific procedure indicated is dependent upon evidence of upstream obstruction at the time of
numerous factors including the etiology of azo- reconstruction may require the more techni-
ospermia (obstructive or non-obstructive), cally challenging vasoepididymostomy.
patient anatomy, procedure setting, and man-
agement goals. For men with prior vasectomy
who wish to father a child and would prefer Conclusions
IVF over surgical reconstruction, percutaneous Male infertility is a broad clinical topic
epididymal sperm aspiration (PESA) using a that accounts for roughly half of all cases
narrow-gauge needle passed repeatedly into the of infertility, and the inability to conceive a
dilated epididymis offers a minimally invasive child often conveys significant anxiety and
approach with good success rates. The use of stress for men suffering from this condition.
the operating microscope to target individual Men with suspected or confirmed infertility
tubules is termed a microsurgical epididymal should be evaluated and treated by a phy-
sperm aspiration (MESA) [66]. This procedure sician with expertise in reproductive health
can increase yield but requires surgical delivery who can navigate the numerous diagnostic
of the testicle and microsurgical expertise and and therapeutic nuances associated with
is less commonly performed. A percutaneous treating this vulnerable population of men.
testicular sperm aspiration (TESA) is another
11 for men with obstructive azoospermia, but suc-
cess rate is typically lower [67]. Non-obstructive Clinical Vignette (Cont’d)
azoospermic men are typically managed using
surgical testicular sperm extraction (TESE) or After obtaining a thorough history, a physical
microdissection testicular sperm extraction exam reveals the presence of a left grade 3
(microTESE or mTESE). This procedure varicocele. Semen testing shows oligozoo-
requires surgical delivery of the testicle fol- spermia with a semen concentration of 10
lowed by incision of the tunica albuginea and million per mL and decreased motility of
sharp removal of a portion of the testicular 20%. He is counseled on management options
parenchyma and tubules. The use of an operat- and elects to proceed with microscopic subin-
ing microscope provides the ability to identify guinal varicocelectomy. Postoperatively, his
islands of tubules that visually appear to con- semen concentration improves to 20 million,
tain spermatogenesis without necessitating and his motility normalizes to 50%. He and
large quantities of parenchymal excision, which his wife successfully conceive 5 months later
may lead to hypogonadism. The overall success and subsequently have a healthy baby girl.
rates for mTESE are reasonably good for men
with NOA and typically hover around 50–60%
[68]. Unfortunately, the only factor consistently 11.14 Review Questions
shown to predict success rates is surgical pathol-
ogy, which is typically not available preopera- ??1. What percentage of couples with infer-
tively. tility has a male component as the pri-
mary or contributing cause?
Vasectomy Reversal While the surgical A. 10%
nuances of vasectomy reversal are beyond the B. 25%
scope of this chapter, it is important for clini- C. 50%
cians to recognize that vasectomy reversal is an D. 75%
Male Infertility
277 11
??2. What is the traditional cutoff for suf- mouse spermatogenesis. Nat Commun.
ficient sperm number to perform intra- 2019;10:1251. https://doi.org/10.1038/s41467-019-
09182-1.
uterine insemination?
7. Punab M, Poolamets O, Paju P, Vihljajev V, Pomm K,
A. One million nonmotile sperm Ladva R, et al. Causes of male infertility: A 9-year
B. One million motile sperm prospective monocentre study on 1737 patients with
C. Five million nonmotile sperm reduced total sperm counts. Hum Reprod. 2017;32:18–
D. Five million motile sperm 31. https://doi.org/10.1093/humrep/dew284.
8. Del Giudice F, Kasman AM, Li S, Belladelli F,
??3. Which Y-chromosome microdeletion
Ferro M, de Cobelli O, et al. Increased mortality
is associated with successful surgical among men diagnosed with impaired fertility:
sperm retrieval? analysis of US claims data. Urology. 2021;147:143–
A. AZFa 9. https://doi.org/10.1016/j.urology.2020.07.087.
B. AZFb 9. Boivin J, Takefman J, Braverman A. The fertility
C. AZFc quality of life (FertiQoL) tool: development and
general psychometric properties. Hum Reprod.
D. None of the above 2011;26:2084–91. https://doi.org/10.1093/humrep/
der171.
10. Taebi M, Kariman N, Montazeri A, Majd
11.15 Answers HA. Development and psychometric evaluation of
the female infertility stigma instrument (ISI-F):
protocol for a mixed method study. Reprod Health.
vv1. C 2020;17:4–9. https://doi.org/10.1186/s12978-020-
0904-5.
vv2. D 11. Warchol-Biedermann K. The risk of psychiatric mor-
bidity and course of distress in males undergoing
vv3. C infertility evaluation is affected by their factor of infer-
tility. Am J Mens Health. 2019;13:1557988318823904.
https://doi.org/10.1177/1557988318823904.
12. Ferraresi SR, Lara LAS, de Sá MFS, Reis RM,
References Rosa e Silva ACJS. Current research on how infer-
tility affects the sexuality of men and women.
1. Agarwal A, Mulgund A, Hamada A, Chyatte Recent Pat Endocr Metab Immune Drug Discov.
MR. A unique view on male infertility around the 2013;7:198–202. https://doi.org/10.2174/18722148
globe. Reprod Biol Endocrinol. 2015;13:1–9. 113079990009.
https://doi.org/10.1186/s12958-015-0032-1. 13. Kerr J, Brown C, Balen AH. The experiences of
2. Thonneau P, Marchand S, Tallec A, Ferial M-L, couples who have had infertility treatment in the
Ducot B, Lansac J, et al. Incidence and main United Kingdom: results of a survey performed in
causes of infertility in a resident population (1 850 1997. Hum Reprod. 1999;14:934–8. https://doi.
000) of three French regions (1988–1989)*. Hum org/10.1093/humrep/14.4.934.
Reprod. 1991;6:811–6. https://doi.org/10.1093/ 14. Zegers-Hochschild F, Adamson GD, Dyer S,
OXFORDJOURNALS.HUMREP.A137433. Racowsky C, de Mouzon J, Sokol R, et al. The
3. Anderson JE, Farr SL, Jamieson DJ, Warner L, international glossary on infertility and fertility
Macaluso M. Infertility services reported by men care, 2017. Fertil Steril. 2017;108:393–406. https://
in the United States: national survey data. Fertil doi.org/10.1016/j.fertnstert.2017.06.005.
Steril. 2009;91:2466–70. https://doi.org/10.1016/j. 15. Hamada A, Esteves SC, Nizza M, Agarwal
fertnstert.2008.03.022. A. Unexplained male infertility: diagnosis and man-
4. Levine H, Jørgensen N, Martino-Andrade A, agement. Int Braz J Urol. 2012;38:576–94. https://
Mendiola J, Weksler-Derri D, Mindlis I, et al. doi.org/10.1590/S1677-55382012000500002.
Temporal trends in sperm count: A systematic 16. Cooper TG, Noonan E, von Eckardstein S, Auger
review and meta-regression analysis. Hum Reprod J, Baker HWG, Behre HM, et al. World Health
Update. 2017;23:646–59. https://doi.org/10.1093/ Organization reference values for human semen
humupd/dmx022. characteristics. Hum Reprod Update. 2009;16:231–
5. Uhlén M, Fagerberg L, Hallström BM, Lindskog C, 45. https://doi.org/10.1093/humupd/dmp048.
Oksvold P, Mardinoglu A, et al. Tissue-based map 17. Schlegel PN, Sigman M, Collura B, de Jonge CJ,
of the human proteome. Science. 2015;347:1260419. Abb H, Eisenberg ML, et al. Diagnosis and
https://doi.org/10.1126/science.1260419. Treatment of Infertility in Men : AUA/ASRM
6. Ernst C, Eling N, Martinez-Jimenez CP, Marioni Guideline Part I. J Urol. 2021;205:36–43.
JC, Odom DT. Staged developmental mapping and 18. Schlegel PN, Sigman M, Collura B, De JCJ, Abb
X chromosome transcriptional dynamics during H, Eisenberg ML, et al. Diagnosis and Treatment
of Infertility in Men : AUA/ASRM Guideline ity. Urol Clin North Am. 2014;41:67–81. https://
PART II. J Urol. 2021;205:44–51. doi.org/10.1016/j.ucl.2013.08.008.
19. Del Giudice F, Kasman AM, Chen T, De Berardinis 31. Carlsen E, Andersson AM, Petersen JH,
E, Busetto GM, Sciarra A, et al. The association Skakkebæk NE. History of febrile illness and vari-
between mortality and male infertility: systematic ation in semen quality. Hum Reprod. 2003;18:2089–
review and meta-analysis. Urology. 2021;154:148– 92. https://doi.org/10.1093/humrep/deg412.
57. https://doi.org/10.1016/j.urology.2021.02.041. 32. Krause W. Male accessory gland infection.
20. Mulhall JP, Trost LW, Brannigan RE, Kurtz EG, Andrologia. 2008;40:113–6. https://doi.
Redmon JB, Chiles KA, et al. Evaluation and org/10.1111/j.1439-0272.2007.00822.x.
management of testosterone deficiency: AUA 33. Matsuda T. Diagnosis and treatment of post-
Guideline. J Urol. 2018;200:423–32. https://doi. herniorrhaphy vas deferens obstruction. Int J Urol.
org/10.1016/j.juro.2018.03.115. 2000;7:35–8. https://doi.org/10.1046/j.1442-2042.
21. Smith LB, Walker WH. The regulation of sper- 2000.00171.x.
matogenesis by androgens. Semin Cell Dev Biol. 34. Meistrich ML. Male gonadal toxicity. Pediatr
2014;30:2–13. https://doi.org/10.1016/j.semcdb. Blood Cancer. 2009;53:261–6. https://doi.
2014.02.012. org/10.1002/pbc.22004.
22. Naelitz B, Shah A, Nowacki AS, Bryk DJ, Farber 35. Oliva A, Spira A, Multigner L. Contribution of
N, Parekh N, et al. Prolactin-to-testosterone ratio environmental factors to the risk of male infertil-
predicts pituitary abnormalities in mildly hyperpro- ity. Hum Reprod. 2001;16:1768–76. https://doi.
lactinemic men with symptoms of hypogonadism. J org/10.1093/humrep/16.8.1768.
Urol. 2021;205:871–8. https://doi.org/10.1097/ 36. Shefi S, Tarapore PE, Walsh TJ, Croughan M,
JU.0000000000001431. Turek PJ. Wet heat exposure: A potentially revers-
23. Darves-Bornoz A, Patel M, Keeter MK, Wren J, ible cause of low semen quality in infertile men. Int
Bennett N, Halpern J, et al. MP26-05 prevalence Braz J Urol. 2007;33:50–6. https://doi.org/10.1590/
of clinically apparent prolactinomas in the subfer- s1677-55382007000100008.
tile male. J Urol. 2020;203:e401. https://doi. 37. Sheynkin Y, Jung M, Yoo P, Schulsinger D,
org/10.1097/JU.0000000000000865.05. Komaroff E. Increase in scrotal temperature in
24. Xu LG, Xu HM, Zhu XF, Jin LM, Xu B, Wu Y, laptop computer users. Hum Reprod. 2005;20:452–
et al. Examination of the semen quality of patients 5. https://doi.org/10.1093/humrep/deh616.
11 with uraemia and renal transplant recipients in

comparison with a control group. Andrologia.
38. Künzle R, Mueller MD, Hänggi W, Birkhäuser
MH, Drescher H, Bersinger NA. Semen quality of
2009;41:235–40. https://doi.org/10.1111/j.1439- male smokers and nonsmokers in infertile couples.
0272.2009.00924.x. Fertil Steril. 2003;79:287–91. https://doi.
25. Prem AR, Punekar SV, Kalpana M, Kelkar AR, org/10.1016/S0015-0282(02)04664-2.
Acharya VN. Male reproductive function in urae- 39. Panara K, Masterson JM, Savio LF, Ramasamy
mia: efficacy of haemodialysis and renal transplan- R. Adverse effects of common sports and recre-
tation. Br J Urol. 1996;78:635–8. ational activities on male reproduction. Eur Urol
26. De La Taille A, Rigot JM, Make P, Vankemmel O, Focus. 2019;5:1146–51. https://doi.org/10.1016/j.
Gervais R, Dumur V, et al. Correlation between euf.2018.04.013.
genito-urinary anomalies, semen analysis and 40. Wise LA, Cramer DW, Hornstein MD, Ashby RK,
CFTR genotype in patients with congenital bilat- Missmer SA. Physical activity and semen quality
eral absence of the vas deferens. Br J Urol. among men attending an infertility clinic. Fertil
1998;81:617–9. https://doi.org/10.1046/j.1464-410x. Steril. 2011;95:1025–30. https://doi.org/10.1016/j.
1998.00589.x. fertnstert.2010.11.006.
27. Bieth E, Hamdi SM, Mieusset R. Genetics of the 41. Milo H, Alice H, Mark H. An observational study
congenital absence of the vas deferens. Hum of erectile dysfunction, infertility, and prostate
Genet. 2021;140:59–76. https://doi.org/10.1007/ cancer in regular cyclists: cycling for health UK
s00439-020-02122-w. study. J Men Health. 2014;11:75–9. https://doi.
28. Ng KK, Donat R, Chan L, Lalak A, Di Pierro I, org/10.1089/JOMH.2014.0012.
Handelsman DJ. Sperm output of older men. Hum 42. Semet M, Paci M, Saïas-Magnan J, Metzler-
Reprod. 2004;19:1811–5. https://doi.org/10.1093/ Guillemain C, Boissier R, Lejeune H, et al. The
humrep/deh315. impact of drugs on male fertility: a review.
29. Jensen TK, Finne KF, Skakkebæk NE, Andersson Andrology. 2017;5:640–63. https://doi.org/10.1111/
AM, Olesen IA, Joensen UN, et al. Self-reported andr.12366.
onset of puberty and subsequent semen quality 43. Ding J, Shang X, Zhang Z, Jing H, Shao J, Fei Q,
and reproductive hormones in healthy young men. et al. FDA-approved medications that impair
Hum Reprod. 2016;31:1886–94. https://doi. human spermatogenesis. Oncotarget. 2017;8:10714–
org/10.1093/humrep/dew122. 25. https://doi.org/10.18632/oncotarget.12956.
30. Bachir BG, Jarvi K. Infectious, inflammatory, and 44. Anderson L, Lewis SEM, McClure N. The effects
immunologic conditions resulting in male infertil- of coital lubricants on sperm motility in vitro.
Male Infertility
279 11
Hum Reprod. 1998;13:3351–6. https://doi. 57. Hopps CV, Mielnik A, Goldstein M, Palermo GD,
org/10.1093/humrep/13.12.3351. Rosenwaks Z, Schlegel PN. Detection of sperm in men
45. Baig A, Shoebuddin M, Ahmed M. Comparison of with Y chromosome microdeletions of the AZFa,
manual sperm analysis with computer-assisted AZFb, and AZFc regions. Hum Reprod. 2003;18:
sperm analysis: A comparative cross-sectional study. 1660–5. https://doi.org/10.1093/humrep/deg348.
Natl J Physiol Pharm Pharmacol. 2019;9:1. https:// 58. Krausz C, Escamilla AR, Chianese C. Genetics of
doi.org/10.5455/njppp.2019.9.0621817062019. male infertility: from research to clinic. Reproduction.
46. Johnson JE, Boone WR, Blackhurst DW. Manual 2015;150:R159–74. https://doi.org/10.1530/REP-
versus computer-automated semen analyses. Part 15-0261.
I. comparison of counting chambers. Fertil Steril. 59. Hussein A, Ozgok Y, Ross L, Rao P, Niederberger
1996;65:150–5. https://doi.org/10.1016/S0015- C. Optimization of spermatogenesis-regulating
0282(16)58043-1. hormones in patients with non-obstructive azo-
47. Hamada A, Agarwal A, Sharma R, French DB, ospermia and its impact on sperm retrieval: A mul-
Ragheb A, Sabanegh ES. Empirical treatment of ticentre study. BJU Int. 2013;111:1–5. https://doi.
low-level leukocytospermia with doxycycline in org/10.1111/j.1464-410X.2012.11485.x.
male infertility patients. Urology. 2011;78:1320–5. 60. Manohar T, Ganpule A, Desai M. Transrectal ultra-
https://doi.org/10.1016/j.urology.2011.08.062. sound- and fluoroscopic-assisted transurethral inci-
48. Agarwal A, Majzoub A, Baskaran S, Selvam sion of ejaculatory ducts: A problem-solving approach
MKP, Cho CL, Henkel R, et al. Sperm DNA frag- to nonmalignant hematospermia due to ejaculatory
mentation: A new guideline for clinicians. World J duct obstruction. J Endourol. 2008;22:1531–5. https://
Mens Health. 2020;38:412–71. https://doi. doi.org/10.1089/end.2007.0415.
org/10.5534/WJMH.200128. 61. Mekhaimar A, Goble M, Brunckhorst O, Alnajjar
49. Agarwal A, Qiu E, Sharma R. Laboratory assessment HM, Ralph D, Muneer A, et al. A systematic
of oxidative stress in semen. Arab J Urol. 2018;16:77– review of transurethral resection of ejaculatory
86. https://doi.org/10.1016/j.aju.2017.11.008. ducts for the management of ejaculatory duct
50. Agarwal A, Sharma R, Roychoudhury S, Du obstruction. Turkish J Urol. 2020;46:335–47.
Plessis S, Sabanegh E. MiOXSYS: a novel method https://doi.org/10.5152/tud.2020.20228.
of measuring oxidation reduction potential in 62. Lundy SD, Sabanegh ES. Varicocele management
semen and seminal plasma. Fertil Steril. for infertility and pain: A systematic review. Arab J
2016;106:566–573.e10. https://doi.org/10.1016/j. Urol. 2018;16:157–70. https://doi.org/10.1016/j.
fertnstert.2016.05.013. aju.2017.11.003.
51. Chen H, Zhou H, Shu J, Gan X, Wang C, Lin R. A 63. Kroese ACJ, de Lange NM, Collins J, Evers
point of confusion for embryologists in the identi- JLH. Surgery or embolization for varicoceles in sub-
fication of viable spermatozoa by the eosin- fertile men. Cochrane Database Syst Rev.
nigrosin test. Clin Exp Reprod Med. 2019;46:36–40. 2012;10:CD000479. https://doi.org/10.1002/14651858.
https://doi.org/10.5653/cerm.2019.46.1.36. CD000479.pub5.
52. Sallam HN, Farrag A, Agameya AF, El-Garem Y, 64. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi
Ezzeldin F. The use of the modified hypo-osmotic HM. Does varicocele repair improve male infertil-
swelling test for the selection of immotile testicular ity? An evidence-based perspective from a random-
spermatozoa in patients treated with ICSI: A randomized, controlled trial. Eur Urol. 2011;59:455–61.
ized controlled study. Hum Reprod. 2005;20:3435–40. https://doi.org/10.1016/j.eururo.2010.12.008.
https://doi.org/10.1093/humrep/dei249. 65. Dohle GR, Elzanaty S, Van Casteren NJ. Testicular
53. Aktan TM, Montag M, Duman S, Gorkemli H, Rink biopsy: clinical practice and interpretation. Asian
K, Yurdakul T. Use of a laser to detect viable but J Androl. 2012;14:88–93. https://doi.org/10.1038/
immotile spermatozoa. Andrologia. 2004;36:366–9. aja.2011.57.
https://doi.org/10.1111/j.1439-0272.2004.00636.x. 66. Bernie AM, Ramasamy R, Stember DS, Stahl
54. Berger GK, Smith-Harrison LI, Sandlow JI. Sperm PJ. Microsurgical epididymal sperm aspiration: indi-
agglutination: prevalence and contributory fac- cations, techniques and outcomes. Asian J Androl.
tors. Andrologia. 2019;51:3–6. https://doi. 2013;15:40–3. https://doi.org/10.1038/aja.2012.114.
org/10.1111/and.13254. 67. Friedler S, Raziel A, Strassburger D, Soffer Y,
55. Barbonetti A, Castellini C, D’Andrea S, Cordeschi Komarovsky D, Ron-El R. Testicular sperm
G, Santucci R, Francavilla S, et al. Prevalence of retrieval by percutaneous fine needle sperm aspira-
anti-sperm antibodies and relationship of degree tion compared with testicular sperm extraction by
of sperm auto-immunization to semen parameters open biopsy in men with non-obstructive azo-
and post-coital test outcome: a retrospective anal- ospermia. Hum Reprod. 1997;12:1488–93. https://
ysis of over 10 000 men. Hum Reprod. 2019;34:834– doi.org/10.1093/HUMREP/12.7.1488.
41. https://doi.org/10.1093/humrep/dez030. 68. Flannigan RK, Schlegel PN. Microdissection tes-
56. Naz RK. Modalities for treatment of antisperm ticular sperm extraction: preoperative patient opti-
antibody mediated infertility: novel perspectives. mization, surgical technique, and tissue processing.
Am J Reprod Immunol. 2004;51:390–7. https:// Fertil Steril. 2019;111:420–6. https://doi.
doi.org/10.1111/j.1600-0897.2004.00174.x. org/10.1016/j.fertnstert.2019.01.003.
281 12
Female Infertility
Elizabeth J. Klein, Roxanne Vrees, and Gary N. Frishman
Contents
12.2 Diagnostic Criteria – 283
12.3 Common Etiologies – 283

12.3.1 ale Factor – 283
M
12.3.2 Ovulatory Dysfunction – 283
12.3.3 Endometriosis – 284
12.3.4 Pelvic and Tubal Adhesions – 285
12.3.5 Systemic Diseases – 285
12.4 Initial Evaluation of the Infertile Couple – 285

12.4.1 istory – 286
H
12.4.2 Review of Systems – 288
12.4.3 Diagnostic Testing – 290
12.4.4 Imaging Studies – 293
12.4.5 Surgery – 293
12.5 Treatment – 294

12.5.1 ral Medications – 294
O
12.5.2 Ovarian Stimulation (Injectable Gonadotropins) – 294
12.5.3 Intrauterine Insemination – 295
12.5.4 Assisted Reproductive Technology – 295
12.5.5 Donor Gametes – 295
12.5.6 Adoption, Fostering, and Childfree Living – 296

https://doi.org/10.1007/978-3-030-99596-6_12
12.6 Comparison of International Protocols
for Evaluation of Female Infertility – 296
12.7 Concluding Remarks – 298
12.9 Answers – 299
References – 299
Female Infertility
283 12
after a prior spontaneous pregnancy regard-
Key Points less of its outcome. Fortunately, an estimated
55 Female infertility is estimated to impact 75% of infertile couples will achieve concep-
1 in 7 couples in the Western world and tion with individualized infertility evaluation
is most often attributed to endometrio- and treatment [3].
sis, ovulatory disorders, and male factor
infertility. Nearly 40% of female infer-
Case Vignette
tility cases are unexplained.
55 The initial evaluation and examination A 37-year-old woman attempting to con-
of the infertile woman should include a ceive presents having had two prior pelvic
comprehensive history, review of sys- infections with PID and an ectopic preg-
tems, physical examination, and, if nancy for which the affected tube was
required, laboratory testing and imag- removed. Her HSG imaging study shows a
ing to attempt to identify an underlying large hydrosalpinx in the remaining tube.
etiology or modifiable cause of infertil-
ity.
55 Established treatment modalities are 12.2 Diagnostic Criteria
highly effective, and approximately 75%
of infertile couples will achieve concep- As noted above, the inability to conceive after
tion after evaluation and treatment. 1 year in women under age 35 or 6 months in
55 There are disparities in knowledge of, women over age 35 is the working definition of
and access to, female infertility treat- infertility. There are many causes, with actual
ment. Special considerations should be percentages ranging widely across different
made for patients who identify as studies. The Centers for Disease Control and
LGBTQ+ and who desire biological Prevention (CDC) cites age, smoking, exces-
children. sive alcohol use, extreme weight fluctuations,
and excessive physical or emotional stress as
non-anatomical risk factors that increase the
12.1 Introduction risk of female infertility [4].
Infertility is defined as the inability to estab-

lish a clinical pregnancy after 12 months of 12.3 Common Etiologies
regular, unprotected sexual intercourse and is
estimated to affect 1 in 7 couples in the 12.3.1 Male Factor
Western world [1]. There are a host of factors
that impact fertility and increasing recogni- A comprehensive analysis of the male partner’s
tion is being given to the impact of age; the fertility should be performed in tandem with
current recommendation is that women over the female infertility evaluation. Semen analy-
35 seek an infertility evaluation after only sis is the main screening tool for male infertility
6 months. Endometriosis (30–50%), ovulatory problems. Sperm function is not assessed in the
disorders (21–25%), male factor (20%), tubal semen analysis and, if indicated, should be
factors (14%), and uterine abnormalities evaluated by a reproductive urologist. Further
(3.5%) are the leading, identifiable causes of information on the male infertility evaluation
female infertility (. Fig. 12.1). Nearly 40% is discussed in 7 Chap. 11.
of female infertility cases are unexplained [2].
Infertility can be further classified as primary
and secondary. Primary infertility is defined 12.3.2 Ovulatory Dysfunction
as women meeting the above criteria who have
never been pregnant. Conversely, secondary Ovulatory dysfunction will be identified in
infertility is the inability to become pregnant approximately 15% of all infertile couples and
284 E. J. Klein et al.
Tubal Factors
Ovulatory Disorders
Endometriosis
Uterine Abnormalities
Unexplained
Male Factor
.. Fig. 12.1 Leading causes of female infertility
accounts for up to 40% of infertility in women. also show markedly elevated anti-Müllerian
It can present as apparent menstrual distur- hormone (AMH) levels due to an increased
bances including oligomenorrhea or amenor- number of small antral follicles and the intrin-
rhea but can also be more subtle. The sic characteristics of their granulosa cells [1].
underlying cause of dysfunction should be
determined to allow for targeted treatment. 12.3.2.2 Hyperprolactinemia
Two of the most common etiologies of In excess, prolactin, a hormone secreted by
ovulatory dysfunction, polycystic ovarian
the anterior pituitary, suppresses secretion of
12 syndrome (PCOS) and hyperprolactinemia, gonadotropin releasing hormone (GnRH)
are described below [5]. from the hypothalamus, leading to reduced
luteinizing hormone (LH) and resulting ovu-
12.3.2.1 Polycystic Ovarian latory dysfunction. Patients with a prolac-
Syndrome tinemia may present with galactorrhea,
PCOS is the most prevalent endocrine disor- hypogonadism, and amenorrhea. Pituitary
der in women, affecting 5–10% of the female adenomas are the most common etiology of
population [6]. The Rotterdam Criteria, which this clinical presentation, accounting for 7%
replaced the National Institutes of Health of cases of female infertility. A prolactin level
(NIH) criteria, are used to define the PCOS is indicated in the infertility evaluation in
diagnosis and incorporate the appearance of women with either irregular or absent cycles
the ovaries on ultrasound into the diagnostic and/or symptoms such as galactorrhea.
algorithm. The American Society of
Reproductive Medicine (ASRM) diagnostic
criteria require no other known endocrine 12.3.3 Endometriosis
abnormality and at least 2 of the following
characteristics: (1) hyperandrogenism (e.g., Endometriosis is a chronic gynecologic disor-
hirsutism and oily skin), (2) irregular menses, der in which endometrial tissue implants are
or (3) polycystic ovaries [3]. These criteria are outside the uterine cavity and is definitively
consistent with those published by the diagnosed upon histological identification of
Androgen Excess and PCOS Society but differ endometrial glands and/or stroma outside the
in that the latter defines hyperandrogenemia uterus in a sample of surgically removed tis-
and its associated clinical features as separate sue. The most commonly utilized classifica-
criteria [7]. Upon further testing, women may tion system for endometriosis was developed
Female Infertility
285 12
by the ASRM and utilizes anatomic location the promoter region of the AMH gene con-
and severity of disease to define disease stages tains a Vitamin D response element [11].
(I–IV) with potential etiologies including Studies have demonstrated that in women
inflammation impairing ovarian function, pel- who are vitamin D replete, chances of achiev-
vic adhesions or masses distorting pelvic anat- ing a positive pregnancy test, clinical preg-
omy, etc. [8]. The prevalence of endometriosis nancy, and live birth after assisted reproductive
is considerably higher in sub-fertile women technology (ART) are higher than those in
than in the general population, approximately women who are vitamin D deficient or insuf-
20–50% compared to 0.8–6% [9]. Importantly, ficient [12, 13]. However, it is difficult to com-
the ASRM criteria do not correlate well with pare studies examining vitamin D levels and
symptoms of pelvic pain or infertility and are female infertility at large, as normal levels
not good predictors of pregnancy rates fol- vary across institutions. Nonetheless, it is rea-
lowing treatment for endometriosis [10]. sonable to prescribe vitamin D to women pre-
senting for infertility evaluation, based on its
beneficial risk-reward profile and lack of sig-
12.3.4 Pelvic and Tubal Adhesions nificant consequences noted to date [11].
Pelvic and tubal adhesions are estimated to 12.3.5.2 Hypothyroidism (CH)

account for 12% of female infertility cases. It is well established that hypothyroidism por-
These adhesions often develop secondary to tends potential reproductive complications,
infectious processes, most commonly pelvic including an increased incidence of infertility,
inflammatory disease (PID) secondary to miscarriage, and adverse obstetric and fetal
Chlamydia trachomatis infection, but may also outcomes [5]. However, the effect of subclini-
form after pelvic surgery or due to endometri- cal hypothyroidism (SCH) – defined as a thy-
osis. Pregnancy rates are inversely propor- rotropin (TSH) level above the upper limit of
tional to the number of PID episodes and can normal but not in the abnormal range and
be as low as 46% after three episodes of PID normal free thyroxine levels (T4) – on female
[8]. Pelvic adhesions increase the risk of a tubal infertility remains in question, with or with-
(ectopic) pregnancy. Blocked tubes (hydrosal- out the presence of anti-thyroid antibodies.
pinges) as well as pelvic adhesions can be The suggested prevalence of SCH in females
treated surgically. However, pregnancy rates of reproductive age is 3–8%. The strongest
are still low and in vitro fertilization (IVF) is evidence to date suggests that SCH (TSH > 4
often the preferred route in these patients. mIU/L) during pregnancy is associated with
higher rates of miscarriage; however, a meta-
analysis of levothyroxine (LT4) supplementa-
12.3.5 Systemic Diseases tion in infertile women with SCH found no
significant association between LT4 supple-
The effects of various systemic diseases have mentation and rates of clinical pregnancy, live
been implicated in female infertility. Two birth, or preterm birth rates [14]. Given a lack
common diseases with emerging evidence of a single standard of care, alongside the low
concerning infertility are described below. cost and safety of replacement, many practi-
tioners will obtain patients’ consent to offer
12.3.5.1 Vitamin D Insufficiency treatment to achieve a TSH of <2.5.
Vitamin D, a steroid hormone acquired
through dietary intake or cutaneous exposure
to UV light, has receptors in reproductive tis- 12.4 Initial Evaluation
sue. The physiologic implications of Vitamin of the Infertile Couple
D in female infertility are currently under
exploration. It is postulated that the transcrip- The primary focus of the initial evaluation of
tion of AMH, a key hormone for implanta- the infertile couple is to identify potential eti-
tion, is dependent on vitamin D levels since ologies and, ideally, modifiable factors that
may improve the chances of a couple estab- 55 Menstrual cycle characteristics including
lishing a successful pregnancy. The clinician duration, flow, mid-cycle spotting, pre-
should obtain a comprehensive history and menstrual symptoms, and changes from
perform a detailed physical examination. The previous norm (including shortening of
initial evaluation appointment is also an the normal cycle length)
opportunity for the care team to establish a 55 Symptoms of endometriosis such as dys-
sense of trust and collaboration with the cou- menorrhea and dyspareunia
ple given the stress and emotion that accom- 55 History of sexually transmitted diseases
panies experiencing infertility. 55 Previous methods of contraception and
any complications
55 Previous abnormal Pap smears and any
12.4.1 History associated interventions
55 History of endometriosis, fibroids, ovarian
The information gathered from a thorough cysts, and any associated interventions
medical history will enable the clinician to
narrow down the wide range of potential eti-
ologies and may permit a more targeted initial 12.4.1.3 Obstetrical History
evaluation and treatment plan. If applicable, the following should be
reviewed:
12.4.1.1 Demographics 55 Gravity, parity, pregnancy outcomes, and
The age of a female patient remains one of any associated complications
the most critical factors influencing her fertil- 55 Interval to conception with any previous
ity. Data have suggested that fertility in women pregnancy including whether fertility
peaks in the early 20s and declines slowly until drugs or other interventions were used and
age 35 at which point this decline accelerates. whether the pregnancy was with the cur-
For this reason, women older than 35 attempt- rent partner
ing to conceive are considered of late repro-
12 ductive age.
12.4.1.4 Medical History
12.4.1.2 Gynecological History The clinician should perform a thorough
Menstrual history is a crucial aspect of a com- review of both the patient’s and partner’s
prehensive gynecological history. An irregular past and present medical conditions includ-
menstrual pattern may suggest a thyroid, pro- ing prior hospitalizations, medications, aller-
lactin, or other hormonal etiology of the gies, and history of communicable diseases.
patient’s infertility while symptoms such as The preconception period is an ideal time to
dysmenorrhea and dyspareunia may provide maximize the patient’s health during preg-
useful information about risk factors for other nancy by optimizing any medical conditions
conditions such as endometriosis. Further such as diabetes, high blood pressure, or
more, characteristics such as shortened cycles body mass index (BMI). Likewise, if the
may be a potential indicator for diminished patient has a medical condition which is
ovarian reserve. One important risk factor for genetically transmitted, it is important to
early menopause is the patient’s mother’s age screen her partner and consider genetic coun-
at time of menopause. seling prior to attempts to conceive. There
The following details should be included are a multitude of screening blood tests that
in the gynecologic history: cover a wide range of conditions and should
55 Age of onset of menses be offered to all women considering preg-
55 Development of secondary sexual charac- nancy. Immunity status for rubella and vari-
teristics including breast (thelarche), pubic cella should be obtained and, if indicated,
hair (pubarche), axillary hair, and the pre- vaccination should be performed prior to
pubertal growth spurt (adrenarche) conception.
Female Infertility
287 12
12.4.1.5 Surgical History screen. Patients who screen positive should be
Surgical procedures should be reviewed encouraged to share this information with
including gynecological or abdominal surger- family members in case they are carriers as
ies, for example, colorectal surgery for inflam- well. If both patient and partner are carriers
matory bowel disease, which can lead to for the same condition, consideration should
adhesive disease and affect fertility [15]. be given to IVF with genetic testing of the
Additionally, information about minor, prior embryos, transferring only those embryos that
non- gynecologic surgeries, such as wisdom will not result in an affected offspring.
teeth removal, can be helpful as it provides
information about the patient’s response to 12.4.1.7 Social History
anesthesia. Information regarding diet, exercise, environ-
mental exposures, and substance use should be
12.4.1.6 Family History ascertained from all patients. Special attention
A thorough family history should be col- should be paid to nutritional status, most
lected, specifically focusing on (1) history of importantly, adequate consumption of folic
subfertility in parents and siblings, (2) age of acid, calcium, and vitamin D. Folic acid intake
menopause in the patient’s mother (as noted is critically important to assess, given its known
earlier, this is a risk factor for the proband) protective impact on certain birth defects;
and, if surgically induced, the indication for however, up to 30% of women attempting
surgery, and (3) heritable diseases including pregnancy may not be taking it, despite knowl-
both medical conditions and birth defects. edge of its benefits [17]. The use of herbal
Historically, populations at risk for specific preparations, vitamin supplements, or mega
genetic diseases were screened upon initial vitamins should also be ascertained, as they
evaluation at the recommendation of the may contain hormones or anti-inflammatory
American College of Obstetricians and agents that may impact fertility [18]. Exercise
Gynecologists [16]. Technology advancements habits should also be reviewed since reproduc-
now permit rapid testing for hundreds of dis- tive dysfunction has been reported to have a
orders without regard for ethnicity or risk fac- higher prevalence in athletes than in non-ath-
tors. This approach is performed by means of letes. Environmental exposures at work or in
a simple blood or saliva test, which costs less the household should be addressed including
than targeted testing and represents a com- smoking, exposure to second-hand smoke,
prehensive approach to identifying previously alcohol consumption, and caffeine intake, as
unscreened heritable conditions. these have known effects on pregnancy success
Disadvantages of testing include the cost of rates. Inhaled organic solvents (e.g., benzene,
generalized screening of all patients attempt- toluene) found in industrial compounds also
ing to conceive, as well as the screen positive impair female fertility; mechanistically, these
rate for non-actionable conditions, i.e., condi- molecules affect hormonal impairment,
tions that may not be clinically relevant. If a molecular alterations, oxidative stress, and
specific heritable condition is identified in the DNA methylation [19].
patient or their partner, screening for the con-
dition should be discussed regardless of the 12.4.1.8 Sexual History
clinical relevance to the patient’s sub-fertility To maximize the chance of conception, the
status. Similarly, for ethnicities with a higher clinician should discuss coital frequency and
prevalence of certain disorders (e.g., timing with the patient and their partner.
Ashkenazi Jewish ethnicity and Tay-Sachs Generally, intercourse is most likely to result
disease), a special panel should be considered in pregnancy when it occurs within the 3 days
as indicated. Additional counseling may be leading up to ovulation based on the survival
provided by a genetic counselor, who can also time of sperm in the female reproductive tract
aid in the determination of whom and how to [20, 21].
12.4.1.9 Considerations adversely impact ovulation and subsequent

for LGBTQ+ Patients implantation [28, 29].
Clinicians should be aware of special infertil-
ity considerations in the LGBTQ+ popula- 12.4.2.2 Visual Changes
tion. First, LGBTQ+ patients may be less Visual impairment is a presenting feature of
likely to seek reproductive services due to a space-occupying pituitary lesions such as cra-
lack of culturally competent messaging. In niopharyngiomas or macroadenomas [30].
the United States, the availability of electronic These pituitary lesions, if large enough, can
information regarding infertility treatment for extend out of the sella turcica and compress
LGBTQ+ patients varies by geographic the optic chiasm. Although uncommon, this
region. Larger fertility clinics in the northeast- most frequently presents as bitemporal hemi-
ern and western regions of the country are anopsia or bilateral loss of the peripheral
more likely to feature LGBTQ+ specific mes- visual fields. These patients often also simulta-
saging, while those in the Midwest and South neously present to an infertility evaluation
are significantly less likely to do so [22]. with menstrual dysfunction and/or galactor-
Second, special attention should be paid to rhea.
fertility preservation in transgender individu-
als. Gender-affirming hormones may compro-
12.4.2.3 ital Signs and Physical
V
mise gonadal function and lead to subfertility Examination
or infertility [23]. Thus, if conceiving biologi- Vital signs and a complete physical examina-
cal children is a possible consideration for the tion should be performed at the initial visit
patient, the clinician ought to refer them to a with emphasis on the following components.
fertility specialist during initial discussions of
gender-affirming treatment. Vital Signs
The vital signs assessment should focus on
patient weight and BMI (discussed below),
12.4.2 Review of Systems blood pressure, and pulse [31]. Hypertension
12 may suggest an underlying disease known to
In addition to the general medical history, a affect female fertility, such as PCOS or endo-
focused review of systems should be per- metriosis. Collecting a history of trends in the
formed, targeting hormonal or physiologic patient’s blood pressure is also useful, as
abnormalities. chronic hypertension can cause poor egg qual-
ity. Some medications used to treat female
12.4.2.1 Headaches infertility may worsen or induce hypertension;
Headaches are a common complaint in the therefore, patients should be advised of this
outpatient setting and are benign in the risk before initiating treatment [32].
majority of cases. However, headaches may
reflect medical conditions and/or pituitary BMI
lesions which can negatively impact fertility A BMI above or below the normal range has
[24–27]. The features of the patient’s head- been associated with anovulation, oligo-
ache should be characterized; specifically, ovulation, subfertility, and infertility [33].
whether the pain is resolved with medication, Patients should be educated on the associa-
presence of associated symptoms such as tion between BMI and ovulation and coun-
visual field disturbances, and whether the seled on lifestyle modifications to optimize
headaches are new or have changed in charac- their BMI. It is important to note that exces-
ter. Additionally, patients should be coun- sive weight negatively impacts fertility inde-
seled that the use of nonsteroidal pendent of ovulatory status. Furthermore, it
anti-inflammatory drugs (NSAIDs) during is well accepted that obesity is associated with
ovulation or infertility treatment may multiple high-risk obstetrical conditions such
Female Infertility
289 12
as diabetes and hypertension that provide an striae, and hirsutism. Acanthosis nigricans is
independent incentive to lose weight. defined as hyperpigmented, velvety plaques
found most commonly along the base of the
Thyroid neck, axilla, and the inner thighs. The forma-
Thyroid hormone disorders are associated tion of these lesions is thought to be triggered
with anovulation and menstrual irregularities. by hyperinsulinemia, a consequence of
The thyroid gland is located in the anterior obesity-induced insulin resistance. Polycystic
neck below the prominence of the thyroid car- ovarian syndrome is often associated with
tilage and should be palpated for thyromegaly insulin resistance; therefore, the presence of
or nodules. Abnormalities on physical exam these lesions warrants further investigation.
should be further evaluated with laboratory Abdominal striae are characterized as vio-
testing and possible imaging. In addition, any laceous striations most frequently noted on
patient with menstrual cycle irregularities the skin of the abdomen and hips [34]. They
should have their TSH assessed. can be associated with Cushing’s syndrome
and therefore warrant further evaluation for
Breast hypercortisolemia.
The breast examination in the fertility evalua- It is also important to assess the patient’s
tion should focus on symmetry of the breasts hair growth pattern to assess for hirsutism.
and any evidence of galactorrhea as this may Hirsutism is the overgrowth of facial or body
be indicative of a pituitary lesion. hair on women. Specifically, it can be seen as
Galactorrhea is defined as active secretion of coarse, dark hair that may appear on the face,
breast milk at a physiologically inappropriate chest, lower abdomen, back, upper arms, or
time, namely other than during pregnancy or upper legs. Hirsutism is caused by hyperan-
lactation. Secretions are usually white in color drogenism, most commonly in the setting of
and occur bilaterally from hormonal stimula- polycystic ovarian syndrome, when the ova-
tion of multiple ducts. Conversely, pathologi- ries produce excessive amounts of androgens.
cal discharge usually originates from a single Hirsutism can affect up to 10% of women and
duct and is therefore unilateral and often non- its presence should also help direct further
white in color. One helpful technique is to laboratory testing [35]. In addition, the patient
have the patient squeeze her breast to attempt should be queried as to what she does for hair
to express any discharge. She will likely pro- growth and maintenance to understand the
vide more pressure than the provider and, in a severity and recognize that an absence of vis-
patient who states that she has discharge, this ible hair growth may reflect recent efforts on
will show what is necessary to generate the her part.
milk (i.e., gentle pressure or significant manip-
ulation). 12.4.2.4 Gynecologic
The gynecologic exam should focus on identi-
Abdomen fying anatomical abnormalities that reflect
In cases of obesity, the abdomen should be congenital structural anomalies or organic
evaluated for distribution of adipose tissue. diseases, both of which may impact fertility.
Central adiposity in addition to other signs of For the purposes of the infertility evaluation,
hypercortisolemia could be associated with the gynecologic exam should assess for the
Cushing’s syndrome. Additionally, the clini- presence of clitoromegaly and structural
cian should inspect thoroughly for any scars abnormalities of the cervix, uterus, and pelvis.
indicating previous surgery that the patient Normally, in the non-erect state, the clito-
neglected to mention. ris is generally 3–4 mm in width, 4–5 mm in
length and partially covered by a hood of
Skin skin. Clitoromegaly, enlargement of the clito-
The skin should be evaluated for findings that ris, is a consequence of inappropriate andro-
can correlate with underlying endocrine gen exposure and is typically defined as a size
pathology: acanthosis nigricans, abdominal greater than 35 mm2 [36]. This finding on
physical exam warrants further investigation exam. The size and contour of the uterus
about ingestion of exogenous androgens, pos- should also be assessed on the bimanual exam.
sible in utero exposure to androgenic sub- Notable findings such as enlargement, irregu-
stances taken by the patient’s mother, or an larity, asymmetry, or tenderness all warrant
androgen-producing tumor. Physical signs of further investigation. Abnormalities associ-
androgen excess should be correlated with ated with decreased fecundity include leiomy-
laboratory testing. omata, adenomyosis, and Müllerian
Examination of the cervix should assess for anomalies. The adnexae should also be evalu-
cervical stenosis and structural abnormalities ated on bimanual exam. Any abnormalities
such as transverse ridges, cervical collars, on bimanual pelvic examination should be
hoods, coxcombs, pseudopolyps, cervical hypo- further evaluated, typically with imaging such
plasia, and agenesis [37]. Cervical stenosis is the as ultrasound.
cervical abnormality most commonly associ-
ated with infertility. It decreases fertility by
diminishing the mucus bridge from the vagina 12.4.3 Diagnostic Testing
to the endocervix that is necessary for sperm
transport. The remaining structural abnormal- Following the medical history and physical
ities are less common and can be secondary to exam, further testing is needed and can be
idiopathic developmental anomalies or obstet- divided into two categories: (1) preconception
rical trauma and surgical procedures. Exposure screening and (2) infertility evaluation.
to diethylstilbestrol (DES), a synthetic estro-
gen, is historical and the associated anatomic 12.4.3.1 Preconception Screening
findings are essentially no longer seen. Preconception screening consists of tests that
The bimanual examination should assess should be performed on all women consider-
for cervical motion tenderness as well as struc- ing pregnancy. This includes a current Pap
tural abnormalities of the uterus and adnexae. smear, type and screen, testing for sexually
Cervical motion tenderness can be elicited by transmitted infections (STIs), and documen-
12 gentle lateral movement of the cervix. This tation of immunity to rubella and varicella.
finding can be associated with an active or Recommended screening for STIs includes
prior pelvic infection or adhesive disease. The syphilis, hepatitis B surface antigen, HIV 1
mechanism of this physical exam finding is and 2 antigen/antibody, hepatitis C antibody,
that the movement of the cervix causes move- and RNA-/DNA-based gonorrhea and chla-
ment of the adnexae as well. Therefore, in the mydia testing. Patients who are not immune
setting of an infection or adhesions around or to varicella or rubella should receive the
in the vicinity of the fallopian tubes or ova- appropriate vaccination at least 1 month prior
ries, sliding of the inflamed peritoneum with to attempting conception. Women should also
this test may elicit significant tenderness. be up to date on their tetanus-diphtheria-
Even without pelvic adhesions, endome- pertussis vaccine [38]. When indicated, addi-
triosis can cause cervical motion tenderness tional targeted well-women health screenings,
when it involves structures attached to the cer- such as mammograms, should be performed
vix such as the vaginal apex, cardinal liga- during this time to maximize health and avoid
ments, uterosacral ligaments, or inferior delays in screening tests.
aspect of the broad ligaments. The cervix may
be laterally deviated as a result of ipsilateral 12.4.3.2 Infertility Evaluation
shortening of a uterosacral ligament which The infertility evaluation consists of labora-
has endometriosis, fibrosis, or a Müllerian tory testing in addition to those performed for
anomaly such as a unicornuate uterus. preconception screening. These tests assess
Nodularity of the uterosacral ligaments can ovulatory function and ovarian reserve.
often be felt on bimanual examination if Imaging studies such as hysterosalpingogra-
endometriosis is present in that region and phy and sonohysterography are also typically
may be especially prominent on recto-vaginal performed, and if warranted from the patient’s
Female Infertility
291 12
history or physical exam, hysteroscopy or lap- with regular cycles (25–35 day intervals) and
aroscopy may be indicated as well. symptoms such as breast tenderness, bloating,
and dysmenorrhea are likely to have normal
Thyroid-Stimulating Hormone (TSH) ovulatory function. As previously noted, sev-
Hypothyroidism is a relatively common medi- eral hormonal abnormalities can commonly
cal problem in women and can result in ovula- cause ovulatory dysfunction in otherwise
tory dysfunction even in the presence of healthy patients.
minimal or no symptoms. Fortunately, it is Therefore, tests such as TSH and prolactin
relatively easy to treat. TSH is the screening are important to obtain in tandem in women
test of choice for identifying thyroid hormone with irregular cycles. Other tests such as mid-
abnormalities and should be performed at the luteal serum progesterone and urine luteiniz-
initial infertility visit. Hypothyroidism is sug- ing hormone surge detection can provide
gested when TSH is elevated and should be additional information about ovulatory func-
repeated with a measurement of free T4 [39]. tion. The infertility evaluation and treatment
When TSH is abnormally low, it can indicate have evolved such that if a woman presents
hyperthyroidism and further testing is with regular cycles many practitioners will not
required. As previously mentioned, there assess for ovulatory dysfunction given a low
remains controversy surrounding the clinical yield, alongside the use of fertility drugs such
significance of subclinical hypothyroidism as clomiphene citrate which may correct any
(SCH) in women attempting to conceive. subtle disturbances.
Given a lack of a single standard of care,
alongside the low cost and safety of replace- zz Serum Progesterone
ment, some practitioners will obtain patients’ Measurement of serum progesterone levels
consent to offer treatment to achieve a TSH can also be used to document ovulation.
of <2.5. Serum progesterone levels below 2–3 ng/mL
are consistent with no ovulation when mea-
Prolactin sured at the appropriate time. After ovulation,
Hyperprolactinemia is an important cause of progesterone is secreted from the corpus
oligomenorrhea or amenorrhea. The most luteum and levels rise steadily until they peak
common cause for hyperprolactinemia in approximately 7–8 days following ovulation.
women is a prolactin-secreting adenoma usu- Typically, a serum progesterone level > 3 ng/
ally diagnosed with MRI after an elevated mL provides reliable evidence that ovulation
prolactin is identified on bloodwork and con- has taken place but does not provide informa-
firmed on repeat sampling. It is also impor- tion on when it occurred [41]. Serum proges-
tant to note that thyrotropin-releasing terone levels are not typically used to assess
hormone (TRH) is a potent prolactin stimu- the strength or adequacy of ovulation but
lating substance and since this is increased rather whether the patient has or has not ovu-
along with TSH in hypothyroid states, prolac- lated. A serum progesterone may be valuable
tin levels can be elevated in women with hypo- if the plan is to induce menstruation via a
thyroidism [40]. For this reason, TSH and course of exogenous progesterone (e.g.,
prolactin should be drawn together at the medroxyprogesterone acetate) followed by a
initial evaluation in women with menstrual withdrawal bleed. If only a pregnancy test is
irregularities as appropriate to establish the obtained prior to administering medroxypro-
correct diagnosis. Lastly, a careful medication gesterone acetate, it is possible that the patient
history should be taken as various medica- may be in her luteal phase and/or with an
tions can also contribute to an elevated pro- early pregnancy.
lactin.
zz Basal Body Temperature Charts (BBTs)
Ovulatory Function Progesterone is a thermogenic hormone and
Ovulatory function can often be deduced will slightly raise core body temperature.
from a patient’s menstrual history. Women Women can measure their temperature with a
thermometer designed to show smaller differ- line FSH levels are >10 IU/L, success with ther-
ences in temperature. This can show ovulation apies including IVF is diminished [43]. Estradiol
and duration of the luteal phase based on levels should be drawn with all basal FSH levels
endogenous progesterone production. Taking to demonstrate that a low FSH level is not
one’s temperature every day can be stressful, falsely suppressed secondary to a prematurely
and as the temperature only rises after ovula- elevated estradiol level (defined as greater than
tion, these are typically not recommended 60–80 pg/mL). Although a day 3 FSH was
especially given the utility of urine LH detec- required historically, FSH and estradiol levels
tion kits. can be drawn on either cycle day 2 or 3 to facil-
itate the process for the patient [44].
zz Urinary Luteinizing Hormone (LH)
Of the tests described in this section, measure- zz Anti-Müllerian Hormone (AMH)
ment of urinary LH is the only test that can Anti-Müllerian hormone, also known as
predict ovulation before it occurs, thereby giv- Müllerian inhibiting substance (MIS), is pro-
ing patients the ability to time intercourse to duced by the granulosa cells of ovarian folli-
attempt conception. These highly accurate cles and reflects the primordial follicle reserve.
over-the-counter tests are designed to change Unlike other ovarian reserve tests, AMH can
color when urinary LH levels reach those asso- be measured at any point during the men-
ciated with the mid-cycle LH surge, indicating strual cycle. Levels less than 1.0 ng/mL are
imminent ovulation. Testing should be per- considered abnormal and are associated with
formed daily starting 3 days before the expected poor ovarian response to gonadotropin stim-
day of ovulation to ensure that ovulation is not ulation [45, 46].
missed. Ovulation will generally follow within
12–36 hours following a positive surge with the zz Antral Follicle Count (AFC)
variability reflecting the once daily testing of The AFC is determined using transvaginal
an ongoing process. If used for timed inter- ultrasound in the early follicular phase to
course or intrauterine insemination (IUI) , the quantify the number of follicles between 2
12 day after the first positive test will have the and 10 mm in diameter. These antral follicles
highest success rate of clinical pregnancy [42]. may be thought of as eggs in the “pipeline”
reflecting overall ovarian reserve and can be
12.4.3.3 Ovarian Reserve Testing used as a predictive measure of overall future
Ovarian reserve has become an integral part production. An AFC of less than 10 has been
of the infertility evaluation and can be shown to correlate with poor ovarian response
assessed with several methods. It is well known to gonadotropin stimulation [47]. High antral
that fertility declines with a woman’s age due follicle counts are often associated with PCOS.
to the decrease in oocyte quantity and quality.
The tests most commonly used to assess ovar- zz Clomiphene Citrate Challenge Test (CCCT)
ian reserve include early follicular phase Clomiphene citrate is a selective estrogen
follicle-stimulating hormone (FSH) and estra- receptor modulator (SERM) that has an
diol levels, anti-Müllerian hormone (AMH), antagonist effect on the hypothalamus, there-
and antral follicle count (AFC). Other tests, fore blocking the inhibitory feedback of estro-
such as the clomiphene citrate challenge test gen. This in turn leads to an increase in GnRH
(CCCT), are employed infrequently. and therefore FSH at the level of the pituitary.
The CCCT is a provocative examination
zz FSH and Estradiol designed to “unmask” those patients with a
FSH is a hormone secreted by the pituitary normal day 3 FSH level. With this test, a basal
gland and functions to recruit follicular cohorts. FSH level and estradiol are measured on cycle
As ovarian reserve diminishes, the pituitary day 3. The patient is given clomiphene citrate
gland increases FSH production in order to 100 mg daily on cycle days 5 through 9 and
compensate. It has been shown that when base- the FSH level is again measured on cycle day
Female Infertility
293 12
10. The test is considered abnormal if the day 12.4.4.3 Hysterosalpingography
3 FSH, day 3 estradiol, or day 10 FSH levels Hysterosalpingography (HSG) is a radio-
are elevated [48]. Given the utility of tests for graphic evaluation of the uterine cavity and
AMH and AFC, and the fact that the CCCT fallopian tubes. Contrast dye is injected
requires exogenous medication (clomiphene through the cervix into the uterine cavity with
citrate) and a second blood draw on day 10, spillage of the dye into the abdominal cavity if
this test is obtained infrequently. the fallopian tube(s) are patent. This test is
used to diagnose synechia and other intracavi-
tary defects such as polyps and fibroids as well
12.4.4 Imaging Studies as Müllerian anomalies such as a septate or
bicornuate uterus. Furthermore, hysterosal-
12.4.4.1 Ultrasonography pingography can not only assess tubal patency
Transvaginal ultrasonography is the first-line but also potentially identify the site of obstruc-
imaging study for identifying structural tion if the fallopian tubes are blocked. Of note,
abnormalities in the pelvis, particularly of the although the primary purpose of this study is
uterus and ovaries [49]. It should be consid- not therapeutic, oil-based media have been
ered if a structural lesion is suspected on shown to increase subsequent pregnancy rates
physical examination. In addition, the ultra- [50]. The HSG is not as sensitive as the SIS for
sound probe can be used to push on structures evaluating the cavity; however, because it pro-
to localize symptoms (such as pain in an vides greater details about the tubes, it is often
endometrioma) as well as to assess sliding of the first-line test in an infertility evaluation.
the ovary or uterus alongside bowel to assess
for adhesions. However, some conditions may
be undetectable, especially if the exam is lim- 12.4.5 Surgery
ited by patient discomfort, body habitus, or if
any abnormalities are located above the field Hysteroscopy involves introducing a small
of view. Transvaginal ultrasound may be con- diameter telescope with a light source through
sidered in all infertile women, especially if the the cervix into the uterine cavity. Similar to
plan is to obtain an AFC. sonohysterography, saline is typically used to
distend the cavity. Hysteroscopy is often con-
12.4.4.2 Sonohysterography sidered the gold standard for visualizing the
Sonohysterography (also known as saline cavity and can be used for both diagnostic and
infusion sonography or SIS) is an imaging test therapeutic purposes. Diagnostic hysteros-
that utilizes transvaginal ultrasonography in copy can often be performed in the office
which a fluid medium, typically saline, is when there is suspicion for an intracavitary
instilled through the cervix to distend the lesion based on the patient’s history such as
uterine cavity in the early follicular phase after abnormal uterine bleeding or specific findings
the conclusion of menses. More accurate than noted on prior imaging. Hysteroscopy in the
transvaginal ultrasound alone, this increases office provides the advantage of potentially
the provider’s ability to identify endometrial being able to immediately treat any findings
or intracavitary lesions such as polyps or found (i.e., “see and treat”) if the lesions are
fibroids and intrauterine adhesions (syn- small. For more substantial findings (i.e.,
echia). When used with specialized contrast fibroids), anesthesia is typically required;
media (saline with bubbles infused), sonohys- hence, the study is more commonly performed
terography may also be used to attempt to in the operating room.
assess tubal patency. If combined with 3D Laparoscopy can be useful for some infer-
ultrasound, SIS provides significant informa- tile women since it is the only definitive
tion about the uterus including possible dif- method of accurately diagnosing anatomic
ferentiation of uterine anomalies such as a lesions such as endometriosis and intraperito-
bicornuate from a septate uterus. neal adhesions and the only modality to treat
structural findings. However, as fertility treat- the hypothalamic–pituitary–gonadal axis to

ments have evolved, fewer laparoscopies are similarly increase FSH production.
done for infertility alone, as IVF provides When using these medications, it is impor-
higher pregnancy rates with a lower risk of tant to distinguish patients who have ovula-
ectopic pregnancy in women with pelvic tory infertility from those with unexplained
pathology. Furthermore, laparoscopic treat- and ovulatory infertility. In women who are
ment of low-stage endometriosis results in anovulatory, the goal is to achieve mono-
only a small absolute increase in pregnancy follicular development. Letrozole has emerged
rates, requiring many women to undergo a as a superior choice over clomiphene in this
laparoscopy to achieve a pregnancy [51]. population [53].
Nevertheless, in situations where higher In women who are ovulatory and not con-
stage endometriosis or pelvic pathology is sus- ceiving despite releasing an egg each month,
pected, the patient has significant pelvic pain the goal is to increase their ovulatory function
which she desires to be addressed surgically, using a more aggressive protocol. Clomiphene
or IVF is not able to be performed, then lapa- citrate remains the protocol of choice over
roscopy may be an excellent option for both letrozole [53].
diagnostic and therapeutic purposes. As opposed to the traditional 50 mg dur-
ing cycle days 5–9, the standard dosing regi-
men for clomiphene, when used for ovulation
12.5 Treatment induction, is 100 mg orally during cycle days
3–7. Furthermore, to optimize pregnancy
There are many options for infertility treat- rates, this should be combined with intrauter-
ment. Specific therapies should be selected ine insemination (IUI) as ovulatory women
based on the results of the patient’s evaluation who take clomiphene and utilize timed inter-
as described above. As many of these thera- course do not have an increased pregnancy
pies can be extremely expensive and are not rate compared to non-medicated cycles [54].
necessarily covered by medical insurance, it is
12 always ideal to begin with the least invasive
and least expensive option. However, there 12.5.2 Ovarian Stimulation
has been greater movement to move immedi- (Injectable Gonadotropins)
ately to IVF if pregnancy has not been
achieved with lesser treatment [52]. Controlled ovarian stimulation with gonado-
Furthermore, some conditions such as tubal tropins (i.e., follicle stimulating hormone) is
blockage and severe male factor dictate mov- used to stimulate the ovaries to produce one
ing directly to IVF. egg in anovulatory women refractory to oral
medications and more than one mature folli-
cle per cycle in women who are infertile and
12.5.1 Oral Medications not conceiving. Multiple follicular develop-
ment increases both the chances of any one
Clomiphene citrate is a selective estrogen recep- egg fertilizing (and therefore overall preg-
tor modulator (SERM) that inhibits the nega- nancy rates) and also more than one egg fertil-
tive feedback effect of estrogen on the izing (increasing the risk of multiple
hypothalamus and, therefore, upregulates the gestations). Gonadotropin therapy is more
hypothalamic–pituitary–gonadal axis to effective than clomiphene or letrozole for ovu-
increase the likelihood of ovulation in anovula- latory women with infertility [55]. Side effects
tory women or the release of more than one egg of these medications include ovarian hyper-
in women who are already ovulatory. Letrozole stimulation syndrome (OHSS) and ovarian
functions as an aromatase inhibitor, decreasing damage or torsion.
the peripheral enzymatic conversion of andro- Multiple gestations typically only occur
gens to estrogens. This overall decreases the in 1–2% of naturally occurring pregnancies.
body’s estrogen level and provides feedback to With injectable gonadotropins, 20–30% of
Female Infertility
295 12
these pregnancies are associated with multi- ment cycle for the majority of women. It
ple implantations. Multiple pregnancies are involves ovarian stimulation with injectable
associated with an increased risk of miscar- gonadotropins typically with the use of a
riage, preterm delivery, pregnancy-induced gonadotropin-releasing hormone (GnRH)
hypertension, postpartum hemorrhage, and agonist or a GnRH antagonist to suppress the
other maternal complications. Given the LH surge and premature ovulation. Human
accepted goal of avoiding multiple gesta- chorionic gonadotropin (hCG) is typically
tions, especially high-order multiple gesta- given to mature the eggs, triggering ovulation.
tions, many providers avoid using The oocytes are then retrieved through needle
gonadotropins other than with IVF, espe- aspiration transvaginally under ultrasound
cially as the literature supports a faster time guidance. In some cycles, all oocytes and/or
to pregnancy by moving directly from clomi- embryos may be frozen, for example, when the
phene to IVF [52]. indication is fertility preservation or when
genetic testing (e.g., preimplantation genetic
testing) is done. Alternatively, the oocytes can
12.5.3 Intrauterine Insemination be fertilized with a prepared sperm sample
and incubated. The embryos are graded using
Intrauterine insemination (IUI) is a procedure quality assessment criteria such as cell regu-
performed in the ambulatory setting in which larity, degree of fragmentation, and other
prepared sperm is placed directly into the microscopic characteristics [58]. Those of
woman’s uterus through a catheter. When highest quality are selected for transfer, which
treating ovulatory infertile women, IUIs are is performed transcervically through a small
typically included routinely in the treatment catheter under ultrasound guidance.
regimen to maximize pregnancy rates. Supplemental progesterone is used to support
There are several indications for IUI alone the luteal phase since no ovulation takes place
including the use of donor sperm, male factor in IVF, and there may be inadequate endoge-
infertility such as low motility [56], coital dys- nous progesterone production.
function, cervical factor such as no mucous The live birth rate using IVF varies widely
production, or stenosis due to a surgical depending on many factors including, but not
procedure such as a loop electrosurgical exci- limited to, the woman’s age, BMI, duration of
sion procedure (LEEP) or cone biopsy. IUIs infertility, and presence of hydrosalpinges.
will not be effective in patients with tubal Importantly, of these, the woman’s age is per-
blockage, severe endometriosis, or intraab- haps the most important and the factor used
dominal adhesions since they still require the when quoting pregnancy rates. The goal of
oocyte to travel from the ovary to the uterine IVF is to achieve a singleton pregnancy, given
cavity. IUI alone is not indicated for ovulatory the risks associated with twins or higher order
women with unexplained infertility or in med- multiple gestations. The Society for Assisted
icated cycles in anovulatory women. Reproductive Technology has an excellent
website with information about IVF and preg-
nancy rates [59], as well as a calculator to help
12.5.4 Assisted Reproductive predict pregnancy rates [60].
Technology
Assisted reproductive technology (ART) con- 12.5.5 Donor Gametes
sists of technologies in which eggs or embryos
are handled which narrows the definition to Donor gametes (sperm or eggs) or donor
IVF. If only the sperm is handled (e.g., intra- embryos should be discussed with appropriate
uterine insemination), this is not considered patients. Care should be taken to anticipate
ART by the CDC [57]. IVF is the most suc- and prepare for the period of grieving or
cessful fertility intervention in any one treat- anger associated with these routes in patients
who have not anticipated this need. Patients unwilling or unable to continue treatment. If
should be given time and resources to address these couples are unwilling to consider adop-
the psychological aspects of the situation tion, the clinician should be prepared to dis-
prior to pursuing either of these options and cuss childfree living, a concept that may be
psychological counseling is recommended difficult for infertile couples to accept. It is
[61]. Of note, although specific recommenda- important to recognize that couples may per-
tions are made for counseling when donor ceive childfree living as their personal failure
gametes are used, psychological support and are prone to develop depressive symp-
should be available for all patients presenting toms or even marital conflict as a result [62].
with infertility given the associated stress. Fortunately, there is evidence to suggest that
cognitive-behavioral therapy focused on
validating emotion, educating on the psycho-
12.5.6 Adoption, Fostering, logical effects of infertility and treatment, and
and Childfree Living providing tools to manage emotions can sig-
nificantly reduce couples’ rejection of the
While advances in female infertility evalua- childfree lifestyle [63]. During this grieving
tion and treatment have greatly improved the period, clinicians may refer patients for sup-
rate of successful pregnancies, a percentage of port to reduce couples’ psychological and
couples will fail all interventions and/or be relational burdens.
12.6 Comparison of International

Protocols for Evaluation
of Female Infertility
Country of United States Canada United Kingdom Germany, Switzer-

12 Origin land, and Austria
Publishing American College of Canadian Fertility National Institute German Society of

Body Obstetricians and and Andrology for Health and Care Gynecology and
Gynecologists’ Society Excellence (UK) Obstetrics; Swiss
Committee on Society of Gynecol-
Gynecologic Practice ogy and Obstetrics;
Austrian Society of
Gynecology and
Obstetrics
Last Updated 2019 2002 2017 2020
Definition of Failure to achieve a Inability to The period of time Failure to achieve a
Infertility successful pregnancy conceive after 1 people have been successful pregnancy
after 12 months or year of unpro- trying to conceive after 12 months or
more of regular tected intercourse without success more of appropriate,
unprotected after which formal timed, unprotected
intercourse investigation is intercourse
justified and
possible treatment
implemented
Female Infertility
297 12
Country of United States Canada United Kingdom Germany, Switzer-

Origin land, and Austria
Recommenda- Serum TSH: Perform Serum TSH: Do Serum TSH: Offer Serum TSH:
tions on for women with not measure in the only to women with Perform for all
Etiology ovulatory dysfunc- absence of symptoms of women; if greater
Testing tion, infertility, or irregular cycles thyroid disease than 2.5 mU/L,
evidence of thyroid Serum Prolactin: Serum Prolactin: measure anti-thyroid
disease Do not measure in Offer only to antibody level
Serum Prolactin: the absence of women who have Serum Prolactin:
Perform in women irregular cycles an ovulatory Perform at time of
with irregular menses Tubal Patency: disorder, galactor- diagnostic workup
or signs of hyperpro- Evaluate using rhea, or a pituitary Tubal Patency:
lactinemia hysterosalpingo- tumor Evaluate using
Tubal Patency: gram Tubal Patency: laparoscopy with
Evaluate using Sexually Offer hysterosalpin- chromopertubation
hysterosalpingogra- Transmitted gogram to women or hysterosalpingo-
phy and/or hystero- Infections: with no known contrast sonography
salpingo-contrast Perform endocer- uterine comorbidi- (HyCoSy)
sonography vical culture to ties to rule out Sexually Transmit-
Sexually Transmitted rule out asymp- tubal occlusion ted Infections: Not
Infections: Obtain tomatic disease Sexually Transmit- stated
exposure information prior to perform- ted Infections: Endometrial Biopsy:
during initial medical ing uterine Offer screening for Do not perform if
interview instrumentation CChlamydia menstrual cycle
Endometrial Biopsy: Endometrial trachomatis prior to length is unremark-
Perform only when Biopsy: Do not performing uterine able and regular
endometrial perform instrumentation
pathology (e.g., Endometrial Biopsy:
neoplasia, chronic Do not offer to
endometriosis) is evaluate the luteal
strongly suspected phase
Evaluation of Antral Follicle Count: Antral Follicle Antral Follicle Antral Follicle
Ovarian Perform for Count: Not stated Count: Perform as Count: Perform
Reserve evaluation of an initial predictor during diagnostic
etiology of infertility of success through workup for
natural conception hormonal disorders
or with IVF
Recommenda- Obesity: Obtain BMI Obesity: Obesity: Advise Obesity: Advise
tions on during initial physical Recommend a women with a women with a BMI
Lifestyle examination supervised BMI ≥ 30 to lose of > 30 to lose
Factors Low Body Weight: weight-loss bodyweight weight
Obtain BMI during program Low Body Weight: Low Body Weight:
initial physical regardless of Advise women with Advise women with a
examination ovulatory status a BMI < 19 to BMI < 19 and
Smoking: Obtain Low Body Weight: increase body disordered ovulation
history during initial Not stated weight to increase body
medical interview Smoking: Advise Smoking: Offer a weight
to give-up referral to a Smoking: Discuss
smoking smoking cessation potential negative
program impact during initial
medical interview
12.7 Concluding Remarks 6 months. If she has not conceived

by then, she will meet criteria for in-
Although infertility is a relatively common fertility evaluation.
medical problem, the process of evaluation C. The patient does not yet meet diag-
and treatment can be long, emotionally tax- nostic criteria. Question her further
ing, and frustrating. Patients should be on her family history, as a family
encouraged to seek care in a timely fashion history of subfertility is a diagnostic
with a provider who can attempt to expedite criterion.
their treatment using modern techniques. The D. The patient does not yet meet diag-
role of the provider is to offer support while nostic criteria. Advise her to contin-
maintaining realistic expectations based on ue her practices and return at 1 year.
the clinical evidence at hand. As in other fields If she has not conceived by then,
of healthcare, there are disparities in access she will meet criteria for infertility
to, and awareness of, infertility treatment. evaluation.
Black women present later for infertility treat-
ment and are less likely to pursue treatment ??2. A 23-year-old transgender man presents
than white women [64]. Providers for women to clinic for consultation on gender-
of minority populations should establish open affirming surgery. During your medi-
communication lines to encourage patients to cal interview, you discover the patient
seek treatment if they so choose. While there desires to start a biological family in
are many options for infertility treatment at the future. How can you honor their
this time, a relatively large proportion of request?
infertility does not carry a readily obtainable A. Advise the patient that unfortu-
diagnosis. Therefore, further research is nately conceiving a biological child
required to better understand how and why will not be possible if they desire
infertility occurs, as well as to develop innova- gender-affirming surgery.
tive treatment techniques and optimize exist- B. Refer the patient to a fertility spe-
12 ing ones. Fortunately, current technologies cialist to discuss options for preserv-
allow a majority of patients to achieve their ing fertility after gender- affirming
dream of a family. procedures have been initiated.
C. Refer the patient to a fertility spe-
cialist to discuss options for preserv-
12.8 Review Questions ing fertility before gender-affirming
procedures have been initiated.
??1. A 28-year-old woman with no signifi- D. Forgo referral to a fertility specialist
cant past medical history presents to an and refer the patient to an adoption
outpatient OB/GYN clinic. She reports counselor.
an inability to conceive despite regular,
timed intercourse for the past 4 months. ?? 3. A 37-year-old woman attempting to con-
She has no family history of subfertility. ceive presents having had two prior pelvic
She is concerned and requests to begin infections with PID and an ectopic preg-
an infertility evaluation. As her pro- nancy for which the affected tube was
vider, which of the following is the most removed. Her HSG imaging study shows
appropriate response? a large hydrosalpinx in remaining tube.
A. The patient meets diagnostic criteria. Based on current evidence, you tell her:
Initiate a formal infertility evaluation. A. Her best chance for pregnancy is sur-
B. The patient does not yet meet diag- gery to repair the remaining tube.
nostic criteria. Advise her to con- B. Her best chance for pregnancy is
tinue her practices and return at in vitro fertilization.
Female Infertility
299 12
C. Her best chance for pregnancy is 9. Tanbo T, Fedorcsak P. Endometriosis-associated
clomiphene citrate with intrauterine infertility: aspects of pathophysiological mecha-
nisms and treatment options. Acta Obstet Gynecol
inseminations (IUI).
Scand. 2017;96(6):659–67. https://doi.org/10.1111/
D. She will not be able to conceive and aogs.13082.
should consider adoption. 10. Practice bulletin no. 114: management of endome-
triosis. Obstet Gynecol. 2010;116(1):223–36.
https://doi.org/10.1097/AOG.0b013e3181e8b073.
11. McGovern PG. Is vitamin D important for in vitro
12.9 Answers fertilization success? Fertil Steril. 2020;114(5):962.
https://doi.org/10.1016/j.fertnstert.2020.08.009.
vv1. D 12. Chu J, Gallos I, Tobias A, Tan B, Eapen A,
Coomarasamy A. Vitamin D and assisted repro-
ductive treatment outcome: a systematic review
and meta-analysis. Hum Reprod. 2018;33(1):65–
vv2. C 80. https://doi.org/10.1093/humrep/dex326.
13. Iliuta F, Pijoan JI, Lainz L, Exposito A, Matorras
R. Women’s vitamin D levels and IVF results: a
vv3. B systematic review of the literature and meta-
analysis, considering three categories of vitamin
status (replete, insufficient and deficient). Hum
Fertil. 2020:1–19. https://doi.org/10.1080/1464727
References 3.2020.1807618.
14. Rao M, Zeng Z, Zhao S, Tang L. Effect of levothy-
roxine supplementation on pregnancy outcomes in
1. Vander Borght M, Wyns C. Fertility and infertility:
women with subclinical hypothyroidism and thy-
definition and epidemiology. Clin Biochem.
roid autoimmuneity undergoing in vitro fertiliza-
2018;62:2–10. https://doi.org/10.1016/j.clinbio-
tion/intracytoplasmic sperm injection: an updated
chem.2018.03.012.
meta-analysis of randomized controlled trials.
2. Gelbaya TA, Potdar N, Jeve YB, Nardo
Reprod Biol Endocrinol. 2018;16(1):92. https://
LG. Definition and epidemiology of unexplained
doi.org/10.1186/s12958-018-0410-6.
infertility. Obstet Gynecol Surv. 2014;69(2):109–15.
15. ten Broek RPG, et al. Burden of adhesions in
https://doi.org/10.1097/OGX.0000000000000043.
abdominal and pelvic surgery: systematic review
3. Marshburn PB. Counseling and diagnostic evaluation
and met-analysis. BMJ. 2013;347:f5588. https://
for the infertile couple. Obstet Gynecol Clin North
doi.org/10.1136/bmj.f5588.
Am. 2015;42(1):1–14. https://doi.org/10.1016/j.
16. American College of Obstetricians and
ogc.2014.10.001.
Gynecologists. Carrier screening. https://www.
4. National public health action plan for the detec-
acog.org/en/womens-health/faqs/carrier-screening.
tion, prevention, and management of infertility.
17. Frishman GN, Spurrell TP, Heber WW. Folic acid.
p. 26.
Preconception knowledge and use by infertile
5. American Society for Reproductive Medicine.
women. J Reprod Med. 2001;46(12):1025–30.
Diagnostic evaluation of the infertile female: a com-
18. Kaye AD, et al. Herbal medicines: current trends
mittee opinion. Fertil Steril. 2015;103(6):e44–50.
in anesthesiology practice--a hospital survey. J
Clin Anesth. 2000;12(6):468–71. https://doi.
6. American College of Obstetricians and
org/10.1016/s0952-8180(00)00195-1.
Gynecologists’ Committee on Practice Bulletins—
19. Kumar S, Sharma A, Kshetrimayum
Gynecology. ACOG Practice Bulletin No. 194:
C. Environmental & occupational exposure &
Polycystic ovary syndrome. Obstet Gynecol.
female reproductive dysfunction. Indian J Med
2018;131(6):e157–71. https://doi.org/10.1097/
Res. 2019;150(6):532–45. https://doi.org/10.4103/
AOG.0000000000002656.
ijmr.IJMR_1652_17.
7. Azziz R, et al. The Androgen Excess and PCOS
20. Williams M, Hill CJ, Scudamore I, Dunphy B, Cooke
Society criteria for the polycystic ovary syndrome:
ID, Barratt CL. Sperm numbers and distribution
the complete task force report. Fertil Steril.
within the human fallopian tube around ovulation.
2009;91(2):456–88. https://doi.org/10.1016/j.fertn-
Hum Reprod. 1993;8(12):2019–26. https://doi.
stert.2008.06.035.
org/10.1093/oxfordjournals.humrep.a137975.
8. Walker MH, Tobler KJ. Female infertility. In:
21. Gould JE, Overstreet JW, Hanson FW. Assessment
StatPearls. Treasure Island (FL): StatPearls
of human sperm function after recovery from the
Publishing; 2020. Accessed: 04 Jan 2021. [Online].
female reproductive tract. Biol Reprod.
Available: http://www.ncbi.nlm.nih.gov/books/
1984;31(5):888–94. https://doi.org/10.1095/biolre-
NBK556033/.
prod31.5.888.
22. Wu HY, et al. Lesbian, gay, bisexual, transgender 36. Gupta M, Saini V, Poddar A, Kumari S, Maitra
content on reproductive endocrinology and infer- A. Acquired Clitoromegaly: a gynaecological
tility clinic websites. Fertil Steril. 2017;108(1):183– problem or an obstetric complication? J Clin
91. https://doi.org/10.1016/j.fertnstert.2017.05.011. Diagn Res JCDR. 2016;10(12):QD10–1. https://
23. Kyweluk MA, Reinecke J, Chen D. Fertility preser- doi.org/10.7860/JCDR/2016/23212.9072.
vation legislation in the United States: potential 37. Long WN. Pelvic examination. In: Walker HK,
implications for transgender individuals. LGBT Hall WD, Hurst JW, editors. Clinical methods: the
Health. 2019;6(7):331–4. https://doi.org/10.1089/ history, physical, and laboratory examinations. 3rd
lgbt.2019.0017. ed. Boston: Butterworths; 1990. Accessed: Apr. 09,
24. Banna M. Craniopharyngioma: based on 160 2021. [Online]. Available: http://www.ncbi.nlm.
cases. Br J Radiol. 1976;49(579):206–23. https:// nih.gov/books/NBK286/.
doi.org/10.1259/0007-1285-49-579-206. 38. Practice Committee of American Society for
25. Sklar CA. Craniopharyngioma: endocrine abnor- Reproductive Medicine. Vaccination guidelines for
malities at presentation. Pediatr Neurosurg. female infertility patients: a committee opinion.
1994;21(Suppl. 1):18–20. https://doi.org/10.1159/ Fertil Steril. 2013;99(2):337–9. https://doi.
000120856. org/10.1016/j.fertnstert.2012.08.027.
26. Schlechte J, et al. Prolactin-secreting pituitary 39. Thyroid Function Tests. American Thyroid
tumors in amenorrheic women: a comprehensive Association. https://www.thyroid.org/thyroid-
study*. Endocr Rev. 1980;1(3):295–308. https:// function-tests/. Accessed 09 Apr 2021.
doi.org/10.1210/edrv-1-3-295. 40. Spencer C, et al. Specificity of sensitive assays of
27. Vallette-Kasic S, et al. Macroprolactinemia revis- thyrotropin (TSH) used to screen for thyroid dis-
ited: a study on 106 patients. J Clin Endocrinol ease in hospitalized patients. Clin Chem.
Metab. 2002;87(2):581–8. https://doi.org/10.1210/ 1987;33(8):1391–6.
jcem.87.2.8272. 41. Wathen NC, Perry L, Lilford RJ, Chard
28. Smith G, Roberts R, Hall C, Nuki G. Reversible T. Interpretation of single progesterone measure-
ovulatory failure associated with the development ment in diagnosis of anovulation and defective
of luteinized unruptured follicles in women with luteal phase: observations on analysis of the normal
inflammatory arthritis taking non-steroidal anti- range. Br Med J (Clin Res Ed). 1984;288(6410):7–9.
inflammatory drugs. Br J Rheumatol. 42. Martinez AR, Bernardus RE, Vermeiden JPW,
1996;35(5):458–62. https://doi.org/10.1093/rheu- Schoemaker J. Time schedules of intrauterine
matology/35.5.458. insemination after urinary luteinizing hormone
29. Zanagnolo V, Dharmarajan AM, Endo K, Wallach surge detection and pregnancy results. Gynecol
12 EE. Effects of acetylsalicylic acid (aspirin) and
naproxen sodium (naproxen) on ovulation, prosta-
Endocrinol. 1994;8(1):1–5. https://doi.org/10.
3109/09513599409028450.
glandin, and progesterone production in the rab- 43. Scott RT, Hofmann GE. Prognostic assessment of
bit. Fertil Steril. 1996;65(5):1036–43. https://doi. ovarian reserve. Fertil Steril. 1995;63(1):1–11.
org/10.1016/s0015-0282(16)58283-1. 44. Hansen LM, Batzer FR, Gutmann JN, Corson SL,
30. Freda PU, Wardlaw SL, Post KD. Unusual causes of Kelly MP, Gocial B. Evaluating ovarian reserve: fol-
sellar/parasellar masses in a large transsphenoidal licle stimulating hormone and oestradiol variability
surgical series. J Clin Endocrinol Metab. during cycle days 2–5. Hum Reprod. 1996;11(3):
1996;81(10):3455–9. https://doi.org/10.1210/jcem.81. 486–9. https://doi.org/10.1093/humrep/11.3.486.
10.8855784. 45. Muttukrishna S, McGarrigle H, Wakim R,
31. Infertility workup for the women’s health special- Khadum I, Ranieri DM, Serhal P. Antral follicle
ist: ACOG committee opinion, number 781. Obstet count, anti-mullerian hormone and inhibin B: pre-
Gynecol. 2019;133(6):e377–84. https://doi. dictors of ovarian response in assisted reproduc-
org/10.1097/AOG.0000000000003271. tive technology? BJOG. 2005;112(10):1384–90.
32. Barekat M, Ahmadi S. Hypertensive disorders in https://doi.org/10.1111/j.1471-0528.2005.00670.x.
pregnant women receiving fertility treatments. Int 46. Ebner T, Sommergruber M, Moser M, Shebl O,
J Fertil Steril. 2018;12(2):92–8. https://doi. Schreier-Lechner E, Tews G. Basal level of anti-
org/10.22074/ijfs.2018.5232. Müllerian hormone is associated with oocyte quality
33. Talmor A, Dunphy B. Female obesity and infertil- in stimulated cycles. Hum Reprod. 2006;21(8):2022–
ity. Best Pract Res Clin Obstet Gynaecol. 6. https://doi.org/10.1093/humrep/del127.
2015;29(4):498–506. https://doi.org/10.1016/j.bpo- 47. Hendriks DJ, Mol B-WJ, Bancsi LFJMM, Te
bgyn.2014.10.014. Velde ER, Broekmans FJM. Antral follicle count
34. Miller JW, Crapo L. The medical treatment of in the prediction of poor ovarian response and
cushing’s syndrome. Endocr Rev. 1993;14(4):443– pregnancy after in vitro fertilization: a meta-
58. https://doi.org/10.1210/edrv-14-4-443. analysis and comparison with basal follicle-
35. American Society for Reproductive Medicine. stimulating hormone level. Fertil Steril.
ASRM Patient Education Booklet: Hirsutism and 2005;83(2):291–301. https://doi.org/10.1016/j.
Polycystic Ovarian Syndrome. fertnstert.2004.10.011.
Female Infertility
301 12
48. Navot D, Rosenwaks Z, Margalioth EJ. Prognostic 57. What is Assisted Reproductive Technology? |
assessment of female fecundity. Lancet Lond Engl. Reproductive Health | CDC. Nov. 09, 2020. https://
1987;2(8560):645–7. https://doi.org/10.1016/s0140- www.cdc.gov/art/whatis.html. Accessed 09 Apr
6736(87)92439-1. 2021.
49. Roach MK, Andreotti RF. The normal female pel- 58. IVF Blastocyst Pictures & Blastocyst Stage
vis. Clin Obstet Gynecol. 2017;60(1):3–10. https:// Embryo Grading Photos. https://advancedfertility.
doi.org/10.1097/GRF.0000000000000259. com/fertility-gallery/blastocyst-images/. Accessed
50. Falcone T, Hurd WW, editors. Clinical reproduc- 09 Apr 2021.
tive medicine and surgery: a practical guide. 2nd 59. Society for Assisted Reproductive Technology.
ed. New York: Springer-Verlag; 2013. https://doi. Success rates. https://www.sart.org/patients/a-
org/10.1007/978-1-4614-6837-0. patients-guide-to-assisted-reproductive-technology/
51. Jacobson TZ, Duffy JM, Barlow D, Farquhar C, general-information/success-rates/. Accessed 08
Koninckx PR, Olive D. Laparoscopic surgery for Apr 2021.
subfertility associated with endometriosis. Cochrane 60. Society for Assisted Reproductive Technology.
Database Syst Rev. 2010;1:CD001398. https://doi. What are my chances with ART? https://www.
org/10.1002/14651858.CD001398.pub2. sartcorsonline.com/Predictor/Patient. Accessed 08
52. Reindollar RH, et al. A randomized clinical trial Apr 2021.
to evaluate optimal treatment for unexplained 61. Psychological Evaluation. https://www.asrm.org/
infertility: the fast track and standard treatment resources/coding/coding-q a/coding-c orner/
(FASTT) trial. Fertil Steril. 2010;94(3):888–99. psychological-evaluation/. Accessed 09 Apr 2021.
https://doi.org/10.1016/j.fertnstert.2009.04.022. 62. Galhardo A, Moura-Ramos M, Cunha M, Pinto-
53. Legro R. S. et al., Letrozole versus clomiphene for Gouveia J. The infertility trap: how defeat and
infertility in the polycystic ovary syndrome. https:// entrapment affect depressive symptoms. Hum
doi.org/10.1056/NEJMoa1313517, 2014. https:// Reprod. 2016;31(2):419–26. https://doi.org/10.1093/
www.n ejm.o rg/doi/10.1 056/NEJMoa1313517. humrep/dev311.
Accessed 09 Apr 2021. 63. Arpin V, Brassard A, El Amiri S, Péloquin
54. Penzias A, et al. Evidence-based treatments for K. Testing a new group intervention for couples
couples with unexplained infertility: a guideline. seeking fertility treatment: acceptability and proof
Fertil Steril. 2020;113(2):305–22. https://doi. of concept. J Sex Marital Ther. 2019;45(4):303–16.
org/10.1016/j.fertnstert.2019.10.014. https://doi.org/10.1080/0092623X.2018.1526836.
55. Diamond MP, et al. Letrozole, gonadotropin, or clo- 64. Chin H, Howards P, Kramer M, Mertens A, Spencer
miphene for unexplained infertility. N Engl J Med. J. Racial disparities in seeking Care for Help Getting
2015;373(13):1230–40. https://doi.org/10.1056/NEJ Pregnant. Paediatr Perinat Epidemiol. 2015;29(5):416–
Moa1414827. 25. https://doi.org/10.1111/ppe.12210.
56. Intrauterine Insemination. https://www.asrm.org/
topics/topics-i ndex/intrauterine-i nsemination/.
Accessed 09 Apr 2021.
303 13
Fertility Preservation
Pasquale Patrizio, Emanuela Molinari, Tommaso Falcone,
and Lynn M. Westphal
Contents
13.2 Evaluation of the Ovarian Reserve – 305
13.3 Antral Follicle Count – 306
13.4 Anti-Müllerian Hormone – 306
13.5 Day 3 FSH and Estradiol – 306
13.6 Patient Population – 306
13.7 Chemotherapy and Ovarian Damage – 306
13.8 Risk Factors for Gonadal Damage – 307
13.9 Predicting Ovarian Failure – 307
13.10 Markers for Gonadal Damage – 308
13.11 Radiation Therapy and Ovarian Damage – 308
13.12 Risk Factors for Ovarian Damage – 308
13.13 Radiotherapy and Uterine Damage – 309
13.14 Pregnancy After Radiation Therapy – 309
13.15 Fertility Preservation Strategies – 309
13.16 Surgical Techniques – 311
13.17 Cervical Cancer – 311
13.18 Ovarian Cancer – 311

13.19 Endometrial Cancer – 311

https://doi.org/10.1007/978-3-030-99596-6_13
13.20 Ovarian Transposition – 311
13.21 Pharmacologic Protection – 312

13.21.1 Gonadotropin-Releasing Hormone Agonists – 312
13.22 Assisted Reproductive Technology – 313
13.23 Embryo Cryopreservation – 313
13.24 Oocyte Cryopreservation – 314
13.25 Tamoxifen and Letrozole – 314

13.25.1 Unconventional Stimulation Protocols – 315
13.26 Cryopreservation of Ovarian Tissue – 315
13.27 In Vitro Maturation – 316
13.28 Whole Ovary Cryopreservation – 316
13.30 Answers – 317
References – 317
305 13
medical conditions such as systemic diseases
Key Points as lupus erythematous, hematological disor-
55 Cytotoxic drugs can destroy maturing ders such as thalassemias, multiple sclerosis,
follicles, impair follicular maturation, and other autoimmune conditions. In addi-
deplete primordial follicles, or some tion, pediatric patients, transgender patients,
combination of these effects. and women interested in delaying childbear-
55 It is very difficult to exactly predict the ing are also benefitting from fertility preser-
risk for premature ovarian failure since vation strategies. Frequently referred to as
it does not consistently occur in patients “elective, social, or planned” fertility preser-
receiving multi-agent chemotherapy, vation, many women are resorting to oocyte
regardless of age or type of chemother- cryopreservation as a means to safeguard
apeutic agent. their future reproductive chances.
55 It is important to note that menstrual This chapter will first focus on fertility
dysfunction that occurs during chemo- preservation options in cancer cases includ-
therapy is not always due to the direct ing evaluation of the ovarian reserve and the
toxic effects on the ovary. pathophysiology of chemotherapy-/radio-
55 For postpubertal patients who have a therapy-induced gonadal toxicity, as well as
committed male partner, embryo cryo- the indications and the outcomes of the vari-
preservation is an established, success- ous techniques used for fertility preservation
ful procedure for fertility preservation. even in other medical indications.
55 Ovarian tissue cryopreservation is no
longer considered an experimental proce-
dure and is indicated to preserve fertility Case Vignette
in women who cannot delay oncological
treatments or cannot undergo ovarian AM is affected by a severe form of beta-
stimulation necessary to create embryos thalassemia requiring repeated blood trans-
or oocytes for cryopreservation. fusions and iron-chelating therapy. At age
22, prior to starting conditioning chemo-
therapy with alkylating drugs for bone mar-
row transplantation, she was referred for
13.1 Introduction fertility preservation and to discuss the
various options.
The prevalence of females being diagnosed
with cancer before age 40 is about 2%. The
good news is that thanks to advances in the 13.2 Evaluation of the Ovarian
treatment of many malignancies, the major- Reserve
ity of cancer patients survive their diagnosis,
with an overall 5-year survival rate greater The age-related decline in fertility is primar-
than 80%. Consequently, fertility preservation ily due to the relentless and progressive dimi-
has become an increasingly important para- nution of both oocyte number and quality.
digm for quality of life after cancer. Advances Accurate assessment of ovarian function is a
in assisted reproduction techniques (ARTs), core part of an infertility evaluation. However,
including ovarian tissue cryopreservation and particularly for cancer patients, there may not
transplantation, oocyte cryopreservation, and be too much time to complete a full assess-
novel ovulation induction approaches, offer ment of the ovarian reserve. In these instances,
concrete hopes to women at risk of being ren- quick indicators for ovarian reserve are serum
dered sterile by their treatments for cancer. levels of anti-Mullerian hormone (AMH) and
In addition to cancer patients, fertil- ultrasound to assess the ovarian antral follicle
ity preservation strategies are also offered count (AFC). Measuring estradiol and FSH
to patients needing chemotherapy for other levels is still useful in the early follicular phase.
306 P. Patrizio et al.
13.3 Antral Follicle Count The specificity of basal FSH levels for pre-
dicting who will respond poorly to stimula-
The antral follicle count utilizes transvaginal tion reaches 83–100%; however, the sensitivity
ultrasound in the early follicular phase to varies widely, from 10% to 80% [12], and this
determine the number of follicles between 2 is one of the main reasons why FSH levels
and 10 mm in diameter. A low AFC is defined have been supplanted by AMH testing.
as fewer than ten total (i.e., including both
ovaries) antral follicles. Low AFC has been
shown to correlate with poor ovarian response 13.6 Patient Population
to stimulation [1].
The patient population that will seek fertility
preservation for a diagnosis of cancer in the
13.4 Anti-Müllerian Hormone reproductive years is relatively small, yet the
impact of lost reproductive capacity is large
Anti-Müllerian hormone is a dimeric glyco- and psychologically devastating. The overall
protein hormone from the family of trans- incidence of cancer in women less than 40 years
forming growth hormone beta superfamily, of age is 754 per 100,000 [13]. The most com-
structurally related to inhibin and activin. It mon malignancies in reproductive-age women
is produced by granulosa cells of the prean- are breast, Hodgkin and non-Hodgkin lym-
tral and small antral follicles and is used as phomas, thyroid, melanoma, and cervical or
a marker of ovarian reserve. It is a conve- uterine cancer [13]. The mainstay of treatment
nient test, because it can be measured at any for many of these malignancies remains sur-
time in the menstrual cycle [2, 3]. Although gery, chemotherapy, and/or radiation.
exact cut-offs for good versus poor ovarian Premature gonadal failure or insufficiency
reserve have not been established, lower levels is a well-known consequence of ovarian expo-
(<1.0 ng/mL) have been correlated with low sure, during the reproductive years, to che-
ovarian response [4, 5]. This hormone is also motherapeutic drugs and radiation therapy.
used as a marker to monitor recovery of ovar- In general, radiotherapy is used cautiously in
ian function after completing chemotherapy/ children and adolescents because of its late
13 radiotherapy treatments or as a marker of sequelae on immature and developing tissues
ovarian function in women that choose not [14]. Pelvic radiotherapy is most commonly
to preserve fertility hoping to maintain their used to provide local disease control for solid
ovarian function in follow-up visits, after tumors, including the bladder, rectum, uterus,
completion of their cancer treatment [6, 7]. cervix, or vagina, all of which are more com-
mon in adult women.
13.5 Day 3 FSH and Estradiol

13.7 Chemotherapy and Ovarian
As the oocyte pool decreases, the FSH Damage
secreted by the pituitary will rise in response
to negative feedback from the follicular pool Cytotoxic drugs can destroy maturing follicles,
secretion of inhibin. As demonstrated many impair follicular maturation, deplete primor-
years ago and still used today, an early follicu- dial follicles, or some combination of these
lar (basal) FSH level drawn on cycle days 2–5 effects. Destruction of maturing follicles results
can have predictive value on fertility potential in temporary amenorrhea, whereas destruction
[8–10]. Estradiol levels, drawn in conjunction of the primordial follicles results in permanent
with basal FSH, help in a proper interpreta- amenorrhea and irreversible ovarian failure.
tion of the FSH levels since early rises of fol- The extent of chemotherapy-induced
licular phase estradiol (>60–80 pg/mL) falsely gonadotoxicity is variable. Histologic sections
suppress FSH [11]. of the ovary following treatment with cytotoxic
307 13
drugs known to cause ovarian failure show a 13.8 isk Factors for Gonadal
R
spectrum of changes, ranging from a decreased Damage
number of follicles to absent follicles to fibro-
sis. The exact incidence of premature ovarian The most important risk factors for gonadal
failure following chemotherapy is difficult to damage are the age of the patient, the drug class,
establish, because many factors contribute to the cumulative dose of the drug, and whether
ovarian toxicity. Alkylating agents (such as the treatment protocol includes a combination
cyclophosphamide) and platinum complexes of chemo- with radiotherapy. The risk related to
(such as cisplatinum) have a similar mechanism the age of the woman is linked to the presence
of action inducing DNA strand breaks that of a smaller oocyte pool in older as compared
ultimately trigger apoptosis [15]. Similarly, cel- to younger patients. In one study of women
lular death is caused by microtubule-stabilizing who had received mechlorethamine, vincris-
agents (such as taxanes) and by DNA-interca- tine, procarbazine, and prednisone (MOPP) for
lating drugs (doxorubicin) [16]. Recent theories Hodgkin’s disease, the subsequent amenorrhea
of chemotherapy-induced ovarian damage rate was 20% for women <25 years old, com-
involve the activation of dormant follicles by pared to 45% for those ≥25 years old [21].
chemotherapy drugs. This activation, mediated Additionally, cytotoxic chemotherapeu-
by an upregulation of PI3K/PTEN/Akt sig- tic agents are not equally gonadotoxic. Cell
naling pathway, leads to acute follicle destruc- cycle-nonspecific chemotherapeutic agents are
tion and drastic reduction of AMH secretion. considered to be more gonadotoxic than cell
Consequently, in order to replace the dying cycle-specific ones (. Table 13.1). Alkylating
cohort of follicles, the hypothalamic suppres- agents are among the most gonadotoxic of these
sion of the primordial follicle pool growth is cell cycle-nonspecific drugs, and women who
ceased, causing a rapid activation and loss of have received high-dose alkylating agent therapy
the remaining follicular cohort [17, 18]. are at highest risk of premature ovarian failure.
DNA damage is also a commonly described Cyclophosphamide is the most commonly used
mechanism of follicle loss as a consequence of gonadotoxic member of this category.
combined radiation and chemotherapy treat-
ment. It has been shown to originate in granu-
losa cells through p63 oncogene pathway [19].
Additionally, microvascular compromise 13.9 Predicting Ovarian Failure
is another mechanism of ovarian damage, as
ovarian blood flow and volume are reduced It is very difficult to exactly predict the risk
shortly after chemotherapy [20]. for premature ovarian failure since it does
It is important to note that menstrual dys- not consistently occur in patients receiving
function that occurs during chemotherapy is multi-agent chemotherapy, regardless of age
not always due to the direct toxic effects on the or type of chemotherapeutic agent. Most
ovary. Severe illness, malnutrition, and general young patients with Hodgkin’s disease treated
mental and physical stress can also interfere with multi-agent chemotherapy and radiation
with normal function of the hypothalamic- to a field that does not include the ovaries
pituitary-ovarian axis. Short-term disruption will likely be fertile, although their fertility
of a menstrual cycle is the result of destruc- will begin to decrease at a younger age than
tion of growing follicles rather than the pool matched controls [22]. Spontaneous concep-
of primordial follicles. Destruction of all tion can occur even after diagnosis of primary
growing follicles will delay menses for at least ovarian insufficiency, such as reported in a
3–4 months, since this is the time for a primor- woman who had completed 14 courses of an
dial follicle entering the growth pathway to alkylating agent combined with pelvic irradia-
reach the stage of ovulation. It is important to tion for treatment of Ewing’s sarcoma of the
note however that a normal menstrual cycle pelvis [23]. This exemplifies the difficulties in
after treatment with chemotherapy is not a predicting the probability of ovarian failure
reliable predictor of a patient’s fertility status. after chemotherapy, which also makes it dif-
.. Table 13.1 Gonadotoxic chemotherapeutic agents
Toxicity Medication class Medication
High Alkylating agents: Cyclophosphamide

Chloroethylamine Chlorambucil
Mechlorethamine Nitrogen mustard
Nitrosourea l-Phenylalanine mustard
Alkyl alkane sulfonate Carmustine
Methylhydrazine derivative Lomustine
Busulfan
Procarbazine
Intermediate Platinum complexes Cisplatinum
Anthracyclines
Carboplatinum
Doxorubicin
Low Antimetabolites Methotrexate
Vinca alkaloids 5-Fluorouracil
Antibiotics 6-Mercaptopurine
Vincristine
Vinblastine
Bleomycin
Dactinomycin
13 ficult to provide counseling and to evaluate licles are remarkably vulnerable to DNA
the efficacy of treatment aimed at preserving damage from ionizing radiation. Irradiation
ovarian function. results in ovarian atrophy and reduced follicle
stores secondary to vascular damage [30]. As
a result, serum FSH and LH levels progres-
13.10 Markers for Gonadal Damage sively rise, and estradiol levels decline within
4–8 weeks following radiation exposure. On
Ovarian reserve testing, which was discussed the cellular level, irradiation of oocytes results
earlier in the chapter, should be offered both in rapid onset of pyknosis, chromosome con-
pre- and post-treatment. Basal FSH levels densation, disruption of the nuclear envelope,
(if the patient has menstrual cycles), AMH, and cytoplasmic vacuolization.
estradiol, and transvaginal ultrasound to
measure AFC are useful markers for assessing
13.12 isk Factors for Ovarian
R
ovarian function after chemotherapy [24].
Damage
13.11 Radiation Therapy Cancer patients are at high risk of primary
and Ovarian Damage ovarian insufficiency after treatment with pel-
vic or total body irradiation. The degree of
Ovarian damage from radiotherapy can lead ovarian damage is related to the patient’s age
to diminished ovarian reserve and primary and the total dose of radiation to the ovaries.
ovarian insufficiency [25–33]. Ovarian fol- It is generally estimated that a single dose of
309 13
5.0 Gy will cause permanent ovarian failure in is when her uterus is irradiated, the more
over 90% of postpubertal women [34]. When the uterus appears to be affected, with atro-
looking at specific age groups, a prepubertal phy of the myometrium, submucosal fibrosis,
girl may have permanent ovarian failure if atrophy of the endometrium, and damage to
exposed to 12 Gy, but only 2 Gy may cause the blood vessels. Although there are no clear
same result in women over the age of 45 [29]. data indicating the dose of direct radiation
The dose response of the ovaries to irra- to the uterus, above which a pregnancy would
diation has been demonstrated in several not be sustainable, patients receiving >45 Gy
studies [27, 31, 33]. It is estimated that as lit- during adulthood would be at very high risk
tle as 3 Gy is enough to destroy 50% of the of infertility.
oocyte population in young, reproductive-age It has been demonstrated in women treated
women [32]. When the mean radiation dose to with total body irradiation that sex steroid
the ovary was 1.2 Gy, 90% of patients retained replacement in physiological doses signifi-
their ovarian function. When mean dose was cantly increases uterine volume and endome-
5.2 Gy, only 60% retained ovarian function. trial thickness, as well as reestablishes uterine
Ovarian failure will occur in virtually blood flow. However, it is not known whether
all patients exposed to pelvic radiation at standard regimens of estrogen replacement
the doses necessary to treat cervical cancer therapy are sufficient to facilitate uterine
(85 Gy), rectal/anal cancer (45 Gy), or total growth in adolescent women treated with
body radiation for bone marrow transplan- total body irradiation in childhood.
tation (8–12 Gy exposed to the ovaries). The
addition of chemotherapy to radiotherapy
further decreases the dose required to induce 13.14 regnancy After Radiation
P
premature ovarian failure. Therapy
Even if the ovaries are not directly in the
radiation field, radiation scatter can reduce Pregnancies achieved by survivors of childhood
ovarian function. Given this risk, it is very cancer who have received pelvic irradiation must
important to discuss with the radiation oncol- be considered high risk [34 – 36]. Radiation
ogist the expected dose that will be delivered damage to the uterine musculature and vascu-
to the ovary either directly or through scatter. lature can adversely affect pregnancy outcomes
in these women. Even if the uterus is able to
respond to exogenous sex steroid stimulation,
13.13 Radiotherapy and Uterine and appropriate ART’s are available, pregnancy
Damage prognosis remains guarded. Common obstet-
ric problems reported in these patients include
Irradiation-induced uterine damage can result early pregnancy loss, premature labor, and low-
in impaired endometrial function and uter- birth-weight infants [37, 38].
ine blood flow [35]. Young women exposed
to radiotherapy (at doses >25Gy) below the
diaphragm are at risk of impaired develop- 13.15 Fertility Preservation
ment of the uterus, in addition to ovarian fail- Strategies
ure. Long-term cancer survivors treated with
total body irradiation (TBI) and bone mar- A wide variety of strategies are available in an
row transplantation are at risk of impaired effort to preserve ovarian function and fertil-
uterine growth and blood flow. Despite stan- ity in women undergoing chemotherapy and/
dard estrogen replacement, the uterine size or radiotherapy. Fertility-sparing procedures,
of young girls is often reduced to 40% of pharmacologic options, and ARTs will be dis-
the normal adult size. The younger the girl cussed (. Table 13.2).
.. Table 13.2 Fertility preservation strategies
Technique Pros Cons Experimen-

tal vs.
Established
Surgical Fertility-preserving May be able to May leave residual Established

surgery (including conceive and carry disease
trachelectomy) future pregnancy Requires close
Less aggressive follow-up
Usually covered by May still require ART
insurance
Ovarian transposition Reduces ovarian Requires surgery Established
exposure to radiation May still be affected
by radiation (Scatter/
fall into field)
Can cause pain
Pharmacologic GnRH agonists Minimal delay in Not proven Experimen-
treatment Side effects similar to tal
menopause
Assisted Embryo cryopreserva- Commonly per- Elevated hormone Established
reproductive tion formed, good success levels
technology rates Time-consuming
(14 days)
Requires a sperm
source
May not be covered
by insurance
Oocyte cryopreserva- Good success rates, Elevated hormone Established
tion (by vitrification) no longer experimen- levels
tal Time-consuming
Does not require a (14 days)
13 sperm source May not be covered
by insurance
Ovarian tissue No delay in treatment Requires surgery Established
cryopreservation Does not require a Ovarian tissue
sperm source ischemia
Option for prepuber- Possible re-exposure
tal females to cancer cells
May not be covered
by insurance
In vitro maturation Minimal delay in Limited experience Experimental
treatment with this procedure
Does not require a
sperm source
May be combined
with Ovarian tissue
cryopreservation
311 13
13.16 Surgical Techniques 13.19 Endometrial Cancer
In general, the conventional therapy for a Both complex endometrial hyperplasia with
gynecologic malignancy consists of removal atypia and early-stage endometrial adeno-
of the uterus, tubes, and ovaries. However, carcinoma (Stage IA1) can be treated con-
there are specific circumstances that may servatively. A hysteroscopy with dilatation
allow a more conservative surgical approach. and curettage, followed by high-dose proges-
terone therapy, is the standard treatment for
those women who desire fertility preserva-
13.17 Cervical Cancer tion. Unfortunately, recurrence is common,
and close periodic evaluation is required to
Cervical cancer is typically treated with sur- avoid progression. It is also important to
gery or radiation therapy, depending on the stress to these patients that they should pur-
stage at presentation. Those with early-stage sue child- rearing sooner rather than later
disease, Stage IA1, may be treated with cervical and then have a complete hysterectomy and
conization and close follow-up. Women who bilateral salpingo-oophorectomy to ensure a
desire future fertility and are diagnosed with disease-free survival. In the event hysterec-
Stage IA2 and Stage IB disease may opt for a tomy is strongly considered before pregnancy,
radical trachelectomy, which involves removal a patient can still preserve oocytes or embryos
of the cervix, surrounding tissues, and lymph but then requires a gestational carrier for
node dissection [39]. Patients treated with future parenthood.
trachelectomy may require ART to achieve a
future pregnancy and cerclage and should be
aware that they are at increased risk of sec- 13.20 Ovarian Transposition
ond-trimester loss and preterm birth after this
procedure [40]. Successful fertility preserva- Transposition of the ovaries out of the field
tion and spontaneous pregnancies have been of radiation appears to help maintain ovar-
reported after robotic trachelectomy [41]. ian function in patients scheduled to undergo
pelvic gonadotoxic radiation therapy. This
technique can be utilized for gynecologic (cer-
13.18 Ovarian Cancer vix and uterus), colon, rectal, and anal can-
cers. Transposition of the ovaries has been
Ovarian tumors classified as low malignant reported to reduce the radiation dose to each
potential, germ cell, sex cord stromal, or early ovary by approximately 90–95% compared to
epithelial malignancies have the potential to ovaries left in their original location [38].
be treated with conservative surgery. Most There are two techniques available, lat-
ovarian cancers diagnosed in the reproductive eral and medial transpositions. Lateral
years tend to be unilateral and are less likely to transposition appears to be more effective
have metastasized. The surgical option most than medial transposition. A compilation of
likely to succeed in removing the cancerous ten case reports and a small series showed
tissue, as well as preserve fertility potential, an ovarian failure rate of 14% after lateral
is unilateral oophorectomy with conservation transposition compared to 50% after medial
of the remaining normal ovary and the uterus. transposition [43].
These women should still undergo complete Ovarian transposition can be performed
staging and be monitored closely by a gyne- by either laparotomy or laparoscopy. When
cologic oncologist for possible recurrence [42]. surgery is required for the treatment of cervi-
cal cancer or during staging and treatment of motherapeutic agents but also on age, ovar-
ovarian cancer, lateral ovarian transposition ian reserve, dose, and duration of treatment.
can be performed simultaneously. However, The unique feature of chemotherapy-induced
if a surgical procedure is not required for irreversible gonadal damage is the destruc-
treatment, the transposition can easily be per- tion of the primordial follicle, which con-
formed as an outpatient procedure. The ova- sists of non-growing cells. Growing follicles
ries have a tendency to migrate back to their are immediately impacted by chemotherapy,
original position, so it is recommended to resulting in amenorrhea. Chemotherapeutic
complete the procedure immediately prior to agents can directly cause apoptosis of fol-
the initiation of radiation therapy [33, 44, 45]. licles, with the dividing granulosa cells being
Most ovaries will maintain function if they particularly susceptible to damage [49–51].
are transposed at least 3 cm from the upper This latter phenomenon leads to the theory
edge of the field [46]. It has been shown that of “follicle burnout” [49]. Since growing fol-
approximately 80% of women undergoing licles have a direct effect in dampening the
laparoscopic ovarian transposition will main- initiation of primordial follicle growth, the
tain ovarian function after radiation therapy immediate and complete loss of growing fol-
for various indications [47]. licles causes an accelerated recruitment of the
Ovarian failure following transposition “resting” primordial follicles and therefore a
can occur because of several different mecha- decrease in the total ovarian follicular reserve.
nisms. Ovarian failure may result if the ovaries In addition to these effects, chemotherapy can
are not moved far enough out of the radia- cause stromal fibrosis and damage to intra-
tion field. Another reason for failure would ovarian vessels. The ideal drug would impede
be ovarian migration back to their original these effects. Drugs that act on apoptotic
position. Ovarian failure following transposi- pathways such as sphingosine-1-phosphate
tion may also be due to compromised ovarian or drugs that impede follicle activation path-
blood flow from surgical technique or radia- ways such as AMH would be ideal. Most
tion injury to the vascular pedicle [48]. are still in preclinical trials and not available
Pregnancies have been reported after clinically. While testing these drugs, it also is
ovarian transposition. Some have occurred important not to interfere with the efficacy
13 spontaneously, but others required reversal of the cancer treatment. The only drug clini-
of the procedure or ART, which may include cally available for use in patients undergoing
abdominal oocyte retrieval if the ovaries are gonadotoxic treatment belongs to the class
still kept outside the pelvic cavity. of gonadotropin-releasing hormone agonists
(GnRHa).
Protection of gonadal function is more
13.21 Pharmacologic Protection than just preservation of fertility. Many
aspects of quality of life are related to
13.21.1 Gonadotropin-Releasing gonadal function. Hypogonadal symptoms
Hormone Agonists such as hot flashes, insomnia, vaginal dry-
ness, dyspareunia, and impaired sexual func-
An ideal approach to decrease or eliminate tion are equally important. Ovarian failure is
the risk of gonadal damage from chemo- associated with osteoporosis, cardiovascular
therapy would be pharmacologic. The patient disease, and neurocognitive decline. Therefore
can take a medication and proceed with her drugs that prevent chemotherapeutic damage
cancer treatment without undergoing an inva- can be efficacious in maintaining an estro-
sive procedure. The critical step in the devel- genic environment and quality of life without
opment of such a drug is an understanding necessarily protecting fertility.
on how chemotherapy actually causes ovar- It is unclear how GnRHa can shield the
ian follicle destruction. The impact, as stated ovaries from the gonadotoxic effects of che-
earlier, depends not only on the type of chemotherapy. Its effect on suppressing the pitu-
itary gonadotropin secretion is well described.
313 13
This aspect of the drug cannot be solely The impact of GnRHa on improving
responsible for its observed effects as pri- fertility potential is less clear. It is especially
mordial follicle activation is independent of difficult to ascertain because spontaneous
gonadotropins. It may be acting on avoiding pregnancy rates in women after breast cancer
follicle recruitment by different mechanisms treatment are high enough to make clinical
[49]. GnRHa are thought to decrease vascu- studies difficult to interpret. The American
larity at the level of the ovary, thereby reduc- Society for Reproductive Medicine (ASRM)
ing the concentration of chemotherapy acting recommends the use of GnRHa in concert
directly on the ovary [49]. with other fertility preservation methods
The use of GnRHa during chemotherapy for patients who desire future pregnancies
is, therefore, still controversial and considered [56]. The use of GnRHa does not impede
experimental. In some circumstances such as the use of other strategies for fertility pres-
preventing the severe menstrual bleeding asso- ervation [55]. Additionally, the National
ciated with some chemotherapeutic drugs, it Comprehensive Cancer Network and the St.
is quite effective. GnRHa can be useful for Gallen International Expert Consensus panel
preservation of gonadal function when used guidelines support the use of GnRHa for the
in conjunction with chemotherapy in some prevention of ovarian failure secondary to
patients with breast cancer showing more gonadotoxic chemotherapy [42]. For individu-
benefit than for lymphoma patients [52–54]. als who have completed childbearing but are
This may be due to the temporal relationship still far from menopause, GnRHa can be con-
of the diagnosis and initiation of treatment. sidered with the goal of preserving of ovarian
Breast cancer patients are often delayed to endocrine function.
start chemotherapy until after surgery as
compared with lymphoma patients who often
start immediately. A review of 14 previously
13.22 Assisted Reproductive
published meta-analyses evaluating RCTs
on this subject showed mixed results [55]. Technology
The majority showed a favorable impact on
gonadal protection, but others did not. This is The utilization of ARTs for patients interested
most probably the result of the heterogeneous in fertility preservation depends on multiple
population of patients with different cancers factors, such as the type of cancer, treatment
and different chemotherapy protocols. planned, time until treatment will start, and
Additionally, GnRHa are often beneficial presence of a partner. There are multiple
as adjuvant treatment in combination with options available, and today the great major-
chemotherapy for a subset of patients. Breast ity of these strategies are considered estab-
cancer patients, including those with estro- lished practices and no longer experimental
gen receptor-positive tumors, who received techniques. The overall goal is to preserve
GnRHa co-treatment had increased or no embryos, oocytes, or ovarian tissue for these
impact on disease-free survival and overall women prior to treatment, so they may have
survival compared to chemotherapy alone [52, options to reproduce in the future.
53]. In the Prevention of Early Menopause
Study [52], a trend toward a higher rate of
disease-free survival in those individuals 13.23 Embryo Cryopreservation
treated with GnRHa was observed, as well
as a statistically significant higher rate of For postpubertal patients who have a commit-
overall survival in this group compared to ted male partner, embryo cryopreservation is
those treated with chemotherapy alone [52]. an established, successful procedure for fertil-
Similarly, in the Lambertini et al. study, a ity preservation [56]. The age of the patient
trend toward improved 5-year disease-free and number, stage, and quality of the frozen
survival was observed in the GnRHa group embryos mainly determine the future likeli-
versus controls [53]. hood of successful live birth when choosing
embryo cryopreservation. The chances of a patients. The greatest concern about utilizing
live birth from a cryopreserved (by vitrifica- oocyte cryopreservation is that the success
tion) embryo in a woman under the age of rate in the past was significantly lower than
40 years old are 28.5–38.7%. In general, the with embryo cryopreservation. Early studies
rewarming survival rate of embryos is very reported a low survival, fertilization, and preg-
high, around 95%, and across most ages, the nancy rate with thawed oocytes, mostly due to
clinical pregnancy rate is between 37.5 and a technique of cryopreservation called slow
62.5% [57]. freezing, which has been now completely sup-
A typical IVF cycle for fertility preserva- planted by a new one called vitrification [63].
tion can be done in a couple of weeks from The structural complexity of the oocyte is
start to finish. In the past, the time constraint most likely responsible for the reduced success
was dependent on where the patient was in rate in oocyte cryopreservation. Unlike fertil-
her menstrual cycle, but today this has been ized embryos, the surface-area-to-volume
completely removed thanks to the so-called ratio is unfavorable in the oocytes, making
random- start ovarian stimulation protocols water exchange more difficult during the dehy-
described below. Some centers have offered dration phase of vitrification and hence more
natural cycle IVF for breast cancer patients. prone to thermal injury [64, 65]. Improvements
During this process, a single oocyte is aspi- in the cryopreservation technique have led to
rated during a woman’s spontaneous men- significant improvements in the overall out-
strual cycle. Unfortunately, cancellation rates come of oocyte cryopreservation. The advent
are high, and the pregnancy rates are very low of vitrification for cryopreservation, rather
for this protocol (7.2% per cycle and 15.8% than the slow- freeze protocol, has reduced
per embryo transfer) [58, 59]. the damage caused from ice crystal formation
Most centers will use mild ovarian stimula- and subsequent cellular damage [66]. Recent
tion with a GnRH antagonist to prevent ovu- reports have seen survival rates after a thaw
lation [60], and particularly for breast cancer, of 75–90%, fertilization rates of 77%, and live
the aromatase inhibitor letrozole is an impor- birth rates of 38% [67]. In those pregnancies
tant part of the ovarian stimulation protocol. that have resulted from oocyte cryopreser-
In patients who present in the luteal phase vation, there appears to be no increase in
13 of the menstrual cycle, gonadotropins can chromosomal abnormalities, birth defects, or
be started immediately (random start) and developmental deficits [68].
GnRH antagonists used as needed, thereby How many oocytes should be cryopre-
reducing the time to retrieval to no more than served to have a good chance for future repro-
2 weeks. Reports in the literature have iden- ductive success? A survey of the literature on
tified similar dosage requirements, numbers oocyte vitrification reported about 5% live
of oocytes retrieved, and fertilization rates in birth rate per vitrified oocyte in women under
women who started in the luteal phase com- the age of 36 years, meaning that on average,
pared to those who started in the follicular one live birth should be expected for about 20
phase of their menstrual cycle [60, 61]. vitrified oocytes [69]. Other reports suggest
live births with as little as 8–10 frozen-thawed
oocytes [70].
13.24 Oocyte Cryopreservation
Postpubertal female patients who do not have 13.25 Tamoxifen and Letrozole
a male partner or do not wish to fertilize their
oocytes and create embryos can cryopreserve There has been some concern that the high
their oocytes for future use [62]. Freezing estrogen levels obtained during ovarian stim-
oocytes, rather than embryos, also avoid ethi- ulation may decrease long-term survival for
cal and legal considerations of embryo stor- breast cancer patients. In those women with
age and disposal, which is of concern for some hormone-sensitive tumors, stimulation with
315 13
tamoxifen, a nonsteroidal antiestrogen, or cannot delay oncological treatments or can-
letrozole, an aromatase inhibitor, may be ben- not undergo ovarian stimulation necessary to
eficial. create embryos or oocytes for cryopreserva-
In a manner similar to clomiphene citrate, tion [78]. It is also the only option currently
tamoxifen (40–60 mg) is started on day 2 or available to prepubertal females. It involves
3 of the cycle and given daily for 5–12 days. removal of strips of ovarian cortical tissue and
Letrozole has more recently been utilized as freezing it as an avascular graft, in an effort
an ovulation induction agent as well. Adding to save thousands of primordial follicles for
letrozole at doses of 2.5 mg or 5 mg during a future use. When the patient is in remission,
standard gonadotropin stimulation protocol the frozen-thawed ovarian tissue can then be
has been shown to lower total serum estradiol transplanted back onto the non-functioning
levels [71]. ovary or to a peritoneal site (orthotopic trans-
plants) or to the patient’s subcutaneous tis-
To date, ovarian stimulation for fertility pres-
ervation has not been associated with an increase sue (heterotopic transplants). When ovarian
in breast cancer recurrence rates [71, 72]. cortex is transplanted onto a remaining ovary
or on nearby peritoneum, there is not always
need for follicular aspiration and ARTs, as the
13.25.1 Unconventional fallopian tube can pick up and transport the
Stimulation Protocols spontaneously ovulated oocyte. However, if
the ovarian cortex is transplanted heterotopi-
Studies on ovarian follicle development of cally, then follicular aspiration and in vitro
large domestic species such as sheep and cattle fertilization are required. It is also possible
demonstrated how follicular growth proceeds that one day the primordial follicles can be
in waves [73]. Likewise in humans, some inves- matured in vitro.
tigators have documented the growth of non- One of the concerns about regrafting tis-
atretic follicles during the luteal phase [74, sue back to the patient is the theoretical risk
75]. This observation paved the way to a new of reintroducing cancer cells. This concern
stimulation protocol called “duo-stim,” aimed may limit its use in malignancies that have a
at collecting oocytes during both the follicu- high chance of involving the ovaries, includ-
lar and luteal phases [76]. Recently, Ubaldi ing leukemia and potentially advanced stages
and collaborators demonstrated the non- of breast cancers.
inferiority of collecting oocytes during the An additional limitation to the procedure
luteal as compared to follicular phase in terms is the loss of a large fraction of follicles dur-
of maturity, chances for fertilization, developing the initial ischemia that occurs after trans-
ment, and euploidy rate [77]. Therefore, the plantation [79–81]. Previous work indicated
possibility to harvest oocytes during both that while loss due to freezing is relatively
phases of the cycle is a suitable tool for fertil- small, up to two-thirds of follicles are lost
ity preservation patients as it allows to maxi- subsequent to transplantation.
mize the number of gametes cryopreserved The return of ovarian function (after
without having to wait for a new menstrual about 4 months from the transplant) and
cycle to repeat stimulation cycles and conse- the occurrence of many pregnancies (>150
quently delay cancer therapies. live births), both spontaneous and after IVF
have been documented in patients after ortho-
topic transplantation [82–85]. It is however
difficult to estimate the true pregnancy rate
13.26 Cryopreservation of Ovarian after ovarian transplantation because there is
Tissue not an official registry that can keep track of
the number of cases performed, and there is
Ovarian tissue cryopreservation is no longer lacking of proper follow-up for many of the
considered an experimental procedure and is women who received the regrafting. However,
indicated to preserve fertility in women who a pregnancy rate of about 25–30% has been
reported by the groups with the largest expe- strips is not yet possible. Contrary to in vitro
rience [86]. In some patients, this does not maturation of oocytes from antral folli-
exclude the possibility that ovarian function cles, which requires days to mature, in vitro
resumed from areas in the ovary that had maturation of oocytes derived from primor-
not been removed and reimplanted. Of note, dial follicles would require months [88–90].
another advantage of ovarian cortical freez-
ing and retransplant is the preservation of the
endocrine function. 13.28 Whole Ovary
Cryopreservation
13.27 In Vitro Maturation One of the major limitations of ovarian tis-
sue freezing is the result of ischemia-induced
In vitro maturation is another potential damage to the tissue, which consequently
modality for obtaining oocytes with little impacts the viability of the primordial fol-
or no ovarian stimulation. In the context of licles within the cortex. Freezing an intact
fertility preservation for cancer patients, this whole ovary instead of ovarian cortex could
approach appears most effective in patients be used as an option for fertility preservation
who undergo ovarian tissue freezing, where [91]. By harvesting the ovary and maintain-
oocytes can be harvested from visible follicles ing its vascular anastomosis, there are higher
on the ovarian strips and allowed to mature chances of follicle pool survival. Moreover,
in vitro. In these instances, a patient will ben- the entire follicular pool will be transplanted
efit from cryopreservation of both ovarian tis- as opposed to a portion of it. Clearly, there
sue and in vitro matured oocytes (87, 88). In are still several obstacles to this procedure,
addition, IVM can be attractive for patients such as the complex microsurgery needed for
who have multiple follicles (e.g., polycystic transplantation and the technical limitations
ovaries), some of which will inevitably proof the cryopreservation procedures [91]. If
vide immature oocytes at the time of retrieval. from one side the surgical limitations have
Patients with a clear contraindication to ovar- been overcome by some, resulting in success-
ian stimulation can also benefit from IVM. In ful pregnancies in animals and in humans
13 these instances, an ultrasound is performed on [92–96], cryopreservation of an entire organ
days 6–8 of the cycle, and human chorionic still represents a major challenge. Technically,
gonadotropin (hCG) is given to help increase it requires the penetration of an adequate
oocyte maturity at the time of retrieval. Oocyte amount of cryoprotectant into a rather com-
retrieval is scheduled 36 h later and immature plex tissue such as the ovary. Although no
oocytes are obtained and incubated in special attempts of frozen-thawed human whole
culture media. If the oocytes mature in 24 h, ovary transplantation have been performed to
as determined by extrusion of the first polar date, promising results have been reported for
body, either the oocytes or embryos (if fertil- experimental models with large animals such
ization is attempted) can be cryopreserved. as ewes and sheep [96, 97]. An alternative, new
This procedure is significantly less success- method of fertility preservation is based on an
ful than those mentioned earlier. To date, over ex vivo perfusion platform of whole ovaries
300 live births have resulted from this proce- using a bioreactor. Preliminary results using
dure; however, significantly fewer embryos ewe ovaries are very promising in being able to
will be obtained per cycle, and the chance maintain the whole organ in culture for 7 days
of implantation, pregnancy, and live birth is and stimulating in vitro folliculogenesis. This
lower than conventional IVF [89]. method could be beneficial for prepubertal
In vitro maturation of primordial follicles girls and for cases of cancer with ovarian
obtained from frozen-thawed ovarian cortical metastasis [98].
317 13
13.29 Review Questions tion of poor ovarian response and pregnancy after
in vitro fertilization: a meta-analysis and compari-
son with basal follicle-stimulating hormone level.
??1. Which of the following fertility preser- Fertil Steril. 2005;83:291–301.
vation options is still considered experi- 3. Tsepelidis S, Devreker F, Demeestere I, Flahaut
mental research? A, Gervy C, Englert Y. Stable serum levels of anti-
A. Oocyte freezing Mullerian hormone during the menstrual cycle:
a prospective study in normo-ovulatory women.
B. Ovarian tissue cryopreservation
Hum Reprod. 2007;22:1837–40.
C. Ovarian transposition 4. La Marca A, Stabile G, Artenisio AC, Volpe
D. In vitro follicular maturation A. Serum anti-Mullerian hormone through-
out the human menstrual cycle. Hum Reprod.
??2.
Which of the following is an appro- 2006;21:3103–7.
5. Muttukrishna S, McGarrigle H, Wakim R, Kha-
priate means to evaluate the ovarian
dum I, Ranieri DM, Serhal P. Antral follicle count,
reserve of women planning to undergo anti-mullerian hormone and inhibin B: predictors
fertility preservation? of ovarian response in assisted reproductive tech-
A. Antral follicle count (AFC), FSH, nology? BJOG. 2005;112:1384–90.
progesterone, and estradiol 6. Meirow D, Levron J, Eldar-Geva T, Hardan I, Frid-
man E, Yemini Z, Dor J. Monitoring the ovaries
B. Antral follicle count (AFC), FSH,
after autotransplantation of cryopreserved ovar-
estradiol, and AMH ian tissue: endocrine studies, in vitro fertilization
C. Antral follicle count (AFC), LH, cycles, and live birth. Fertil Steril. 2007;87:418.
FSH, and inhibin B e7–e15.
D. AMH, FSH, LH, and progesterone 7. Sanchez-Serrano M, Crespo J, Mirabet V, Cobo
AC, Escriba MJ, Simon C, Pellicer A. Twins born
after transplantation of ovarian cortical tissue
??3. The return of ovarian function after the and oocyte vitrification. Fertil Steril. 2010;93:268.
retransplant of ovarian tissue occurs: e11–3.
A. At about 2 months from the trans- 8. Scott RT, Toner JP, Muasher SJ, Oehninger S, Rob-
plant inson S, Rosenwaks Z. Follicle-stimulating hor-
mone levels on cycle day 3 are predictive of in vitro
B. At about 1 month from the trans-
fertilization outcome. Fertil Steril. 1989;51:651–4.
plant 9. Toner JP, Philput CB, Jones GS, Muasher SJ. Basal
C. At about 4 months from the trans- follicle-stimulating hormone level is a better pre-
plant dictor of in vitro fertilization performance than
D. At about 6 months from the trans- age. Fertil Steril. 1991;55:784–91.
10. Pearlstone AC, Fournet N, Gambone JC, Pang
plant
SC, Buyalos RP. Ovulation induction in women
age 40 and older: the importance of basal follicle-
stimulating hormone level and chronological age.
13.30 Answers Fertil Steril. 1992;58:674–9.
11. Evers JL, Slaats P, Land JA, Dumoulin JC, Dunsel-
man GA. Elevated levels of basal estradiol-17beta
vv1. D predict poor response in patients with normal basal
levels of follicle-stimulating hormone undergoing
vv2. B in vitro fertilization. Fertil Steril. 1998;69:1010–4.
12. Broekmans FJ, Kwee J, Hendriks DJ, Mol BW,
Lambalk CB. A systematic review of tests pre-
vv3. C
dicting ovarian reserve and IVF outcome. Hum
Reprod Update. 2006;12:685–718.
13. Ebner T, Sommergruber M, Moser M, Shebl O,
References Schreier-Lechner E, Tews G. Basal level of anti-
Mullerian hormone is associated with oocyte
1. Broekmans FJ, de Ziegler D, Howles CM, Gou- quality in stimulated cycles. Hum Reprod.
geon A, Trew G, Olivennes F. The antral follicle 2006;21:2022–6.
count: practical recommendations for better stan- 14. Statistics, SEaERC. http://seer.cancer.gov. Accessed
dardization. Fertil Steril. 2010;94:1044–51. 20 Jul 2016.
2. Hendriks DJ, Mol BW, Bancsi LF, Te Velde ER, 15. Meirow D, Biederman H, Anderson RA, Wal-
Broekmans FJ. Antral follicle count in the predic- lace WH. Toxicity of chemotherapy and radiation
on female reproduction. Clin Obstet Gynecol. in the postnatal mammalian ovary. Nature.
2010;53:727–39. 2004;428:145–50.
16. Fan W. Possible mechanisms of paclitaxel-induced 29. Lushbaugh CC, Casarett GW. The effects of
apoptosis. Biochem Pharmacol. 1999;57:1215–21. gonadal irradiation in clinical radiation therapy: a
17. McLaughlin M, Kinnell HL, Anderson RA, Telfer review. Cancer. 1976;37:1111–25.
EE. Inhibition of phosphatase and tensin homo- 30. Meirow D, Schenker JG, Rosler A. Ovarian
logue (PTEN) in human ovary in vitro results in hyperstimulation syndrome with low oestradiol
increased activation of primordial follicles but in non-classical 17 alpha-hydroxylase, 17,20-lyase
compromises development of growing follicles. deficiency: what is the role of oestrogens? Hum
Mol Hum Reprod. 2014;20:736–44. Reprod. 1996;11:2119–21.
18. Roness H, Kashi O, Meirow D. Prevention of 31. Morice P, Juncker L, Rey A, El-Hassan J, Haie-
chemotherapy- induced ovarian damage. Fertil Meder C, Castaigne D. Ovarian transposition for
Steril. 2016;105:20–9. patients with cervical carcinoma treated by radio-
19. Livera G, Petre-Lazar B, Guerquin MJ, Traut- surgical combination. Fertil Steril. 2000;74:743–8.
mann E, Coffigny H, Habert R. p63 null mutation 32. Wallace WH, Thomson AB, Saran F, Kelsey
protects mouse oocytes from radio-induced apop- TW. Predicting age of ovarian failure after radia-
tosis. Reproduction. 2008;135:3–12. tion to a field that includes the ovaries. Int J Radiat
20. Soleimani R, Heytens E, Darzynkiewicz Z, Oktay Oncol Biol Phys. 2005;62:738–44.
K. Mechanisms of chemotherapy-induced human 33. Williams RS, Littell RD, Mendenhall NP. Lapa-
ovarian aging: double strand DNA breaks and roscopic oophoropexy and ovarian function
microvascular compromise. Aging (Albany NY). in the treatment of Hodgkin disease. Cancer.
2011;3:782–93. 1999;86:2138–42.
21. You W, Dainty LA, Rose GS, Krivak T, McHale 34. Anchan RM, Ginsburg ES. Fertility concerns and
MT, Olsen CH, Elkas JC. Gynecologic malig- preservation in younger women with breast cancer.
nancies in women aged less than 25 years. Obstet Crit Rev Oncol Hematol. 2010;74:175–92.
Gynecol. 2005;105:1405–9. 35. Critchley HO, Wallace WH. Impact of cancer
22. Schilsky RL, Sherins RJ, Hubbard SM, Wesley treatment on uterine function. J Natl Cancer Inst
MN, Young RC, DeVita VT. Long-term follow up Monogr. 2005;2005(34):64–8.
of ovarian function in women treated with MOPP 36. Bath LE, Wallace WH, Critchley HO. Late effects
chemotherapy for Hodgkin's disease. Am J Med. of the treatment of childhood cancer on the female
1981;71:552–6. reproductive system and the potential for fertility
23. Multidisciplinary Working Group convened by the preservation. BJOG. 2002;109:107–14.
British Fertility Society. A strategy for fertility ser- 37. Hawkins MM, Smith RA. Pregnancy outcomes
vices for survivors of childhood cancer. Hum Fertil in childhood cancer survivors: probable effects
(Camb). 2003;6:A1–40. of abdominal irradiation. Int J Cancer. 1989;43:
13 24. Bath LE, Tydeman G, Critchley HO, Anderson
RA, Baird DT, Wallace WH. Spontaneous concep- 38.
399–402.
Noyes N, Knopman JM, Long K, Coletta JM,
tion in a young woman who had ovarian cortical Abu-Rustum NR. Fertility considerations in the
tissue cryopreserved before chemotherapy and management of gynecologic malignancies. Gyne-
radiotherapy for a Ewing's sarcoma of the pelvis: col Oncol. 2011;120:326–33.
case report. Hum Reprod. 2004;19:2569–72. 39. Plante M, Renaud MC, Francois H, Roy M. Vagi-
25. Bath LE, Wallace WH, Shaw MP, Fitzpatrick C, nal radical trachelectomy: an oncologically safe
Anderson RA. Depletion of ovarian reserve in fertility-preserving surgery. An updated series
young women after treatment for cancer in child- of 72 cases and review of the literature. Gynecol
hood: detection by anti-Mullerian hormone, Oncol. 2004;94:614–23.
inhibin B and ovarian ultrasound. Hum Reprod. 40. Plante M. Fertility preservation in the manage-
2003;18:2368–74. ment of cervical cancer. CME J Gynecol Oncol.
26. Crofton PM, Thomson AB, Evans AE, Groome 2003;8:97–107.
NP, Bath LE, Kelnar CJ, Wallace WH. Is inhibin B 41. Johansen G, Lonnerfors C, Falconer H, Persson
a potential marker of gonadotoxicity in prepuber- J. Reproductive and oncologic outcome following
tal children treated for cancer? Clin Endocrinol. robot-assisted laparoscopic radical trachelectomy
2003;58:296–301. for early stage cervical cancer. Gynecol Oncol.
27. Gaetini A, De Simone M, Urgesi A, Levis A, 2016;141:160–5.
Resegotti A, Ragona R, Anglesio S. Lateral high 42. Lambertini M, Del Mastro L, Pescio MC, Ander-
abdominal ovariopexy: an original surgical tech- sen CY, Azim HA Jr, Peccatori FA, Costa M, Rev-
nique for protection of the ovaries during curative elli A, Salvagno F, Gennari A, Ubaldi FM, La Sala
radiotherapy for Hodgkin's disease. J Surg Oncol. GB, De Stefano C, Wallace WH, Partridge AH,
1988;39:22–8. Anserini P. Cancer and fertility preservation: inter-
28. Johnson J, Canning J, Kaneko T, Pru JK, Tilly national recommendations from an expert meet-
JL. Germline stem cells and follicular renewal ing. BMC Med. 2016;14:1.
319 13
43. Howard FM. Laparoscopic lateral ovarian trans- treated with chemotherapy: final long-term report
position before radiation treatment of Hodg- of a prospective randomized trial. J Clin Oncol.
kin disease. J Am Assoc Gynecol Laparosc. 2016;34:2568–74.
1997;4:601–4. 55. Hickman LC, Valentine LN, Falcone T. Preserva-
44. Treissman MJ, Miller D, McComb PF. Laparo- tion of gonadal function in women undergoing
scopic lateral ovarian transposition. Fertil Steril. chemotherapy: a review of the potential role for
1996;65:1229–31. gonadotropin-releasing hormone agonists. Am J
45. Yarali H, Demirol A, Bukulmez O, Coskun F, Obstet Gynecol. 2016;215(4):415–22.
Gurgan T. Laparoscopic high lateral transposition 56. Practice Committee of American Society for
of both ovaries before pelvic irradiation. J Am Reproductive Medicine. Fertility preservation
Assoc Gynecol Laparosc. 2000;7:237–9. in patients undergoing gonadotoxic therapy or
46. Bidzinski M, Lemieszczuk B, Zielinski J. Evalua- gonadectomy: a committee opinion. Fertil Steril.
tion of the hormonal function and features of the 2013;100:1214–23.
ultrasound picture of transposed ovary in cervical 57. Kolibianakis EM, Venetis CA, Tarlatzis BC. Cryo-
cancer patients after surgery and pelvic irradia- preservation of human embryos by vitrification
tion. Eur J Gynaecol Oncol. 1993;14:77–80. or slow freezing: which one is better? Curr Opin
47. Morice P, Castaigne D, Haie-Meder C, Pautier Obstet Gynecol. 2009;21:270–4.
P, El Hassan J, Duvillard P, Gerbaulet A, Michel 58. Oktay K, Buyuk E, Davis O, Yermakova I, Veeck
G. Laparoscopic ovarian transposition for pelvic L, Rosenwaks Z. Fertility preservation in breast
malignancies: indications and functional out- cancer patients: IVF and embryo cryopreservation
comes. Fertil Steril. 1998;70:956–60. after ovarian stimulation with tamoxifen. Hum
48. Feeney DD, Moore DH, Look KY, Stehman FB, Reprod. 2003;18:90–5.
Sutton GP. The fate of the ovaries after radical 59. Pelinck MJ, Hoek A, Simons AH, Heineman
hysterectomy and ovarian transposition. Gynecol MJ. Efficacy of natural cycle IVF: a review of the
Oncol. 1995;56:3–7. literature. Hum Reprod Update. 2002;8:129–39.
49. Roness H, Gavish Z, Cohen Y, Meirow D. Ovar- 60. Noyes N, Knopman JM, Melzer K, Fino ME,
ian follicle burnout: a universal phenomenon? Cell Friedman B, Westphal LM. Oocyte cryopreserva-
Cycle. 2013;12:3245–6. tion as a fertility preservation measure for cancer
50. Morgan S, Anderson RA, Gourley C, Wal- patients. Reprod Biomed Online. 2011;23:323–33.
lace WH, Spears N. How do chemotherapeutic 61. von Wolff M, Thaler CJ, Frambach T, Zeeb C,
agents damage the ovary? Hum Reprod Update. Lawrenz B, Popovici RM, Strowitzki T. Ovarian
2012;18:525–35. stimulation to cryopreserve fertilized oocytes in
51. Hasky N, Uri-Belapolsky S, Goldberg K, Miller I, cancer patients can be started in the luteal phase.
Grossman H, Stemmer SM, Ben-Aharon I, Shalgi Fertil Steril. 2009;92:1360–5.
R. Gonadotrophin-releasing hormone agonists for 62. Practice Committees of American Society for
fertility preservation: unraveling the enigma? Hum Reproductive Medicine, Society for Assisted
Reprod. 2015;30:1089–101. Reproductive Technology. Mature oocyte cryo-
52. Moore HC, Unger JM, Phillips KA, Boyle F, Hitre preservation: a guideline. Fertil Steril. 2013;99:
E, Porter D, Francis PA, Goldstein LJ, Gomez HL, 37–43.
Vallejos CS, Partridge AH, Dakhil SR, Garcia 63. Oktay K, Kan MT, Rosenwaks Z. Recent prog-
AA, Gralow J, Lombard JM, Forbes JF, Martino ress in oocyte and ovarian tissue cryopreservation
S, Barlow WE, Fabian CJ, Minasian L, Meyskens and transplantation. Curr Opin Obstet Gynecol.
FL Jr, Gelber RD, Hortobagyi GN, Albain KS, 2001;13:263–8.
Investigators PS. Goserelin for ovarian protection 64. Magistrini M, Szollosi D. Effects of cold and of
during breast-cancer adjuvant chemotherapy. N isopropyl-N-phenylcarbamate on the second mei-
Engl J Med. 2015;372:923–32. otic spindle of mouse oocytes. Eur J Cell Biol.
53. Lambertini M, Boni L, Michelotti A, Gamucci 1980;22:699–707.
T, Scotto T, Gori S, Giordano M, Garrone O, 65. Stachecki JJ, Cohen J, Willadsen S. Detrimental
Levaggi A, Poggio F, Giraudi S, Bighin C, Vecchio effects of sodium during mouse oocyte cryopreser-
C, Sertoli MR, Pronzato P, Del Mastro L, GIM vation. Biol Reprod. 1998;59:395–400.
Study Group. Ovarian suppression with triptore- 66. Shaw JM, Jones GM. Terminology associated with
lin during adjuvant breast cancer chemotherapy vitrification and other cryopreservation procedures
and long-term ovarian function, pregnancies, and for oocytes and embryos. Hum Reprod Update.
disease-free survival: a randomized clinical trial. 2003;9:583–605.
JAMA. 2015;314:2632–40. 67. Doyle JO, Richter KS, Lim J, Stillman RJ, Gra-
54. Demeestere I, Brice P, Peccatori FA, Kentos A, ham JR, Tucker MJ. Successful elective and medi-
Dupuis J, Zachee P, Casasnovas O, Van Den Neste cally indicated oocyte vitrification and warming
E, Dechene J, De Maertelaer V, Bron D, Englert for autologous in vitro fertilization, with predicted
Y. No evidence for the benefit of gonadotropin- birth probabilities for fertility preservation accord-
releasing hormone agonist in preserving ovar- ing to number of cryopreserved oocytes and age at
ian function and fertility in lymphoma survivors retrieval. Fertil Steril. 2016;105:459–66.. e2
68. Noyes N, Porcu E, Borini A. Over 900 oocyte cryo- of primordial follicles from fresh and cryopre-
preservation babies born with no apparent increase served human ovarian tissue. Fertil Steril. 1997;67:
in congenital anomalies. Reprod Biomed Online. 481–6.
2009;18:769–76. 82. Donnez J, Dolmans MM, Demylle D, Jadoul P,
69. ESHRE Task Force on Ethics and Law, Dondorp Pirard C, Squifflet J, Martinez-Madrid B, van
W, de Wert G, Pennings G, Shenfield F, Devroey P, Langendonckt A. Livebirth after orthotopic trans-
Tarlatzis B, Barri P, Diedrich K. Oocyte cryopreser- plantation of cryopreserved ovarian tissue. Lancet.
vation for age-related fertility loss. Hum Reprod. 2004;364:1405–10.
2012;27:1231–7. 83. Silber S, Pineda J, Lenahan K, DeRosa M, Mel-
70. Cobo A, Garcia-Velasco JA, Coello A, Domingo J, nick J. Fresh and cryopreserved ovary transplan-
Pellicer A, Remohi J. Oocyte vitrification as an effi- tation and resting follicle recruitment. RBMO.
cient option for elective fertility preservation. Fertil 2015;30:643–50.
Steril. 2016;105:755–64.. e8 84. Meirow D, Levron J, Eldar-Geva T, Hardan I, Frid-
71. Oktay K, Buyuk E, Libertella N, Akar M, Ros- man E, Zalel Y, Schiff E, Dor J. Pregnancy after
enwaks Z. Fertility preservation in breast cancer transplantation of cryopreserved ovarian tissue in
patients: a prospective controlled comparison of a patient with ovarian failure after chemotherapy. N
ovarian stimulation with tamoxifen and letro- Engl J Med. 2005;353:318–21.
zole for embryo cryopreservation. J Clin Oncol. 85. Oktay K, Buyuk E, Veeck L, Zaninovic N, Xu K,
2005;23:4347–53. Takeuchi T, Opsahl M, Rosenwaks Z. Embryo devel-
72. Azim AA, Costantini-Ferrando M, Oktay K. Safety opment after heterotopic transplantation of cryopre-
of fertility preservation by ovarian stimulation with served ovarian tissue. Lancet. 2004;363:837–40.
letrozole and gonadotropins in patients with breast 86. Andersen CY. Success and challenges in fertility
cancer: a prospective controlled study. J Clin Oncol. preservation after ovarian tissue grafting. Lancet.
2008;26:2630–5. 2015;385:1947–8.
73. Evans AC. Characteristics of ovarian follicle devel- 87. Nikiforov D, Junping C, Cadenas J, Shukla V, Blan-
opment in domestic animals. Reprod Domest Anim. shard R, Pors SE, Kristensen SG, Macklon KT,
2003;38:240–6. Colmorn L, Ernst E, Bay-Bjørn AM, Ghezelay-
74. Baerwald AR, Adams GP, Pierson RA. A new model agh Z, Wakimoto Y, Grøndahl ML, Hoffmann E,
for ovarian follicular development during the human Andersen CY. Improving the maturation rate of
menstrual cycle. Fertil Steril. 2003;80:116–22. human oocytes collected ex vivo during the cryo-
75. McNatty KP, Hillier SG, van den Boogaard AM, preservation of ovarian tissue. J Assist Reprod
Trimbos-Kemper TC, Reichert LE Jr, van Hall Genet. 2020;37(4):891–904.
EV. Follicular development during the luteal phase 88. Silber S.Goldsmith S, Castleman L, Hurlbut K, Fan
of the human menstrual cycle. J Clin Endocrinol Y, Melnick J, Hayashi K. In vitro maturation and
Metab. 1983;56:1022–31. transplantation of cryopreserved ovarian tissue:
13 76. Kuang Y, Chen Q, Hong Q, Lyu Q, Ai A, Fu Y,
Shoham Z. Double stimulations during the follicu-
understanding ovarian longevity. RBMO. 2022 (in
press).
lar and luteal phases of poor responders in IVF/ 89. Smitz JE, Thompson JG, Gilchrist RB. The prom-
ICSI programmes (Shanghai protocol). Reprod ise of in vitro maturation in assisted reproduction
Biomed Online. 2014;29:684–91. and fertility preservation. Semin Reprod Med.
77. Ubaldi FM, Capalbo A, Vaiarelli A, Cimadomo 2011;29:24–37.
D, Colamaria S, Alviggi C, Trabucco E, Venturella 90. McLaughlin M, Albertini DF, Wallace WHB,
R, Vajta G, Rienzi L. Follicular versus luteal phase Anderson R, Telfer E. Metaphase II oocytes from
ovarian stimulation during the same menstrual cycle human unilaminar follicles grown in a multi-step
(DuoStim) in a reduced ovarian reserve population culture system. Mol Hum Reprod. 2018;24:135–
results in a similar euploid blastocyst formation 14291. Wallin A, Ghahremani M, Dahm-Kahler P,
rate: new insight in ovarian reserve exploitation. Brannstrom M. viability and function of the cryo-
Fertil Steril. 2016;105:1488–95.. e1 preserved whole ovary: in vitro studies in the sheep.
78. Oktay K, Buyuk E. The potential of ovarian tissue Hum Reprod 2009;24:1684–94.
transplant to preserve fertility. Expert Opin Biol 91. Brännström M, Milenkovic M. Whole ovary cryo-
Ther. 2002;2:361–70. preservation with vascular transplantation – a
79. Aubard Y. Ovarian tissue graft: from animal experi- future development in female oncofertility. Middle
ment to practice in the human. Eur J Obstet Gyne- East Fertil Soc J. 2010;15:125–38.
col Reprod Biol. 1999;86:1–3. 92. Racho El-Akouri R, Kurlberg G, Dindelegan G,
80. Baird DT, Webb R, Campbell BK, Harkness LM, Molne J, Wallin A, Brannstrom M. Heterotopic
Gosden RG. Long-term ovarian function in sheep uterine transplantation by vascular anastomosis in
after ovariectomy and transplantation of autografts the mouse. J Endocrinol. 2002;174:157–66.
stored at −196 ° C. Endocrinology. 1999;140:462–71. 93. Silber SJ, Grudzinskas G, Gosden RG. Successful
81. Oktay K, Nugent D, Newton H, Salha O, Chatter- pregnancy after microsurgical transplantation of an
jee P, Gosden RG. Isolation and characterization intact ovary. N Engl J Med. 2008;359:2617–8.
321 13
94. Wranning CA, Akhi SN, Kurlberg G, Brannstrom 97. Torre A, Vertu-Ciolino D, Mazoyer C, Selva J,
M. Uterus transplantation in the rat: model devel- Lornage J, Salle B. Safeguarding fertility with
opment, surgical learning and morphological whole ovary cryopreservation and microvascular
evaluation of healing. Acta Obstet Gynecol Scand. transplantation: higher follicular survival with vit-
2008;87:1239–47. rification than with slow freezing in a ewe model.
95. Wranning CA, El-Akouri RR, Lundmark C, Transplantation. 2016;100(9):1889–97.
Dahm-Kahler P, Molne J, Enskog A, Brannstrom 98. Tsiartas P, Mateoiu C, Deshmukh M, Banerjee D,
M. Auto-transplantation of the uterus in the Arvind M, Padma AM, Milenkovic M, Gandolfi
domestic pig (Sus scrofa): surgical technique and F, Hellström M, Patrizio P, Akouri R. Seven days
early reperfusion events. J Obstet Gynaecol Res. ex vivo perfusion of whole ewe ovaries with fol-
2006;32:358–67. licular maturation and oocyte retrieval: towards
96. Imhof M, Bergmeister H, Lipovac M, Rudas M, the development of an alternative fertility preserva-
Hofstetter G, Huber J. Orthotopic microvascular tion method. Reprod Fertil Dev. (epub 1/28/2022).
reanastomosis of whole cryopreserved ovine ovaries https://doi.org/10.1071/RD21197.
resulting in pregnancy and live birth. Fertil Steril.
2006;85(Suppl 1):1208–15.
323 14
Ovarian Reserve Testing

Paula Amato
Contents
14.2 Basic Principles of Screening Tests – 326
14.3 A Shortened Menstrual Cycle – 326
14.4 Biochemical Markers of Ovarian Response – 327

14.4.1 Basal Follicle Stimulating Hormone – 327
14.5 Basal Estradiol – 327
14.6 Anti-Müllerian Hormone – 328
14.7 Inhibin B – 328
14.8 Clomiphene Citrate Challenge Test – 329
14.9 Home Fertility Tests – 329
14.10 Ultrasound Evaluation of Ovarian Reserve – 329

14.10.1 Antral Follicle Count – 329
14.11 Ovarian Volume – 330
14.12 Combined Ovarian Reserve Tests – 330
14.13 Repetitive Testing – 330
14.15 Answers – 332
References – 332

https://doi.org/10.1007/978-3-030-99596-6_14
324 P. Amato
reproductive potential [1, 2]. Ovarian reserve

Key Points testing should be performed in women older
55 Currently, AMH and antral follicle than 35 years who have not conceived after
count (AFC) are the most sensitive and 6 months of attempting pregnancy (or women
reliable markers of ovarian reserve. less than 35 who have not conceived after
55 Markers of ovarian reserve do not pre- 1 year) and women at higher risk of dimin-
dict reproductive potential, indepen- ished ovarian reserve, such as those with a his-
dent of age, in women with unproven tory of cancer or other medical conditions
fertility. treated with gonadotoxic therapy and/or pel-
55 Markers of ovarian reserve predict vic irradiation, or women who have had ovar-
ovarian response and oocyte yield dur- ian surgery for endometriomas.
ing controlled ovarian stimulation in Available tests for ovarian reserve include
the context of IVF. biochemical markers, i.e., FSH, estradiol,
AMH, and inhibin B, and ovarian ultrasound
imaging, i.e., antral follicle count and ovarian
volume [1] (. Fig. 14.1). For general
14.1 Introduction obstetrician-gynecologists, the most appropri-
ate ovarian reserve screening tests to use in
The general purpose of ovarian reserve test- practice are basal FSH plus estradiol levels or
ing is to assess the quantity and quality of the anti-Müllerian hormone (AMH) levels. An
remaining oocytes in an attempt to predict antral follicle count (AFC) may also be useful
Poor Response to
Ovarian Stimulation Nonpregnancy*
Test Cutpoint Sensitivity Specificity Sensitivity Specificity Reliability Advantages Limitations
FSH 10–20 10–80 83–100 7–58 43–100 Limited Widespread Reliability
(international use Low sensitivity
units/L)
AMH (ng/mL) 0.2–0.7 40–97 78–92 † † Good Reliability Limit of
detectability
Two commercial
assays
14 Does not predict
nonpregnancy
AFC (n) 3–10 9–73 73–100 8–33 64–100 Good Reliability Low sensitivity
Widespread
use
Inhibin B 40–45 40–80 64–90 † – Limited – Reliability
(pg/mL) Does not predict
nonpregnancy
CCCT, day 10 10–22 35–98 68–98 23–61 67–100 Limited Higher Reliability
FSH sensitivity Limited additional
(international than basal value to basal FSH
units/L) FSH Requires drug
administration
Abbreviations: AFC, antral follicle count; AMH, antimüllerian hormone; CCCT, clomiphene citrate challenge test; FSH, follicle-stimulating hormone.
Note: Laboratories ELISA.
*Failure to conceive
†Insufficient evidence
Testing and interpreting measures of ovarian reserve: a committee opinion. Practise Committee of the American Society for reproductiveMedicine.
Fertile Steril 2012;98:1407-15.
.. Fig. 14.1 Available tests for ovarian reserve include biochemical markers, i.e., FSH, estradiol, AMH, and inhibin
B, and ovarian ultrasound imaging, i.e., antral follicle count and ovarian volume
325 14
Advanced reproductive age (older than 35 years)
Family history of early menopause
Genetic conditions (eg, 45, X mosaicism)
FMR1 (Fragile X) premutation carrier
Conditions that can cause ovarian injury (eg, endometriosis,

pelvic infection)
Previous ovarian surgery (eg, for endometriomas)
Oophorectomy
History of cancer treated with gonadotoxic therapy or

pelvic irradiation
History of medical conditions treated with gonadotoxic

therapies
Smoking
Data from Testing and interpreting measures of ovarian reserve:a committee
opinion. Practice Committee of the American Society for Reproductive
Medicin e. Fertile Steril 2012;98:1407–15; Gurtcheff SE, Klein NA_Diminished
ovarian reserve and infertility. Clin Obstet Gynecol 2011;54:666–74; te Velde
ER, Pearson PL Thevariability of female reproductive ageing. Hum Reprod
Update 200;8:141–54; and Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B,
Nargund G, Gianaroli L. ESHRE consensus on the definition of ‘poor response’
to ovarian stimulation for in vitro fertilization: the Bologna criteria. ESHRE
working group on poor Ovarian Response Definition. HUM Repord
2011;26:1616–24.
.. Fig. 14.2 Risk factors for diminished ovarian reserve
if there is an indication to perform transvagi- As women age oocytes decrease in quality

nal ultrasonography. These screening tests are and quantity and do not regenerate. The num-
better predictors of oocyte yield from ovarian ber of human oocytes in a female peaks at 6–7
stimulation during in vitro fertilization (IVF) million during fetal life around midgestation,
than rate of pregnancy. Low ovarian response followed by profound atresia. Approximately
to stimulation, usually defined as fewer than one to 2 million oocytes are present at birth,
three to five developing follicles during an 300,000–500,000 at the start of puberty, and
IVF cycle, is an indicator of a poor reproduc- 1000 at 51 years of age, which is the average
tive outcome. It is important to recognize, age of menopause in the USA [2]. Factors
however, that a poor result from ovarian such as genetics, lifestyle, environment, and
reserve testing does not signify an absolute medical issues including endometriosis, ovar-
inability to conceive and should not be the ian surgery, chemotherapy, and radiation can
sole criteria considered to limit or deny access influence the quantity and quality of a wom-
to infertility treatment. Although these tests an’s oocytes [1] (. Fig. 14.2). Cross-sectional
are used to assess oocyte quantity and quality, studies suggest that fertility declines before
the best surrogate marker for oocyte quality is the onset of the premenopausal transition.
age. At this time, ovarian reserve testing The goal of ovarian reserve testing is to add
results cannot be extrapolated to predict the more prognostic information to the counseling
likelihood of spontaneous conception. and planning process so as to help couples
326 P. Amato
chose among treatment options. Ovarian 14.2 asic Principles of

B
reserve tests should not be the sole criteria used Screening Tests
to deny patients access to assisted reproductive
technology or other treatments. Evidence of The purpose of using ovarian reserve testing
decreased ovarian reserve does not necessarily as a screening test is to identify infertility
equate with inability to conceive. patients at risk for decreased ovarian reserve,
In women from the general population, who are likely to exhibit a poor response to
with no known history of infertility, who are gonadotropin stimulation and to have a lesser
attempting to conceive naturally, cumulative chance of achieving pregnancy with
probability of pregnancy has been shown to IVF. Good screening tests have validity as
decrease with age [3]. Cross-sectional studies measured by sensitivity and specificity. A valid
have shown that chronological age is corre- test correctly categorizes persons who have
lated with ovarian reserve, as measured by the disease as test positive (highly sensitive) and
size of the follicle pool in histologic studies of those without disease as test negative (highly
ovaries. Chronological age is strongly associ- specific).
ated with other biomarkers of ovarian reserve For clinical purposes, specificity is the test
including antral follicle count, anti-Müllerian characteristic that should be optimized to
hormone (AMH) levels, and early follicular decrease false positives or wrongly categoriz-
phase follicle-stimulating hormone (FSH) lev- ing patients with normal ovarian reserve as
els. Chronological age is an excellent predictor having decreased ovarian reserve (DOR).
of fertility among infertile women undergoing Graphically, the sensitivity and specificity of
assisted reproduction [4]. different cut-off points of a diagnostic test
Existing research on ovarian reserve test- can be plotted as receiver operating character-
ing is often confusing because of heterogene- istic (ROC) curves.
ity among tested populations (the general Positive predictive value (PPV) and nega-
population, infertility patients of all ages, tive predictive value (NPV) are screening test
infertility patients more than 35 years old, characteristics that change with the preva-
etc.). No single result is definitive, since find- lence of disease (DOR) in the study popula-
ings must be interpreted in context and should tion. The PPV is the probability that a woman
be repeated or supplemented as appropriate. who tests positive truly has DOR. The NPV is
This chapter will discuss the application of the probability that a woman who tests nega-
ovarian reserve tests in evaluating fertility.
14 tive has normal ovarian reserve. Ovarian
reserve testing is most useful in identifying
Case Vignette DOR in women at high risk for DOR. Ovarian
reserve testing in women at low risk for DOR
A 38-year-old nulligravid female and her will yield a larger number of false-positive
male partner present with a 3-year history results (lower PPV).
of infertility. She has regular cycles. A hys-
terosalpingogram shows a normal uter-
ine cavity and bilateral patent tubes. Her
AMH level is 0.7 ng/mL. Day 3 FSH and 14.3 A Shortened Menstrual Cycle
estradiol levels are 11 IU/L and 20 pg/dL,
respectively. Her partner had a semen anal- As the ovary ages, the size of the follicle pool
ysis which showed normal semen param- declines. Fewer follicles result in less produc-
eters. The couple has failed three cycles of tion of AMH and inhibin. Because of lower
controlled ovarian stimulation using clo- inhibin levels, FSH rises prematurely or more
miphene citrate in combination with intra- rapidly leading to elevated early follicular
uterine insemination (IUI). How would you phase serum FSH levels. Premature and rapid
counsel this patient regarding her treatment follicular growth results in elevated early fol-
options and chance of pregnancy success? licular phase estradiol levels and a shortened
follicular phase and overall shortened men-
327 14
strual cycle. A short menstrual cycle length is nancy. The value of serum or urinary FSH
associated with a lower probability of con- levels as predictors of reproductive potential
ceiving naturally or following IVF [5]. The in the general population has not been deter-
cut-off value to define “short” cycle length mined. Testing is cycle day specific (cycle days
varies by study ranging from 25 to 26 days. 2–4), limiting flexibility.
Women having an abnormally elevated
FSH value will have DOR. The PPV of FSH
14.4 Biochemical Markers for poor response to ovarian stimulation or
of Ovarian Response failure to conceive is higher in older women.
Limited evidence suggests that women with
14.4.1 asal Follicle Stimulating
B fluctuating FSH levels should not wait for the
ideal cycle, wherein the FSH concentration is
Hormone normal, to undergo IVF stimulation [8].
FSH is a late marker of dwindling ovarian
Follicle stimulating hormone is released by
function. With AMH and AFC demonstrat-
the pituitary gland in response to
ing better predictive value for ovarian response
gonadotropin- releasing hormone from the
than FSH, these are more likely to be the tests
hypothalamus and is subject to negative feed-
of choice. It remains unknown whether high
back from estradiol and inhibin B. In the set-
FSH levels in women of reproductive age pre-
ting of a smaller follicular cohort and
dict an earlier onset of menopause.
decreased estradiol and inhibin B levels, an
increase in pituitary FSH secretion occurs,
which can be identified as an elevated early
follicular phase FSH level. This higher FSH 14.5 Basal Estradiol
level stimulates rapid ovarian follicular
growth, which results in higher estradiol levels Estradiol levels vary over the course of a men-
as well as a shorter follicular phase and menstrual cycle, peaking in both the late follicular
strual cycle. and mid-luteal phases. As ovarian reserve
FSH is typically measured by immunoas- declines, the follicular phase shortens because
say on cycle day 3. The basal FSH level can of decreasing feedback inhibition by follicles
vary, so a single FSH value has limited reli- recruited during the previous cycle. As a
ability. Moreover, there is variability among result, an elevated day 3 estradiol level could
different FSH assays. Although basal FSH is reflect diminishing ovarian reserve.
commonly used to assess ovarian reserve, and Estradiol is released from the ovary during
high values (>10–20 IU/L) are associated with follicular development. The estradiol level is
diminished ovarian reserve and poor response usually low (<50 pg/mL) on days 2–4 of the
to ovarian stimulation, the test is not predic- menstrual cycle. An elevated value (>60–
tive of failure to conceive [6]. If FSH values 80 pg/mL) in the early follicular phase can
are consistently elevated, a poor reproductive indicate reproductive aging and hastened
prognosis is likely; in contrast, a single ele- oocyte development. Through central nega-
vated FSH value in women younger than tive feedback, a high estradiol level can sup-
40 years predicts a lower oocyte yield during press an elevated FSH concentration into the
IVF but does not predict the rate of preg- normal range. The value of obtaining an
nancy [7]. estradiol level is that it allows the correct
Early follicular phase FSH levels have not interpretation of a normal basal FSH level.
been a sensitive test for nonpregnancy, sug- Basal estradiol has low predictive accuracy for
gesting that an elevated FSH is an excellent poor ovarian response and failure to conceive
predictor of nonpregnancy following ART, and, therefore, this test should not be used in
but a normal level is not predictive of preg- isolation to assess ovarian reserve [9].
328 P. Amato
14.6 Anti-Müllerian Hormone AMH-level testing may be valuable in

assessing ovarian reserve in young women
AMH is a homodimeric glycopeptide that with cancer before and after chemotherapy
is produced predominantly by granulosa [18]. AMH may enable assessment of ovarian
cells. AMH is believed to downregulate reserve before and after ovarian surgery and
FSH-
mediated folliculogenesis. Its expres- for women at high risk of primary ovarian
sion is highest in secondary, preantral, and insufficiency. AMH-level testing may in future
small antral follicles. AMH seems to have a provide an accurate method of predicting the
role in selecting the dominant follicle in addi- reproductive lifespan and the timing of meno-
tion to generally mediating preantral follicular pause [19].
recruitment. AMH levels start undergoing a AMH has the advantage over FSH in that
log-linear decline approximately 15 years prior AMH levels remain relatively stable over the
to menopause and drop to very low levels menstrual cycle; thus measurement does not
approximately 5 years before menopause [10]. need to be cycle day specific. A recent meta-
The anti-Müllerian hormone concentra- analysis of earlier studies showed no signifi-
tion is fairly stable within and between men- cant association between AMH, modeled as a
strual cycles [11]. As the number of ovarian continuous variable, and pregnancy following
follicles decreases with age, a concomitant ART [20]. However, more recent studies of
decrease in AMH levels occurs, which reflects larger sizes, modeling AMH using cut-off val-
this age-related oocyte depletion [12]. ues, have shown lower odds of pregnancy and
Although an undetectable AMH level suggests live birth following ART among women with
diminished ovarian reserve and can identify low AMH levels [21–24].
individuals at risk of poor ovarian response to High AMH values are associated with
stimulation, undetectable and low AMH levels polycystic ovary syndrome (PCOS) and may
(0.2–0.7 ng/mL DSL ELISA) are not predic- identify women at risk of ovarian hyper-
tive of failure to conceive [13]. AMH levels stimulation syndrome (OHSS). It is believed
may allow treatment to be tailored to each that AMH remains a valid assay even when
individual. Lower AMH levels are associated ovarian suppression occurs through oral
with reduced ovarian response to stimulation, contraceptives, although age-specific AMH
and high levels are associated with a brisk percentiles decrease by 11% with oral contra-
ovarian response to stimulation [13]. Although ceptives [25].
the AMH level is a good predictor of oocyte
14 quantity, it may not provide information about
egg quality. Young women with low AMH lev- 14.7 Inhibin B
els may have a reduced number of oocytes but
normal age-appropriate oocyte quality [14]. Inhibin B is a glycoprotein hormone that is
One limitation of AMH level testing is the secreted primarily by preantral and antral fol-
variability of results between the available licles. The serum concentration of inhibin B
assays. In clinical practice, individual AMH- decreases with the age-related decrease in the
level test results must be interpreted based on number of oocytes. Inhibin B has central neg-
the normal range of the assay used [15]. AMH- ative feedback that controls FSH secretion.
level testing is a useful screening test in women Therefore, a decrease in inhibin B levels leads
at high risk of diminished ovarian reserve and to increased pituitary FSH secretion and
in women undergoing IVF [16, 17]. higher early follicular FSH levels.
The nonpregnancy predictive value of a Inhibin B levels exhibit high intra-cycle
low AMH value appears to increase if older variability [16]. Inhibin B levels also vary
women at risk for ovarian aging are tested. significantly between menstrual cycles [16].
The use of AMH as a routine screening tool Inhibin B levels are a late finding for dimin-
for DOR in a low-risk population is not rec- ished ovarian reserve and typically start fall-
ommended. ing around 4 years prior to menopause [10],
329 14
and are thus suboptimal. Inhibin levels are 14.9 Home Fertility Tests
measured by immunoassay. Inhibin B is typ-
ically measured on the third day of the men- Available home fertility tests use a urine sam-
strual cycle. It has limited sensitivity and ple to assess the FSH level on cycle day 3. The
specificity. This marker does not reliably tests are marketed directly to consumers. The
predict a poor response to ovarian stimula- limitations of these tests include misinterpre-
tion and thus is not a recommended test. tation of instructions and results and the
unavailability of a medical professional to
interpret and explain the results [1]. Although
14.8 Clomiphene Citrate these tests are used commonly by women at
Challenge Test low risk of diminished ovarian reserve, the
results may provide false reassurance or raise
Clomiphene is a selective estrogen receptor unnecessary concern.
modulator (SERM) that inhibits negative
feedback inhibition by estradiol on the hypo-
thalamus, thereby increasing FSH secretion,
14.10 Ultrasound Evaluation
which enhances follicular recruitment.
Clomiphene can be used for ovulation induc- of Ovarian Reserve
tion and superovulation.
The clomiphene citrate challenge test is 14.10.1 Antral Follicle Count
performed by measuring serum FSH on cycle
day 3, administering 100 mg clomiphene The antral follicle count records the number
citrate daily on cycle days 5–9, and again mea- of visible ovarian follicles (2–10 mm mean
suring serum FSH on cycle day 10. An ele- diameter) that are observed during transvagi-
vated FSH level on day 10 of the CCCT is nal ultrasonography in the early follicular
suggestive of diminished ovarian reserve. phase (cycle days 2–5). The number of antral
However, cycle-to-cycle variability in ovarian follicles correlates with the quantity of
biomarkers limits the reliability of this pro- remaining follicles and with the ovarian
vocative test [26]. The stimulated FSH level on response during controlled ovarian stimula-
cycle day 10 of the CCCT is predictive of tion. Good intercycle and interobserver reli-
poor ovarian response but is not predictive of ability has been demonstrated [16]. A low
failure to conceive [27]. Compared with the antral follicle count is considered three to six
basal FSH level and the antral follicle count, total antral follicles and is associated with
the cycle-day-10 FSH level does not improve poor response to ovarian situation during
the prediction for poor ovarian response [27]. IVF, but it does not reliably predict failure to
In studies comparing the test performance of conceive; in a meta-analysis, a low antral fol-
basal (cycle day 3) and stimulated (cycle day licle count was a mean of 5.2 (2.11 SD) total
10) FSH values, stimulated FSH levels have antral follicles [28]. When AFC was compared
higher sensitivity but lower specificity than to age, basal FSH, basal estradiol, AMH,
basal FSH concentrations [27]. inhibin B, and ovarian volume, antral follicle
In summary, basal measure of FSH may count and AMH were the most significant
be preferable to the CCCT, unless one is using predictors of poor response to ovarian stimu-
the test to purposely increase sensitivity. It is lation but were not predictive of failure to
unclear if the CCCT confers any benefit over conceive [29].
basal FSH alone, and it is less cost-effective. Low AFC cut-off points are highly spe-
The CCCT may have a role in helping dis- cific for predicting poor ovarian response but
criminate normal ovarian reserve from poor have lower sensitivity [28]. The high specificity
ovarian reserve in patients with potentially of a low AFC makes the test useful for pre-
borderline function. dicting poor ovarian response and treatment
330 P. Amato
failure, but its clinical utility is limited by its 14.13 Repetitive Testing
low sensitivity. Inter- and intra-observer vari-
ability also may be limiting. There is a debate Repetitive testing of biomarkers of ovarian
regarding the effect of oral contraceptives on reserve to assess reproductive potential
the measurement of antral follicle count. appears to be of little benefit. In general, hor-
monal biomarkers do not appear to fluctuate
greatly between cycles [30]. However, intercy-
14.11 Ovarian Volume cle variability does appear to increase with
age, suggesting that repetitive testing may be
The calculation of ovarian volume requires valuable among older women to rule out
ovarian measurements in three planes and the DOR. Fluctuations in biomarker values
use of the formula for the volume of an ellip- reflect diminished ovarian reserve. However,
soid: D1 × D2 × D3 × 0.52. Mean ovarian vol- within a given individual, the probability of
ume, the average volume calculated for both conceiving in a given ART treatment cycle
ovaries from the same individual, is the value does not appear to correlate with the cycle-
used to assess ovarian reserve. With age, specific biomarker level [8, 31].
changes in ovarian volume are concordant
with the age-related decrease in ovarian
follicles.
Several studies have demonstrated that Conclusions
low ovarian volume, typically <3 mL, predicts The primary goal of ovarian reserve testing
poor response to ovarian stimulation with is to identify women at risk of decreased
high specificity and a wide range of sensitivity ovarian reserve, with a secondary goal of
[16]. In general, ovarian volume has been a individualizing treatment strategies for each
poor predictor of pregnancy. woman. Although these may predict ovar-
The generalizability to patients with ovarian response to infertility treatment, they do
ian pathology is limited. Ovarian volume may not reliably predict failure to conceive.
vary in response to normal physiologic Generally, women of the same age
changes and coexisting medical conditions with higher FSH levels seem to have lower
(such as endometriomas). Exogenous hor- fecundability. Younger women with elevated
mones can decrease ovarian volume. For these FSH levels often have much better fecund-
reasons, AFC is believed to be a better marker
14 for ovarian reserve.
ability than older women with comparably
elevated FSH, and age can be a better pre-
dictor of outcome than FSH. The assay in
general has suboptimal sensitivity for both
14.12 Combined Ovarian ovarian response and pregnancy rates, as
Reserve Tests reflected by receiver-operator curves. AMH
and AFC have a better balance of sensitivity
AMH and AFC are the most accurate predic- and specificity than FSH. AMH and AFC
tors, but combinations of a few tests are only seem to be emerging as the best approaches
slightly better than a single test. Models of to procreative testing [1] (. Fig. 14.3).
combined ovarian reserve tests do not signifi- These measures can also be used to predict
cantly improve the ability to predict poor hyperstimulation.
reproductive outcomes over a single ovarian No ovarian reserve test should be
reserve test [29]. Furthermore, the use of mul- used as a sole criterion for the use of
tiple ovarian reserve tests may increase the ART. Combined tests do not consistently
expense of screening. Further research is improve the ability to predict ovarian
needed to determine an optimal combination response. Combined testing is unlikely to be
of tests. cost-effective. Though some ovarian reserve
331 14
tests appear better than others in predicting not sensitive for cycle failure (nonpreg-
ovarian response to stimulation, most are nancy). Biomarkers of ovarian reserve are
limited at best in predicting pregnancy, and being used as fertility tests in the general
this predictive value is highly dependent on population. The value of these biomarkers
patient demographics within a study. The as predictors will likely depend on the study
number of false-positive test results will population, with the highest predictive
increase when screening tests for DOR are value likely to be observed in women at risk
used in low-risk populations. for ovarian aging (older reproductive age
In summary, biomarkers of ovarian women). Among the laboratory biomark-
reserve are associated with natural and ers, AMH appears to have the most prom-
treatment-related fertility. However, contro- ise as a measure of reproductive potential;
versy remains as to their ability to predict however, studies are especially limited in
reproductive potential. Cut-off values vary the general population. Further studies are
tremendously in the literature. For infertile needed to determine test characteristics in
women undergoing ART treatment, these the prediction of natural fertility or infertil-
biomarkers tend to be highly specific but ity in the general population.
Test Details
FSH plus estradiol • Serum level on cycle day 2–3

• Variation between cycles possible
• High FSH value is associated with poor

response to ovarian stimulation
• Does not predict failure to conceive
AMH • No specific timing for the test
• Stable value within and between

menstrual cycles
• Low AMH value is associated with poor

response to ovarian stimulation
AFC • Number of visible follicles (2–1 0 mm)

during transvaginal ultrasound
• Performed on cycle days 2–5
• Number of antral follicles correlates with

ovarian response to stimulation
Abbreviations: AFC, antral follicle count; AMH, antimOIIerian hormone; FSH,

follicle-stimulatin hormone.
.. Fig. 14.3 AMH and AFC seem to be emerging as the best approaches to procreative testing
332 P. Amato
14.14 Review Questions the management of infertility. Hum Reprod.

2003;18(9):1959–66.
4. Centers for Disease Control and Prevention,
??1. Ovarian reserve tests predict which of A.S.f.R.M., Society for Assisted Reproductive Tech-
the following? nology. Assisted reproducrtive technology fertility
A. Pregnancy and live birth rates after clinic success rates report. Atlanta: Department of
ovarian stimulation and IUI for un- Health and Human Services; 2010. p. 2014.
5. Brodin T, et al. Menstrual cycle length is an age-
explained infertility
independent marker of female fertility: results from
B. Age at menopause 6271 treatment cycles of in vitro fertilization. Fertil
C. Oocyte yield after controlled ovar- Steril. 2008;90(5):1656–61.
ian stimulation for IVF 6. Esposito MA, Coutifaris C, Barnhart KT. A moder-
D. Reproductive potential in the gen- ately elevated day 3 FSH concentration has limited
predictive value, especially in younger women. Hum
eral population
Reprod. 2002;17(1):118–23.
7. Roberts JE, et al. Taking a basal follicle-stimulating
??2. Which combination of tests is the most hormone history is essential before initiating in vitro
sensitive and reliable measure of ovar- fertilization. Fertil Steril. 2005;83(1):37–41.
ian reserve? 8. Abdalla H, Thum MY. Repeated testing of basal
FSH levels has no predictive value for IVF outcome
A. D3FSH and AMH
in women with elevated basal FSH. Hum Reprod.
B. AMH and AFC 2006;21(1):171–4.
C. Day 3 estradiol and day 3 FSH 9. Broekmans FJ, et al. A systematic review of tests
D. Inhibin B and AFC predicting ovarian reserve and IVF outcome. Hum
Reprod Update. 2006;12(6):685–718.
10. Sowers MR, et al. Anti-mullerian hormone and
??3. Which of the following is not a risk fac-
inhibin B in the definition of ovarian aging and the
tor for decreased ovarian reserve? menopause transition. J Clin Endocrinol Metab.
A. Advanced maternal age 2008;93(9):3478–83.
B. History of gonadotoxic chemo- 11. Tsepelidis S, et al. Stable serum levels of anti-
therapy Mullerian hormone during the menstrual cycle: a
prospective study in normo-ovulatory women. Hum
C. Smoking
Reprod. 2007;22(7):1837–40.
D. PCOS 12. Bentzen JG, et al. Maternal menopause as a predic-
tor of anti-Mullerian hormone level and antral fol-
licle count in daughters during reproductive age.
Hum Reprod. 2013;28(1):247–55.
14.15 Answers 13. Nelson SM, Yates RW, Fleming R. Serum anti-
14 Mullerian hormone and FSH: prediction of live
vv1. C birth and extremes of response in stimulated cycles-
-implications for individualization of therapy. Hum
Reprod. 2007;22(9):2414–21.
vv2. B 14. Toner JP, Seifer DB. Why we may abandon basal
follicle-stimulating hormone testing: a sea change in
vv3. D determining ovarian reserve using antimullerian
hormone. Fertil Steril. 2013;99(7):1825–30.
15. Practice Committee of the American Society for
Reproductive Medicine. Testing and interpreting
References measures of ovarian reserve: a committee opinion.
Fertil Steril. 2015;103(3):e9–e17.
1. Committee on Gynecologic Practice. Committee 16. McIlveen M, Skull JD, Ledger WL. Evaluation of
opinion no. 618: ovarian reserve testing. Obstet the utility of multiple endocrine and ultrasound
Gynecol. 2015;125(1):268–73. measures of ovarian reserve in the prediction of
2. Practice Committee of the American Society for cycle cancellation in a high-risk IVF population.
Reproductive Medicine. Electronic address: asrm@ Hum Reprod. 2007;22(3):778–85.
asrm.org; Practice Committee of the American 17. Muttukrishna S, et al. Inhibin B and anti-Mullerian
Society for Reproductive Medicine. Testing and hormone: markers of ovarian response in IVF/ICSI
interpreting measures of ovarian reserve: a commit- patients? BJOG. 2004;111(11):1248–53.
tee opinion. Fertil Steril 2020;114(6): 18. Peigne M, Decanter C. Serum AMH level as a
1151–1157. marker of acute and long-term effects of chemo-
3. Gnoth C, et al. Time to pregnancy: results of therapy on the ovarian follicular content: a system-
the German prospective study and impact on atic review. Reprod Biol Endocrinol. 2014;12:26.
333 14
19. Nelson SM. Biomarkers of ovarian response: cur- 26. Kwee J, et al. Intercycle variability of ovarian
rent and future applications. Fertil Steril. reserve tests: results of a prospective randomized
2013;99(4):963–9. study. Hum Reprod. 2004;19(3):590–5.
20. Broer SL, et al. Added value of ovarian reserve test- 27. Hendriks DJ, et al. The clomiphene citrate challenge
ing on patient characteristics in the prediction of test for the prediction of poor ovarian response and
ovarian response and ongoing pregnancy: an indi- nonpregnancy in patients undergoing in vitro fertil-
vidual patient data approach. Hum Reprod Update. ization: a systematic review. Fertil Steril.
2013;19(1):26–36. 2006;86(4):807–18.
21. La Marca A, et al. Anti-Mullerian hormone-based 28. Hendriks DJ, et al. Antral follicle count in the pre-
prediction model for a live birth in assisted repro- diction of poor ovarian response and pregnancy
duction. Reprod Biomed Online. 2011;22(4):341–9. after in vitro fertilization: a meta-analysis and com-
22. Lee TH, et al. Impact of female age and male infer- parison with basal follicle-stimulating hormone
tility on ovarian reserve markers to predict outcome level. Fertil Steril. 2005;83(2):291–301.
of assisted reproduction technology cycles. Reprod 29. Jayaprakasan K, et al. A prospective, comparative
Biol Endocrinol. 2009;7:100. analysis of anti-Mullerian hormone, inhibin-B, and
23. Lukaszuk K, et al. Use of ovarian reserve parame- three-dimensional ultrasound determinants of
ters for predicting live births in women undergoing ovarian reserve in the prediction of poor response to
in vitro fertilization. Eur J Obstet Gynecol Reprod controlled ovarian stimulation. Fertil Steril.
Biol. 2013;168(2):173–7. 2010;93(3):855–64.
24. Brodin T, et al. Antimullerian hormone levels are 30. Steiner AZ. Biomarkers of ovarian reserve as pre-
strongly associated with live-birth rates after dictors of reproductive potential. Semin Reprod
assisted reproduction. J Clin Endocrinol Metab. Med. 2013;31(6):437–42.
2013;98(3):1107–14. 31. Scott RT Jr, et al. Intercycle variability of day 3 fol-
25. Dolleman M, et al. The relationship between anti- licle-stimulating hormone levels and its effect on
Mullerian hormone in women receiving fertility stimulation quality in in vitro fertilization. Fertil
assessments and age at menopause in subfertile Steril. 1990;54(2):297–302.
women: evidence from large population studies. J
Clin Endocrinol Metab. 2013;98(5):1946–53.
335 15
Recurrent Early Pregnancy

Loss
Krystle Y. Chong and Ben W. Mol
Contents
15.1 Definition – 337
15.2 Evaluation and Treatment – 337

15.2.1 Introduction – 337
15.3 Epidemiological Risk Factors – 339

15.3.1 ge – 339
A
15.3.2 Previous Reproductive History – 339
15.4 Anatomic Risk Factors – 339

15.4.1 ongenital Malformations – 340
C
15.4.2 Intrauterine Adhesions – 340
15.4.3 Intrauterine Masses – 341
15.4.4 Cervical Incompetence – 341
15.5 Genetic Factors – 341

15.5.1 ytogenetic Abnormalities – 341
C
15.5.2 Parental Chromosomal Disorders – 342
15.5.3 Genetic Evaluation in RPL – 342
15.6 Endocrine Risk Factors – 342

15.6.1 L uteal Phase Deficiency – 342
15.6.2 Polycystic Ovarian Syndrome (PCOS) – 343
15.6.3 Thyroid Dysfunction – 343
15.6.4 Management of Thyroid Dysfunction in RPL – 344
15.6.5 Abnormal Glucose Metabolism – 344
15.6.6 Hyperprolactinaemia – 344
15.6.7 Diminished Ovarian Reserve – 344
15.7 Immunological Factors – 345
15.8 Thrombophilia – 345

https://doi.org/10.1007/978-3-030-99596-6_15
15.8.1 ntiphospholipid Syndrome – 345
A
15.8.2 Hereditary Thrombophilia – 346
15.9 Infection – 347
15.10 Environmental and Psychological Factors – 347

15.10.1 L ifestyle Factors – 347
15.10.2 Obesity – 347
15.10.3 Psychological Factors – 347
15.11 Unexplained Pregnancy Loss – 347
15.12 Future Pregnancy Outcomes – 347
15.13 ReviewQuestions – 348
15.14 Answer – 348
References – 348
Recurrent Early Pregnancy Loss
337 15
Key Points 55 Most women with unexplained recur-

55 Most miscarriages are sporadic, and rent pregnancy loss will have successful
thought to be associated with genetic outcomes in subsequent pregnancies.
causes, influenced by maternal age.
55 More than 50% of recurrent pregnancy
loss will not have a clearly defined cause
after thorough evaluation.
Case Vignette
A 33-year-old G2P0 woman presents with her with no other significant medical history. Her
partner of 2 years for a consultation for recurrent only surgeries were her two D&C procedures.
pregnancy loss. She has been trying to conceive She has no gynaecological history and reports
with her partner for 2 years and has experienced regular menses every 28 days with no heavy
two first trimester miscarriages, which were both menstrual bleeding or dysmenorrhoea and
managed surgically with dilation and curettage onset of menarche at age 13. She reports nor-
(D&C). She reports she has always had her preg- mal and up-to-date cervical screening tests and
nancies confirmed on ultrasound on an early dat- denies a history of sexually transmitted infec-
ing scan at 6 weeks with subsequent foetal loss tions. She has been taking regular antenatal
before 12 weeks on repeat ultrasound. Genetic vitamins and has no known allergies.
evaluation was not performed on products of Her husband is medically well with no sig-
conception from either of these pregnancies. nificant medical or surgical history. They both
She has a known history of polycystic ovar- deny the use of alcohol, tobacco or substance
ian syndrome but is otherwise medically well use.
15.1 Definition for investigation and management. For most

investigations, the decision on when to start
The definition of recurrent pregnancy loss investigations will need to be decided in a
(RPL) has traditionally included only couples shared decision-making process between cou-
with three or more spontaneous, consecutive ples and their physician [6].
miscarriages. Professional organisations such
as the American Society for Reproductive
Medicine (ASRM) and European Society 15.2 Evaluation and Treatment
of Human Reproduction and Embryology
(ESHRE) have now redefined RPL as the loss 15.2.1 Introduction
of two or more clinically recognised pregnan-
cies, excluding molar and ectopic pregnancies The following chapter will review a general
[1, 2]. However, the previous definition of approach to investigation and management of
three or more consecutive pregnancy losses recurrent pregnancy loss. A detailed descrip-
remains in use by other organisations such tion of potential contributing factors to RPL
as the Royal College of Obstetricians and will follow, as well as the appropriate diagnos-
Gynaecologists (RCOG) in the UK, as well tic and therapeutic strategies. An initial evalu-
as the French College of Gynaecologists and ation for early pregnancy loss is included in
Obstetricians [4, 5]. As the revised defini- . Fig. 15.1, followed by a summary overview
tion of recurrent miscarriage is used across of standard workup for RPL in . Table 15.1.
more countries and regions, more women Factors generally accepted to be associ-
and couples will be able to access services ated with RPL include embryonic chromo-
338 K. Y. Chong and B. W. Mol
.. Fig. 15.1 Initial

First Pregnancy Loss
evaluation of pregnancy
No action unless clinically indicated
loss. (Adapted from
Edition 3)
Second Pregnancy Loss
Obtain foetal / products of
conception karyotyping
Aneuploidy Euploidy Unbalanced chromosomal

No further investigation Further RPL translocation or inversion
investigations Parental karyotyping
.. Table 15.1 Investigations and management of RPL
Aetiology Routine screening Consider on Treatment

individualised basis
Anatomical Ultrasonography (two-dimensional Magnetic Consider surgical correction

or three-dimensional), sonohys- resonance imaging
teroscopy, hysterosalpingogram
Genetic Karyotyping of products of Parental karyotyp- Genetic counselling and
conception ing preimplantation genetic
testing (in known parental
karyotype anomalies)
Thrombophilia Antiphospholipid syndrome panel Congenital Aspirin and heparin for
thrombophilia APS
screen
Endocrine Thyroid-stimulating hormone (and Control of diabetes mellitus
full thyroid panel and antibody and thyroid disorders
screen if abnormal)
HbA1c
Prolactin levels
Infection None Sexually transmit- Targeted antibiotic therapy
ted infections,
15 vaginal cultures
Endometrial biopsy
Immunological None
Male factor Sperm DNA Lifestyle modifications
fragmentation
index
Psychological History Offer psychological support
Lifestyle factors History of smoking, drug use, Health behaviour modifica-
excessive alcohol or caffeine intake tion
339 15
somal abnormalities, uterine malformations, 15.3 Epidemiological Risk Factors
endocrine dysfunction, autoimmune disor-
ders and acquired thrombophilia such as 15.3.1 Age
antiphospholipid syndrome [4, 7, 8]. Other
causes have been proposed but remain contro- Advanced maternal age is a well-established
versial, including chronic endometritis, infec- risk factor for subfertility, foetal anoma-
tious diseases, inherited thrombophilia, luteal lies, stillbirth and obstetric complications.
phase deficiency and high sperm DNA frag- Fecundity decreases gradually beginning
mentation levels [1, 4, 7]. from 32 years and more rapidly from 37 years,
Investigations for RPL were traditionally reflecting a decline in the number and qual-
only initiated after three consecutive miscar- ity of remaining oocytes. This progressive
riages. However, recent data does not support atresia of oocytes is associated with elevated
this protocol. Several recent studies showed levels of follicle-stimulating hormone and
that women with two or three pregnancy anti-Mullerian hormone [13]. Furthermore,
losses had similar obstetric characteristics and age-related decline in fertility is also accom-
investigation results with two RPL and three panied by significant increases in rates of
RPL had very similar obstetric characteris- aneuploidy and spontaneous miscarriage [4,
tics and associated causative factors. Hence, 7]. Advanced paternal age has also been iden-
couples with two pregnancy losses should be tified as a risk factor for pregnancy loss, with
offered the same care pathway [8–10]. the highest combined risk seen in couples
Over the years, evidence-based treat- where the woman is 35 years or older and the
ments such as surgical management of uter- man is 40 years or older [14, 15].
ine anomalies and aspirin and heparin for
antiphospholipid syndrome have improved
outcomes for couples with RPL. However, 15.3.2 Previous Reproductive
more than 50% of cases of recurrent mis-
History
carriage will not have a clearly defined aeti-
ology [7]. Most investigations and treatment
The risk of further miscarriages increases
also remain controversial, with a lack of
after each successive pregnancy loss, reach-
consensus amongst international groups
ing 40% after three consecutive pregnancy
regarding standard investigations and treat-
losses. A previous live birth does not prevent
ment options for RPL [11]. Nevertheless,
a woman from experiencing RPL, and the
standard investigations for recurrent miscar-
prognosis worsens with increasing maternal
riage continue to be important in evaluating
age [16, 17].
potential factors responsible for pregnancy
loss [12].
A standard initial evaluation of RPL
should include a complete patient history
15.4 Anatomic Risk Factors
including medical, obstetric and family
Anatomic defects are found in up to 15% of
history, as well as lifestyle factors such as
women with RPL and may be classified as
smoking, alcohol consumption and exercise.
congenital malformations or acquired anoma-
Medical and family history could be used to
lies including intrauterine adhesions, myomas
tailor diagnostic investigations in RPL. Any
and endometrial polyps. They are thought to
previous investigations on prior miscarriages
interrupt endometrial vasculature and prompt
should be reviewed, as well as any evidence of
abnormal placentation [1, 2, 4].
acute or chronic disease.
15.4.1 Congenital Malformations There is still insufficient evidence on the

efficacy and safety of surgical interventions
Congenital malformations of the reproduc- for improving reproductive outcomes. Some
tive tract result from failure of development, reports have shown hysteroscopic metroplasty
fusion and degeneration of the parameso- for women with septal divisions to reduce mis-
nephric ducts. Congenital uterine malfor- carriages and improve live birth rates [24–26],
mations have a well-established association whilst other studies show surgical manage-
with recurrent pregnancy loss, in addition to ment of fusion or unification defects to be of
other complications such as preterm birth, limited benefit [27]. The primary limitation
foetal malpresentation and increased rates of to this data is the lack of large randomised
Caesarean delivery [18, 19]. Congenital uter- controlled therapeutic trials. An international
ine abnormalities may have varying degrees of randomised controlled trial found no evidence
symptomatology but can be broadly classified that hysteroscopic septum resection improved
into unification defects (unicornuate, bicornu- live birth rates in women with a septate uterus,
ate or didelphys uterus) and/or canalisation as compared with expectant management.
defects from incomplete resorption of the mid- However, this was limited by a small sample
line septum (subseptate or septate uterus) [20]. size of 80 women [28]. Until such a study can
Imaging for the detection of uterine mal- robustly prove an improvement in reproduc-
formations is commonly performed via hys- tive outcomes, patients should be adequately
terosalpingography but now may be more counselled regarding the potential risks of
fully characterised by sonohysterography, surgery, such as uterine perforation, and par-
laparoscopy, magnetic resonance imaging ticipate in a shared decision-making process
or ultrasound imaging (two-dimensional or for ongoing management.
three-dimensional) [21]. Sonohysterography
uses the introduction of saline or contrast fluid
into the uterine cavity to enhance ultrasound 15.4.2 Intrauterine Adhesions
imaging studies and has higher sensitivity and
specificity compared to hysterosalpingogra- Intrauterine adhesions, or synechiae, occur
phy or diagnostic hysteroscopy in diagnosis in sites where the endometrial basal layer has
of uterine malformations, with . Fig. 15.2 been destroyed, most frequently from curet-
demonstrating a hysteroscopic approach. In tage, uterine surgery or infection. Endometrial
contrast, hysterosalpingography has a good trauma may cause minimal or significant inter-
sensitivity for diagnosing more pronounced ruption to vasculature, resulting in menstrual
uterine malformations, but it is limited in dif- abnormalities, infertility and recurrent preg-
15 ferentiating between the types of malforma- nancy loss. Asherman syndrome describes the
tions [22, 23]. presence of intrauterine adhesions with oligo-
or amenorrhoea [29].
Hysteroscopic adhesiolysis is now the
treatment of choice due to its minimally inva-
sive nature and being able to be performed
under direct vision. It does carry significant
risks of uterine perforation, and dense scar
tissue and difficult entry into the cervix may
necessitate laparoscopic or ultrasound guid-
ance, ultrasonography or laparoscopic guid-
ance [30]. Some studies have reported on the
use of a Foley catheter introduced into the
uterine cavity with an inflated balloon for sev-
eral days after lysis of adhesions to prevent
recurrence. However, this has the added risk
.. Fig. 15.2 Uterine septum at hysteroscopy of infection and patient discomfort, as well
341 15
as potential disadvantages of reducing blood causing pregnancy loss. However, they are also
flow to the regenerating uterine walls. There benign growth, which may be present in up to
is no current consensus regarding surgical 30–40% of the normal population, and their
method, instruments and any barriers to pre- effect on reproductive outcomes is controver-
vent recurrence and hormonal treatment for sial. There is no evidence for surgical manage-
endometrial regeneration [31–33]. ment to improve fertility outcomes [34–36].
15.4.3 Intrauterine Masses 15.4.4 Cervical Incompetence

Intrauterine masses such as endometrial pol- Cervical incompetence is a clinical diagnosis,
yps (as seen in . Fig. 15.3) and myomas (in based on a history of late miscarriage pre-
. Fig. 15.4) are postulated to have space- ceded by spontaneous rupture of membranes
occupying effect that impedes embryonic or painless cervical dilation. It is frequently
implantation and potential acts as a foreign cited as a cause of RPL, more commonly
body causing subacute endometritis, hence occurring in mid-trimester. However, there
are no objective investigations that can iden-
tify non-pregnant women with underlying
cervical incompetency [37]. It is thought to
arise from previous surgical trauma such as
cone biopsies, large loop excision of the trans-
formational zone, repeated dilation and curet-
tage or obstetric lacerations. A rarer cause is
exposure to diethylstilbestrol (DES) whilst in
utero. A Cochrane review identified no con-
clusive evidence that prophylactic cervical
cerclage reduces the risk of recurrent mid-
trimester miscarriage. Hence the benefits of
serial cervical length measurements and the
prophylactic cervical cerclage may be ques-
.. Fig. 15.3 Endometrial polyp at hysteroscopy tionable [38].
15.5 Genetic Factors
Over 50% of spontaneous miscarriages are

the result of chromosomal abnormalities,
which may be of parental origin, or arise de
novo in the embryo from parents with nor-
mal chromosomes [39]. The most common
genetic errors include aneuploidy (gain or loss
of a chromosome), chromosomal imbalances
(from translocations, inversions, deletions or
duplications) and single gene mutations.
15.5.1 Cytogenetic Abnormalities
Embryonic aneuploidies are the most com-

.. Fig. 15.4 Submucosal uterine myoma on saline infu- mon cause of early pregnancy loss, with up
sion sonogram to 90% of chromosomally abnormal embryos
spontaneously aborted, as a natural selec- 15.5.3 Genetic Evaluation in RPL

tion mechanism [2, 4, 39]. The most common
abnormalities are numeric chromosome errors If no foetal product of conception histopa-
such as trisomy (60%), polyploidy (20%) and thology is available from previous pregnancy
monosomy X (20%). The autosomal triso- losses, then parental karyotyping may be con-
mies typically arise de novo owing to meiotic sidered after an individual risk assessment [1,
nondisjunction during gametogenesis and are 2, 4]. However, routine screening of parental
associated with increase in age. The parental karyotyping is not recommended. In cou-
karyotypes are normal in most of these cases ples with no other cause of RPL other than
conferring a minimal recurrence risk [40, 41]. a structural chromosomal rearrangement,
nearly two-thirds are likely to have a normal
outcome in subsequent pregnancy [42, 47, 48].
15.5.2 Parental Chromosomal Genetic counselling is crucial when a struc-
Disorders tural genetic factor is identified, as strategies to
prevent recurrence will depend on the under-
Most miscarriages occur in chromosomally lying cause of pregnancy loss. Reproductive
normal parents. Abnormal parental karyo- options may include preimplantation genetic
types such as translocations, inversions and diagnosis and antenatal genetic diagnosis
rarely ring chromosomes are found in around such as chorionic villus sampling and amnio-
2–5% of individuals referred for genetic test- centesis. This allows for foetal karyotyping
ing after RPL [42, 43]. to be performed followed by more specific
Balanced translocations are the most genetic testing such as gene sequencing, poly-
common chromosomal abnormalities con- merase chain reactions (PCR) and restric-
tributing to RPL. They occur where there tion fragment length polymorphism (RFLP).
is an exchange of chromosome segments Preimplantation genetic diagnosis (PGD)
and can be categorised as reciprocal or with embryo transfer allows for the transfer
Robertsonian translocations. Robertsonian of only unaffected foetuses or for the use of
translocations occur where the two acrocen- donor gametes [46–48].
tric chromosomes (numbers 13, 14, 15, 21,
22) are combined near the centromere, with
loss of the short arms [44]. Balanced translo- 15.6 Endocrine Risk Factors
cations include an exchange of chromosome
segments with no loss in the two non-homol- 15.6.1 Luteal Phase Deficiency
ogous chromosomes. The risk of miscarriage
15 is influenced by the chromosome involved, Progesterone is necessary for the maintenance
the size and type of rearrangement as well as of early pregnancy and is initially produced
the genetic content of the rearranged chro- by the corpus luteum, until the developing
mosomal segments. Notably, parents carrying placenta takes over production between 7 and
balanced translocations are usually asymp- 9 weeks of gestation. Luteal phase deficiency
tomatic [42, 43]. was first described in 1949, and its defining
Rarer chromosomal abnormalities include characteristic is a deficiency in endogenous
inversions and ring chromosomes. Inversions progesterone, hence affecting normal embryo
occur where a piece of chromosome breaks at implantation and maintenance of early preg-
two points and reinserts within the same chro- nancy [49]. Luteal phase insufficiency can be
mosome. Paracentric and pericentric inver- caused by endocrinopathies such as stress,
sions are much rarer but are also associated PCOS and prolactin disorders [50].
with an increased risk of RPL. Ring chromo- Although luteal phase deficiency is known
somes occur when two breaks are created in to be associated with RPL, finding consistent,
one chromosome and the resulting ends fuse accessible and reliable diagnostic criteria for
to form a ring [45, 46]. luteal phase deficiency has been challenging,
343 15
and there remains no consensus regarding its There is a need for a reappraisal of avail-
definition [51]. Classically, serum progester- able evidence to determine the true prevalence
one levels below 10 ng/ml have been associ- and the role of PCOS in recurrent pregnancy
ated with an increased risk of miscarriage. loss.
However, serum progesterone levels are sub-
ject to high levels of fluctuations due to the
pulsatile release of luteinising hormone. 15.6.3 Thyroid Dysfunction
Traditionally, serial endometrial biopsies
would be performed for diagnosis; however, Thyroid function may vary significantly dur-
this is not recommended currently for diagno- ing normal pregnancy. If overall thyroid
sis, as there is poor reproducibility of findings homeostasis is to be maintained, the thyroid
and high interobserver variation with histo- gland is challenged to increase thyroid hor-
logical diagnoses [50–52]. mone production. A study of thyroid function
Progesterone use has been found to be of and pregnancy outcome revealed a positive
limited benefit in an unselected population linear relationship between miscarriage and
with sporadic miscarriages; however, there is a maternal thyroid-stimulating hormone (TSH)
potential benefit in a subpopulation with three levels [58]. Thyroid disorders, especially hypo-
or more consecutive miscarriages [53, 54]. thyroidism and increased thyroid peroxidase
antibodies, are correlated with disturbed fol-
liculogenesis, spermatogenesis, fertilisation
15.6.2 Polycystic Ovarian and embryogenesis and have long been asso-
Syndrome (PCOS) ciated with RPL, preterm birth, low birth
weight and detrimental effects with foetal
PCOS is a complex disorder involving abnor- neurocognitive development [59, 60].
malities within the hypothalamic-pituitary-
ovarian axis, to cause anovulatory dysfunction, 15.6.3.1 Hypothyroidism
hyperandrogenism and polycystic ovarian The most common cause of hypothyroidism
morphology. Women may have oligo- or amen- in pregnant women, affecting nearly 0.5% of
orrhoea, obesity and laboratory evidence of patients, is chronic autoimmune (Hashimoto)
elevated androgens, elevated levels of lutein- thyroiditis, followed by endemic iodine defi-
ising hormone (LH), insulin resistance and ciency through poor supplementation, poor
hyperinsulinemia [50]. PCOS is associated with radioactive iodine therapy and post-thyroid-
several complications of pregnancy including ectomy state [60].
gestational diabetes, hypertensive disorders Whilst overt hypothyroidism is associated
including pre-eclampsia and early pregnancy with an increased rate of pregnancy loss, the
loss. Several of the abnormalities seen in PCOS association between subclinical hypothyroid-
patients have been independently associated ism (SCH) and miscarriage is less clear. SCH
with RPL, including insulin resistance, hyper- refers to elevated TSH levels with preserved
insulinemia, hyperandrogenemia and obesity. free thyroxine levels [60, 61]. Hypothyroidism
However, there is a lack of clear evidence that may be easily diagnosed with a serum thyroid-
PCOS predisposes to recurrent pregnancy stimulating hormone level; however, the
loss, as available studies have not used the threshold level for diagnosing subclinical
Rotterdam criteria to define PCOS, but rather hypothyroidism is contentious. It is contro-
have only used polycystic ovarian morphology versial whether to lower the upper limit of
[55, 56]. Furthermore, current research indi- normal TSH from 4–5mIU/L to 2.5mIU/L,
cates that metformin does not reduce risk of which represents two standard deviations
pregnancy loss in PCOS, and there is limited above the euthyroid population [61, 62].
evidence to suggest that clomiphene citrate or However, studies which utilised the pre-preg-
ovarian drilling is beneficial in this population nancy TSH threshold of 2.5mIUL/L found
[56, 57]. no association with increased pregnancy loss
and no improvement with thyroxine replace- mIU/L but not at TSH of 2.5–4 mIU/L in the
ment therapy [62–66]. absence of thyroid antibodies [63, 71].
There is fair evidence that subclinical
hypothyroidism when defined as TSH > 4
mIU/L during pregnancy is associated with 15.6.5 Abnormal Glucose
miscarriage and routine screening with TSH Metabolism
levels should be offered in RPL [63].
Pregestational diabetes complicates around 1%
15.6.3.2 Thyroid Autoimmunity of pregnancies, and many studies have shown
The presence of anti-thyroid antibodies may patients with poorly controlled diabetes are
imply abnormal T-cell function, suggesting an known to have an elevated risk of spontane-
additional immune-mediated role in causing ous miscarriage, preterm birth and hyperten-
pregnancy loss. For women with thyroid anti- sive disorders. The main underlying cause of
bodies and a serum TSH 2–4mIU/L, treatment miscarriage is thought to be lethal embryonic
should be considered in early pregnancy [67]. malformations due to glucose teratogenicity if
Selenium is postulated to play a key role in the patient has poorly controlled diabetes in
thyroid homeostasis through integration into the periconceptional period [72, 73]. Current
thyroid enzymes responsive for protection evidence suggests that well-controlled diabetes
against immune-mediated oxidative damage. is not a risk factor for RPL and that optimal
There have been several studies suggesting metabolic control for diabetic women is cru-
selenium treatment to reduce antibody levels, cial in the periconceptional period and first
which may allow for lower doses or thyroxine trimester [1, 4]. Metformin is known to be a
supplementation in women with Hashimoto’s safe, effective and low-risk oral hypoglycaemic
thyroiditis. Unfortunately, there are no cur- agent for management of diabetes [73].
rent randomised controlled trials to support
this treatment in RPL [68].
15.6.6 Hyperprolactinaemia
15.6.3.3 Hyperthyroidism
Hyperthyroidism, found in 0.1–0.4% of preg- Prolactin is commonly measured because
nancies, is not a known causative factor of elevated prolactin levels are associated with
RPL. Nevertheless, it is noted that women ovulatory dysfunction. The underlying mech-
with untreated overt hyperthyroidism are at anism is unclear, but prolactin is postulated to
high risk of thyroid storm, congestive heart maintain corpus luteum function and proges-
failure, pre-eclampsia, preterm birth and terone secretion, although the mechanism is
15 spontaneous miscarriage [69, 70]. still unclear [74]. Normalisation of prolactin
levels in RPL population, with a dopamine
agonist such as bromocriptine, was effective
15.6.4 Management of Thyroid in preventing miscarriages but showed no sig-
Dysfunction in RPL nificant difference in conception and live birth
rates [75]. Due to the absence of consistent
In conclusion, screening with TSH and thyroid evidence on its association with RPL, pro-
autoantibodies and treatment of subclinical lactin testing is not routinely recommended
hypothyroidism are recommended in women in the absence of symptoms of hyperprolac-
with RPL. Thyroxine administration, com- tinaemia such as oligo- or amenorrhoea [1].
mencing at a low dose such as 50 microg daily,
is a safe and effective method in reducing early
pregnancy loss in women with overt hypo- 15.6.7 Diminished Ovarian Reserve
thyroidism or in euthyroid women with anti-
thyroid antibodies. Current recommendations Diminished ovarian reserve (DOR), defined as
support thyroxine administration for TSH >4 reduced ovarian reserve markers with regular
345 15
menstrual cycles, has been suggested to be a some studies have shown a weak association
causative or prognostic factor in RPL. Ovarian between ANA and RPL, and there is evi-
reserve can be assessed with measurements dence that the presence of ANA may confer a
of FSH, oestrogen (E2), inhibin B and anti- poorer prognosis [82, 83]. Overall, there is no
Mullerian hormone (AMH) or ultrasound evidence that available immunotherapies such
investigation to determine antral follicle count as intravenous immunoglobulins, paternal cell
(AFC) and ovarian volume [1, 2, 3]. immunisation or donor leukocytes provide any
DOR may be seen following pelvic sur- benefit for improving live birth rates. Hence,
gery, chemotherapy and radiotherapy but no immunological tests are recommended as
also conversely in the general population of part of routine RPL workup [84].
young women conceiving naturally and is
not necessarily considered as a pathological
entity. Additionally, ovarian aging may lead 15.8 Thrombophilia
to increased rates in foetal aneuploidy, which
makes investigation into a direct causative 15.8.1 Antiphospholipid Syndrome
effect with RPL difficult [76, 77]. A recent sys-
tematic review and meta-analysis has found an Antiphospholipid syndrome (APS) is the
apparent association between DOR and RPL only proven thrombophilia associated with
as measured by low AMH levels and AFC recurrent pregnancy loss, with international
[78]. However, more studies are required to consensus diagnostic criteria outlined in
evaluate their prognostic value in RPL, and . Table 15.2 [85]. Between 15 and 20% of
assessment of ovarian reserve is not recom- women with RPL have positive antiphospho-
mended as part of routine screening [1, 2, 4, 5]. lipid antibodies, with the three most clinically
15.7 Immunological Factors .. Table 15.2 International consensus

classification criteria for antiphospholipid
The immune system of pregnant women is syndrome (APS), which is diagnosed with one of
tightly controlled to defend against microbial the following clinical and one of the following
infections and to accept an embryo or the laboratory criteria are met
foetus, and inflammation-like processes are Clinical criteria Laboratory criteria
crucial for tissue growth, remodelling and dif-
ferentiation of the decidua during pregnancy. Vascular thrombosis: Lupus anticoagulant
A failure in normal immune control mecha- defined as one or more present in plasma, on
nisms may result in an autoimmune response clinical episodes of two or more occasions
vascular thrombosis at least 12 weeks apart
to a developing foetus, like those that develop
(venous, arterial or
after rejected grafts in organ transplanta- small vessel)
tion [79]. Autoantibody formation against
Pregnancy morbidity Anticardiolipin
phospholipids, thyroid antigens and nuclear
such as: antibody present in
antigens has been investigated as a potential Three or more consecu- medium or high titre
causative factor in RPL, and 20% of women tive spontaneous (>40 GPL or MPL or
with RPL will have increased serum levels of pregnancy losses at less 99th percentile), on
autoantibodies, most commonly antiphos- than 10 weeks two or more
One or more prema- occasions at least
pholipid antibodies [80].
ture birth <34 weeks due 12 weeks apart
There is currently insufficient evidence to to pre-eclampsia or
recommend immune testing such as human Anti-beta-2 glycopro-
placental insufficiency
tein I antibody in high
leukocyte antigen (HLA) determination, cyto- One or more unex-
titre (>99th percen-
kine levels and natural killer cell analyses [81]. plained death of a
tile), on two or more
morphologically normal
Antinuclear antibodies (ANA) will be detected occasions at least
foetus after 10 weeks of
in 10–15% of women, with no clear relation- gestation
12 weeks apart
ship with pregnancy outcomes. However,
recognised and relevant antibodies including increases risks of hypertensive disorders,

lupus anticoagulant (LA), anticardiolipin gestational diabetes and preterm birth and
antibody and anti-beta-2 glycoprotein I which is not recommended for treatment of APS
contribute to the laboratory diagnosis of [91]. Postpartum thromboprophylaxis is con-
APS. It has been suggested that the presence sidered for a short interval, and women with
of anti-beta-2 glycoprotein may indicate an known APS should consider avoiding oestro-
increased risk of thrombosis [86, 87]. gen containing oral contraceptives due to the
The diagnosis of antiphospholipid syn- persistent thrombotic risk [89, 90].
drome can be complex and is based on a com-
bination of clinical manifestations of vascular
thrombosis or pregnancy morbidity, as well as 15.8.2 Hereditary Thrombophilia
the presence of autoantibodies, on two tests
performed 12 or more weeks apart [85]. The Hereditary thrombophilia predisposing
hypothesis behind APS and recurrent mis- patients to venous thromboembolisms include
carriage is the encouragement of a hyperco- Factor V Leiden mutation, prothrombin
agulable state, inflammatory processes and mutation, protein C, protein S and antithrom-
defective angiogenesis. This is corroborated bin deficiency. The prevalence of hereditary
by the presence of microthrombi within pla- thrombophilia in women with RPL is unclear,
cental vasculature and decidua in pregnancy and there is no clear association between RPL
samples of women with RPL [87, 88]. and hereditary thrombophilia [92]. Current
Standard treatment for APS includes a guidelines recommend screening only in the
combination of low-dose aspirin and low- presence of additional risk factors, such as a
dose heparin, which may reduce pregnancy positive family history of thrombophilia or
loss by 54% [89]. Aspirin may be commenced a personal history of VTE [93]. Where pos-
in the periconceptual period, whilst heparin sible, this should occur 6 weeks following a
should be commenced after the first posi- pregnancy loss or thrombotic event and whilst
tive pregnancy test, with both continued not on anticoagulants, with suggested testing
until delivery [90]. The use of prednisolone methods outlined in . Table 15.3.
.. Table 15.3 Inherited thrombophilia testing
Thrombophilia Testing method Is testing Is testing reliable Is testing reliable

reliable in during acute with anticoagula-
pregnancy thrombosis tion
15
Factor V Leiden Activated protein C Yes Yes No
mutation resistance assay
If abnormal, then Yes Yes Yes
DNA analysis
Prothrombin gene DNA analysis Yes Yes Yes
mutation G20210A
Protein C deficiency Protein C activity Yes No No
(<60%)
Protein S deficiency Functional assay No No No
(<55%)
Antithrombin Antithrombin Yes No No
deficiency activity (<60%)
Adapted from ACOG Practice Bulletin [93]

347 15
15.9 Infection general health but also in the periconceptual
period. It is associated with poor reproduc-
Ureaplasma urealyticum, Mycoplasma homi- tive outcomes, including miscarriages, con-
nis, chlamydia, Listeria monocytogenes, genital malformations, gestational diabetes,
Toxoplasma gondii, rubella, cytomegalovirus, pre-
eclampsia, higher rates of Caesarean
herpes virus and other less frequent patho- delivery, thromboembolic events and postpar-
gens have been identified more frequently in tum infection [99, 100]. A recent systematic
vaginal and cervical cultures and serum from review found higher rates of pregnancy loss in
women with sporadic miscarriages [94]. Simi- obese women with a history of RPL, but not
larly, chronic endometritis has been linked to in women who were overweight [101].
RPL, as small studies showed an increased
prevalence in this subpopulation [95]. How-
ever, there remains uncertainty regarding the 15.10.3 Psychological Factors
true impact of chronic endometritis on repro-
ductive outcomes, and there is no consensus Recurrent pregnancy loss can have significant
on treatment options, coupled with the need emotional impacts on couples, with feelings
for an endometrial biopsy to confirm resolu- of loss of and grief intensified with repeated
tion. Overall, there is no convincing evidence losses [102]. Several reports have tried to find
that infections cause RPL, and hence there a possible psychological aetiology for RPL,
is a limited benefit of routine screening and but such associations are inherently difficult
antibiotic prophylaxis [96]. to prove, due to the presence of various con-
founding factors and variables. International
societies recommend offering supportive care
15.10 Environmental in dedicated miscarriage clinics for couples
and Psychological Factors with RPL [1, 4].
15.10.1 Lifestyle Factors

15.11 Unexplained Pregnancy Loss
Smoking is strongly associated with adverse
obstetric outcomes such as miscarriage, still- Therapeutic interventions should be targeted
birth, ectopic pregnancy, placenta praevia to the cause of RPL. However, after a thor-
as well as poor neonatal outcomes including ough evaluation, almost half of the patients
preterm birth, foetal growth restrictions and will remain without a definite diagnosis. In
congenital abnormalities. It is thought that this subpopulation with unexplained RPL
cigarette smoking causes adverse trophoblas- with early pregnancy bleeding, progestogen
tic function and hence is linked to sporadic supplementation may reduce the risk of mis-
pregnancy loss [97]. carriage and increase live birth rates in subse-
Other lifestyle factors such as alcohol con- quent pregnancies [54, 103].
sumption (3–5 drinks per week) and caffeine
consumption (more than three cups of coffee)
have been associated with the risk of miscar- 15.12 Future Pregnancy Outcomes
riage in a dose-dependent manner. However,
current evidence is insufficient to confirm this Pregnancy loss can be an extremely traumatic
association [98]. event for couples, with feelings of helpless-
ness, desperation and despair compounded
with subsequent pregnancy losses. These
15.10.2 Obesity symptoms may also be exacerbated by unnec-
essary tests that fail to enhance reproductive
Obesity represents a major public health outcomes [104]. In this way, it is imperative
challenge worldwide, as it poses a high dis- that clinical and diagnostic tests focus on
ease burden and mortality, affecting not only minimising the risk of future miscarriages,
optimising the time required to become preg- 2. Practice Committee of the American Society for
nant again and optimising the chances of live Reproductive Medicine. Evaluation and treat-
ment of recurrent pregnancy loss: A committee
birth. Thankfully, women with unexplained opinion. Fertil Steril. 2012;98:1103–11.
recurrent first trimester miscarriage have an 3. Gibbins KJ, Porter TF. The importance of an
excellent pregnancy outcome if offered sup- evidence-based workup for recurrent pregnancy
portive care and conceive a subsequent preg- loss. Clin Obstet Gynecol. 2016;59(3):456–63.
nancy with 50–60% success rate [4]. 4. Royal College of Obstetricians and Gynaecolo-
gists, Scientific Advisory Committee, Guideline
No. 17. The Investigation and treatment of cou-
ples with recurrent miscarriage, 2011.
15.13 ReviewQuestions 5. Huchon C, Deffieux X, Beucher G, Capmas P,
Carcopino X, Costedoat-Chalumeau N, Dela-
baere A, Gallot V, Iraola E, Lavoue V, Legen-
??1.
Spontaneous pregnancy loss is most
dre G, Lejeune-Saada V, Leveque J, Nedellec S,
commonly due to: Nizard J, Quibel T, Subtil D, Vialard F, Lemery
A. Uterine malformations D. Collège National des Gynécologues Obsté-
B. Lifestyle factors triciens Français. Pregnancy loss: French clinical
C. Endocrine dysfunction practice guidelines. Eur J Obstet Gynecol Reprod
Biol. 2016;201:18–26.
D. Genetic abnormalities
6. Hennessy M, Dennehy R, Meaney S, Linehan L,
Devane D, Rice R, O’Donoghue K. Clinical prac-
??2.
What is the most common anatomic tice guidelines for recurrent miscarriage in high-
defect associated with recurrent preg- income countries: a systematic review. Reprod
nancy loss? Biomed Online. 2021;42(6):1146–71.
7. El Hachem H, Crepaux V, May-Panloup P, Des-
A. Leiomyomas
camps P, Legendre G, Bouet PE. Recurrent preg-
B. Bicornuate uterus nancy loss: current perspectives. Int J Women’s
C. Endometrial polyps Health. 2017;17(9):331–45.
D. Uterine synechiae 8. van Dijk MM, Kolte AM, Limpens J, Kirk E,
Quenby S, van Wely M, Goddijn M. Recurrent
pregnancy loss: diagnostic workup after two or
??3. Which of the following is not a diag-
three pregnancy losses? A systematic review of
nostic criterion for antiphospholipid the literature and meta-analysis. Hum Reprod
syndrome? Update. 2020;26(3):356–67.
A. Antithrombin antibody 9. Youssef A, Lashley L, Dieben S, Verburg H, van
B. Anticardiolipin antibody der Hoorn ML. Defining recurrent pregnancy
loss: associated factors and prognosis in couples
C. Lupus anticoagulant
with two versus three or more pregnancy losses.
D. Anti-beta-2 glycoprotein antibody Reprod Biomed Online. 2020;41(4):679–85.
10. Bashiri A, Ratzon R, Amar S, Serjienko R,
15 Mazor M, Shoham-Vardi I. Two vs. three or more
15.14 Answer primary recurrent pregnancy losses--are there
any differences in epidemiologic characteristics
and index pregnancy outcome? J Perinat Med.
vv1. D 2012;40(4):365–71.
11. Youssef A, Vermeulen N, Lashley EELO, God-
vv2. B dijn M, van der Hoorn MLP. Comparison and
appraisal of (inter)national recurrent preg-
nancy loss guidelines. Reprod Biomed Online.
vv3. A
2019;39(3):497–503.
12. Clifford K, Rai R, Watson H, Regan L. An
informative protocol for the investigation of

References recurrent miscarriage: preliminary experi-
ence of 500 consecutive cases. Hum Reprod.
1994;9(7):1328–32.
1. ESHRE Guideline Group on RPL, Bender Atik R,
13. American College of Obstetricians and Gyne-
Christiansen OB, Elson J, Kolte AM, Lewis S, Mid-
cologists Committee on Gynecologic Practice
deldorp S, Nelen W, Peramo B, Quenby S, Vermeu-
and Practice Committee. Female age-related fer-
len N, Goddijn M. ESHRE guideline: recurrent
tility decline. Committee Opinion No. 589. Fertil
pregnancy loss. Hum Reprod Open. 2018;2018(2):
Steril. 2014;101(3):633–4.
hoy004.
349 15
14. de la Rochebrochard E, Thonneau P. Paternal age 27. Akhtar MA, Saravelos SH, Li TC, Jayaprakasan
and maternal age are risk factors for miscarriage; K, Royal College of Obstetricians and Gynaeco-
results of a multicentre European study. Hum logists. Reproductive implications and manage-
Reprod. 2002;17(6):1649–56. ment of congenital uterine anomalies: scientific
15. Sharma R, Agarwal A, Rohra VK, Assidi M, impact paper No. 62 November 2019. BJOG.
Abu-Elmagd M, Turki RF. Effects of increased 2020;127(5):e1–e13.
paternal age on sperm quality, reproductive out- 28. Rikken JFW, Kowalik CR, Emanuel MH,
come and associated epigenetic risks to offspring. Bongers MY, Spinder T, Jansen FW, Mulders
Reprod Biol Endocrinol. 2015;13:35. AGMGJ, Padmehr R, Clark TJ, van Vliet HA,
16. Clifford K, Rai R, Regan L. Future pregnancy Stephenson MD, van der Veen F, Mol BWJ, van
outcome in unexplained recurrent first trimester Wely M, Goddijn M. Septum resection versus
miscarriage. Hum Reprod. 1997;12(2):387–9. expectant management in women with a sep-
17. Nybo Andersen AM, Wohlfahrt J, Christens P, tate uterus: an international multicentre open-
Olsen J, Melbye M. Maternal age and fetal loss: label randomized controlled trial. Hum Reprod.
population based register linkage study. BMJ. 2021;36(5):1260–7.
2000;320(7251):1708–12. 29. Hooker AB, Lemmers M, Thurkow AL, Hey-
18. Saravelos SH, Cocksedge KA, Li TC. Preva- mans MW, Opmeer BC, Brolmann HA, Mol BW,
lence and diagnosis of congenital uterine Huirne JA. Systematic review and meta-analysis
anomalies in women with reproductive failure: a of intrauterine adhesions after miscarriage:
critical appraisal. Hum Reprod Update. 2008;14(5): prevalence, risk factors and long-term reproduc-
415–29. tive outcome. Hum Reprod Update. 2014;20:
19. Oppelt P, von Have M, Paulsen M, Strissel 262–78.
PL, Strick R, Brucker S, Wallwiener D, Beck- 30. Berman JM. Intrauterine adhesions. Semin
mann MW. Female genital malformations and Reprod Med. 2008;26(4):349–55.
their associated abnormalities. Fertil Steril. 31. Deans R, Abbott J. Review of intrauterine adhe-
2007;87:335–42. sions. J Minim Invasive Gynecol. 2010;17(5):
20. Chandler TM, Machan LS, Cooperberg PL, Har- 555–69.
ris AC, Chang SD. Mullerian duct anomalies: from 32. Polishuk WZ, Sadovsky E. A syndrome of recur-
diagnosis to intervention. Br J Radiol. 2009;82: rent intrauterine adhesions. Am J Obstet Gyne-
1034–42. https://doi.org/10.1259/bjr/99354802. col. 1975;123(2):151–8.
21. Ludwin A, Ludwin I, Banas T, Knafel A, Miedzy- 33. Pabuccu R, Onalan G, Kaya C, Selam B, Ceyhan
blocki M, Basta A. Diagnostic accuracy of T, Ornek T, Kuzudisli E. Efficiency and pregnancy
sonohysterography, hysterosalpingography and outcome of serial intrauterine device-guided hys-
diagnostic hysteroscopy in diagnosis of arcuate, teroscopic adhesiolysis of intrauterine synechiae.
septate and bicornuate uterus. J Obstet Gynaecol Fertil Steril. 2008;90(5):1973–7.
Res. 2011;37(3):178–86. 34. Bosteels J, van Wessel S, Weyers S, Broek-
22. Acholonu UC, Silberzweig J, Stein DE, Keltz mans FJ, D’Hooghe TM, Bongers MY, Mol
M. Hysterosalpingography versus sonohys- BWJ. Hysteroscopy for treating subfertility
terography for intrauterine abnormalities. JSLS. associated with suspected major uterine cav-
2011;15(4):471–4. ity abnormalities. Cochrane Database Syst Rev.
23. Grimbizis GF, Camus M, Tarlatzis BC, Bontis 2018;12(12):CD009461.
JN, Devroey P. Clinical implications of uter- 35. Donnez J, Jadoul P. What are the implications of
ine malformations and hysteroscopic treatment myomas on fertility? A need for a debate? Hum
results. Hum Reprod Update. 2001;7(2):161–74. Reprod. 2002;17(6):1424–30.
24. Carrera M, Pérez Millan F, Alcázar JL, Alonso 36. Metwally M, Raybould G, Cheong YC, Horne
L, Caballero M, Carugno J, Dominguez JA, AW. Surgical treatment of fibroids for subfer-
Moratalla E. Effect of hysteroscopic metro- tility. Cochrane Database Syst Rev. 2020;1(1):
plasty on reproductive outcomes in women CD003857.
with septate uterus: systematic review and 37. Drakeley AJ, Quenby S, Farquharson RG. Mid-
meta-analysis. J Minim Invasive Gynecol. trimester loss--appraisal of a screening protocol.
2021;S1553-4650(21):01210–3. Hum Reprod. 1998;13(7):1975–80. https://doi.
25. Kim MA, Kim HS, Kim YH. Reproductive, org/10.1093/humrep/13.7.1975.
obstetric and neonatal outcomes in women with 38. Drakeley AJ, Roberts D, Alfirevic Z. Cervi-
congenital uterine anomalies: a systematic review cal stitch (cerclage) for preventing pregnancy
and meta-analysis. J Clin Med. 2021;10(21):4797. loss in women. Cochrane Database Syst Rev.
26. Rikken JF, Kowalik CR, Emanuel MH, Mol BW, 2003;2003(1):CD003253.
Van der Veen F, van Wely M, Goddijn M. Sep- 39. Sugiura-Ogasawara M, Ozaki Y, Katano K,
tum resection for women of reproductive age with Suzumori N, Kitaori T, Mizutani E. Abnor-
a septate uterus. Cochrane Database Syst Rev. mal embryonic karyotype is the most frequent
2017;1(1):CD008576. cause of recurrent miscarriage. Hum Reprod.
2012;27(8):2297–303.
40. Mikwar M, MacFarlane AJ, Marchetti F. Mech- 55. Homburg R. Pregnancy complications in
anisms of oocyte aneuploidy associated with PCOS. Best Pract Res Clin Endocrinol Metab.
advanced maternal age. Mutat Res Rev Mutat 2006;20(2):281–92.
Res. 2020;785:108320. 56. Cocksedge KA, Li TC, Saravelos SH, Metwally
41. Warren JE, Silver RM. Genetics of pregnancy M. A reappraisal of the role of polycystic ovary
loss. Clin Obstet Gynecol. 2008;51(1):84–95. syndrome in recurrent miscarriage. Reprod
42. Barber JC, Cockwell AE, Grant E, Williams S, Biomed Online. 2008;17(1):151–60.
Dunn R, Ogilvie CM. Is karyotyping couples 57. Palomba S, Falbo A, Orio F Jr, Zullo F. Effect
experiencing recurrent miscarriage worth the of preconceptional metformin on abortion risk
cost? BJOG. 2010;117(7):885–8. in polycystic ovary syndrome: a systematic review
43. Flynn H, Yan J, Saravelos SH, Li TC. Com- and meta-analysis of randomized controlled tri-
parison of reproductive outcome, including the als. Fertil Steril. 2009;92(5):1646–58.
pattern of loss, between couples with chromo- 58. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte
somal abnormalities and those with unexplained TG, Bonsel GJ. Higher maternal TSH levels in
repeated miscarriages. J Obstet Gynaecol Res. pregnancy are associated with increased risk for
2014;40(1):109–16. miscarriage, fetal or neonatal death. Eur J Endo-
44. Crolla JA, Youings SA, Ennis S, Jacobs PA. Super- crinol. 2009;160(6):985–91.
numerary marker chromosomes in man: parental 59. Haddow JE, Palomaki GE, Allan WC, Wil-
origin, mosaicism and maternal age revisited. Eur liams JR, Knight GJ, Gagnon J, O’Heir CE,
J Hum Genet. 2005;13(2):154–60. Mitchell ML, Hermos RJ, Waisbren SE, Faix
45. De Braekeleer M, Dao TN. Cytogenetic studies in JD, Klein RZ. Maternal thyroid deficiency dur-
couples experiencing repeated pregnancy losses. ing pregnancy and subsequent neuropsycho-
Hum Reprod. 1990;5(5):519–28. logical development of the child. N Engl J Med.
46. Laurino MY, Bennett RL, Saraiya DS, Bau- 1999;341(8):549–55.
meister L, Doyle DL, Leppig K, Pettersen B, 60. Abalovich M, Gutierrez S, Alcaraz G, Maccal-
Resta R, Shields L, Uhrich S, Varga EA, Ras- lini G, Garcia A, Levalle O. Overt and subclinical
kind WH. Genetic evaluation and counseling of hypothyroidism complicating pregnancy. Thy-
couples with recurrent miscarriage: recommenda- roid. 2002;12(1):63–8.
tions of the National Society of Genetic Counsel- 61. Baloch Z, Carayon P, Conte-Devolx B, Demers
ors. J Genet Couns. 2005;14(3):165–81. LM, Feldt-Rasmussen U, Henry JF, LiVosli VA,
47. Franssen MTM, Musters AM, van der Veen Niccoli-Sire P, John R, Ruf J, Smyth PP, Spen-
F, Repping S, Leschot NJ, et al. Reproductive cer CA, Stockigt JR, Guidelines Committee,
outcome after PGD in couples with recurrent National Academy of Clinical Biochemistry.
miscarriage carrying a structural chromosome Laboratory medicine practice guidelines. Labora-
abnormality: a systematic review. Hum Reprod tory support for the diagnosis and monitoring of
Update. 2011;17:467–75. thyroid disease. Thyroid. 2003;13(1):3–126.
48. Kochhar PK, Ghosh P. Reproductive outcome of 62. Garber JR, Cobin RH, Gharib H, Hennessey JV,
couples with recurrent miscarriage and balanced Klein I, Mechanick JI, Pessah-Pollack R, Singer
chromosomal abnormalities. J Obstet Gynaecol PA, Woeber KA. American Association Of Clini-
Res. 2013;39(1):113–20. cal Endocrinologists And American Thyroid
49. Jones GS. The luteal phase defect. Fertil Steril. Association Taskforce On Hypothyroidism In
15 1976;27(4):351–6. https://doi.org/10.1016/s0015- Adults. Clinical practice guidelines for hypothy-
0282(16)41769-3. roidism in adults: cosponsored by the American
50. Ke RW. Endocrine basis for recurrent pregnancy Association of Clinical Endocrinologists and
loss. Obstet Gynecol Clin N Am. 2014;41(1): the American Thyroid Association. Thyroid.
103–12. 2012;22(12):1200–35.
51. Smith ML, Schust DJ. Endocrinology and recur- 63. Practice Committee of the American Society for
rent early pregnancy loss. Semin Reprod Med. Reproductive Medicine. Subclinical hypothyroid-
2011;29(6):482–90. ism in the infertile female population: a guideline.
52. Duggan MA, Brashert P, Ostor A, Scurry J, Bill- Fertil Steril. 2015;104(3):545–53.
son V, Kneafsey P, Difrancesco L. The accuracy 64. Wang S, Teng WP, Li JX, Wang WW,
and interobserver reproducibility of endometrial Shan ZY. Effects of maternal subclinical
dating. Pathology. 2001;33(3):292–7. hypothyroidism on obstetrical outcomes dur-

53. Haas DM, Ramsey PS. Progestogen for preventing early pregnancy. J Endocrinol Investig.
ing miscarriage. Cochrane Database Syst Rev. 2012;35(3):322–5.
2013;(10):CD003511. 65. Uchida S, Maruyama T, Kagami M, Miki F,
54. Haas DM, Hathaway TJ, Ramsey PS. Progestogen Hihara H, Katakura S, Yoshimasa Y, Masuda
for preventing miscarriage in women with recur- H, Uchida H, Tanaka M. Impact of borderline-
rent miscarriage of unclear etiology. Cochrane subclinical hypothyroidism on subsequent preg-
Database Syst Rev. 2019;2019(11):CD003511. nancy outcome in women with unexplained
351 15
recurrent pregnancy loss. J Obstet Gynaecol Res. 79. Labarrere CA. Allogeneic recognition and rejec-
2017;43(6):1014–20. tion reactions in the placenta. Am J Reprod
66. Maraka S, Mwangi R, McCoy RG, Yao X, San- Immunol. 1989;21(3–4):94–9.
garalingham LR, Singh Ospina NM, O’Keeffe 80. McNamee K, Dawood F, Farquharson
DT, De Ycaza AE, Rodriguez-Gutierrez R, RG. Thrombophilia and early pregnancy loss.
Coddington CC 3rd, Stan MN, Brito JP, Mon- Best Pract Res Clin Obstet Gynaecol. 2012;26(1):
tori VM. Thyroid hormone treatment among 91–102.
pregnant women with subclinical hypothyroid- 81. Jeve YB, Davies W. Evidence-based management
ism: US national assessment. BMJ. 2017;25(356): of recurrent miscarriages. J Hum Reprod Sci.
i6865. 2014;7(3):159–69.
67. Negro R, Formoso G, Mangieri T, Pezzarossa A, 82. Cavalcante MB, Costa Fda S, Araujo Júnior
Dazzi D, Hassan H. Levothyroxine treatment in E, Barini R. Risk factors associated with a new
euthyroid pregnant women with autoimmune thy- pregnancy loss and perinatal outcomes in cases
roid disease: effects on obstetrical complications. of recurrent miscarriage treated with lymphocyte
J Clin Endocrinol Metab. 2006;91(7):2587–91. immunotherapy. J Matern Fetal Neonatal Med.
68. van Zuuren EJ, Albusta AY, Fedorowicz Z, Carter 2015;28(9):1082–6.
B, Pijl H. Selenium supplementation for Hashi- 83. Ogasawara M, Aoki K, Kajiura S, Yagami Y. Are
moto’s thyroiditis: summary of a Cochrane sys- antinuclear antibodies predictive of recurrent
tematic review. Eur Thyroid J. 2014;3(1):25–31. miscarriage? Lancet. 1996;347:1183–4.
69. Marx H, Amin P, Lazarus JH. Hyperthyroidism 84. Wong LF, Porter TF, Scott JR. Immunotherapy
and pregnancy. BMJ. 2008;336(7645):663–7. for recurrent miscarriage. Cochrane Database
70. Glinoer D. Thyroid hyperfunction during preg- Syst Rev. 2014;2014(10):CD000112.
nancy. Thyroid. 1998;8(9):859–64. https://doi. 85. Miyakis S, Lockshin MD, Atsumi T, Branch DW,
org/10.1089/thy.1998.8.859. Brey RL, Cervera R, Derksen RH, de Groot
71. Reid SM, Middleton P, Cossich MC, Crowther PG, Koike T, Meroni PL, Reber G, Shoenfeld
CA, Bain E. Interventions for clinical and sub- Y, Tincani A, Vlachoyiannopoulos PG, Krilis
clinical hypothyroidism pre-pregnancy and dur- SA. International consensus statement on an
ing pregnancy. Cochrane Database Syst Rev. update of the classification criteria for definite
2013;(5):CD007752. antiphospholipid syndrome (APS). J Thromb
72. Ray JG, O’Brien TE, Chan WS. Preconception Haemost. 2006;4(2):295–306.
care and the risk of congenital anomalies in the 86. Lassere M, Empson M. Treatment of antiphos-
offspring of women with diabetes mellitus: a pholipid syndrome in pregnancy--a systematic
meta-analysis. QJM. 2001;94(8):435–44. review of randomized therapeutic trials. Thromb
73. Melamed N, Hod M. Perinatal mortality in Res. 2004;114(5–6):419–26.
pregestational diabetes. Int J Gynaecol Obstet. 87. Opatrny L, David M, Kahn SR, Shrier I, Rey
2009;104(Suppl 1):S20–4. E. Association between antiphospholipid anti-
74. Li W, Ma N, Laird SM, Ledger WL, Li TC. The bodies and recurrent fetal loss in women without
relationship between serum prolactin concen- autoimmune disease: a metaanalysis. J Rheuma-
tration and pregnancy outcome in women with tol. 2006;33(11):2214–21.
unexplained recurrent miscarriage. J Obstet Gyn- 88. Kutteh WH. Antiphospholipid antibody syn-
aecol. 2013;33(3):285–8. drome and reproduction. Curr Opin Obstet
75. Chen H, Fu J, Huang W. Dopamine agonists for Gynecol. 2014;26(4):260–5.
preventing future miscarriage in women with 89. Empson M, Lassere M, Craig J, Scott J. Preven-
idiopathic hyperprolactinemia and recurrent mis- tion of recurrent miscarriage for women with
carriage history. Cochrane Database Syst Rev. antiphospholipid antibody or lupus antico-
2016;(7):CD008883. agulant. Cochrane Database Syst Rev. 2005;2:
76. Trout SW, Seifer DB. Do women with unex- CD002859.
plained recurrent pregnancy loss have higher day 90. Hamulyák EN, Scheres LJ, Marijnen MC, God-
3 serum FSH and estradiol values? Fertil Steril. dijn M, Middeldorp S. Aspirin or heparin or both
2000;74(2):335–7. for improving pregnancy outcomes in women
77. Massé V, Ferrari P, Boucoiran I, Delotte J, Isnard with persistent antiphospholipid antibodies and
V, Bongain A. Normal serum concentrations of recurrent pregnancy loss. Cochrane Database
anti-Mullerian hormone in a population of fertile Syst Rev. 2020;5(5):CD012852.
women in their first trimester of pregnancy. Hum 91. Laskin CA, Bombardier C, Hannah ME,
Reprod. 2011;26(12):3431–6. et al. Prednisone and aspirin in women with
78. Bunnewell SJ, Honess ER, Karia AM, Keay autoantibodies and unexplained recurrent fetal
SD, Al Wattar BH, Quenby S. Diminished ovar- loss. N Engl J Med. 1997;337:148–53.
ian reserve in recurrent pregnancy loss: a sys- 92. Arachchillage DRJ, Makris M. Inherited throm-
tematic review and meta-analysis. Fertil Steril. bophilia and pregnancy complications: should we
2020;113(4):818–827.e3. test? Semin Thromb Hemost. 2019;45(1):50–60.
93. American College of Obstetricians and Gynecol- 99. Stang J, Huffman LG. Position of the academy
ogists’ Committee on Practice Bulletins–Obstet- of nutrition and dietetics: obesity, reproduction,
rics. ACOG Practice Bulletin No. 197: inherited and pregnancy outcomes. J Acad Nutr Diet.
thrombophilias in pregnancy. Obstet Gynecol. 2016;116:677–91.
2018;132(1):e18–34. 100. Boots C, Stephenson MD. Does obesity increase
94. Penta M, Lukic A, Conte MP, Chiarini F, Fioriti the risk of miscarriage in spontaneous concep-
D, Longhi C, Pietropaolo V, Vetrano G, Vil- tion: a systematic review. S1emin Reprod Med.
laccio B, Degener AM, Seganti L. Infectious 2011;29(6):507–13.
agents in tissues from spontaneous abortions in 101. Cavalcante MB, Sarno M, Peixoto AB, Araujo
the first trimester of pregnancy. New Microbiol. Júnior E, Barini R. Obesity and recurrent miscar-
2003;26(4):329–37. riage: A systematic review and meta-analysis. J
95. Kitaya K. Prevalence of chronic endome- Obstet Gynaecol Res. 2019;45(1):30–8.
tritis in recurrent miscarriages. Fertil Steril. 102. Bardos J, Hercz D, Friedenthal J, Missmer
2011;95(3):1156–8. SA, Williams Z. A national survey on public
96. Giakoumelou S, Wheelhouse N, Cuschieri K, perceptions of miscarriage. Obstet Gynecol.
Entrican G, Howie SE, Horne AW. The role of 2015;125(6):1313–20.
infection in miscarriage. Hum Reprod Update. 103. Devall AJ, Papadopoulou A, Podesek M, Haas
2016;22(1):116–33. DM, Price MJ, Coomarasamy A, Gallos ID. Pro-
97. Lindbohm ML, Sallmén M, Taskinen H. Effects gestogens for preventing miscarriage: a network
of exposure to environmental tobacco smoke meta-analysis. Cochrane Database Syst Rev.
on reproductive health. Scand J Work Environ 2021;4(4):CD013792.
Health. 2002;28(Suppl 2):84–96. 104. Speraw SR. The experience of miscarriage: how
98. Ness RB, Grisso JA, Hirschinger N, Markovic N, couples define quality in health care delivery. J
Shaw LM, Day NL, Kline J. Cocaine and tobacco Perinatol. 1994;14(3):208–15.
use and the risk of spontaneous abortion. N Engl
J Med. 1999;340(5):333–9.
15
353 16
Ovulation Induction
Ginevra Mills and Togas Tulandi
Contents
16.2 linical Presentation and Classification of

C
Anovulatory Infertility – 355
16.3 Hypogonadotropic Hypogonadism – 356

16.3.1 reviously WHO Group I: Hypogonadotropic
P
Hypogonadal Anovulation – 356
16.4 Polycystic Ovary Syndrome – 356

16.4.1 reviously WHO Group II: Eugonadotropic Estrogenic
P
Anovulation – 356
16.5 Primary Ovarian Insufficiency – 356

16.5.1 reviously WHO Group III: Hypergonadotropic
P
Hypoestrogenic Anovulation – 356
16.6 Hyperprolactinemic Anovulation – 357
16.7 Treatments for Ovulatory Disorders – 357
16.8 Lifestyle Modifications – 357
16.9 Aromatase Inhibitors – 358
16.10 Pharmacology and Mechanism of Action – 358
16.11 Dosage and Administration – 358
16.12 Side Effects and Risks – 358
16.13 Effectiveness – 359
16.14 Clomiphene Citrate – 359

https://doi.org/10.1007/978-3-030-99596-6_16
16.14.1 harmacology and Mechanism of Action – 359
P
16.14.2 Dosage and Administration – 359
16.14.3 Side Effects and Risks – 360
16.14.4 Effectiveness – 360
16.15 Gonadotropins – 360

16.15.1 harmacology and Mechanism of Action – 360
P
16.15.2 Dosage and Administration – 361
16.15.3 Side Effects and Risks – 361
16.15.4 Effectiveness – 361
16.16 Additional Treatment Options – 362

16.16.1 I nsulin-Sensitizing Agents – 362
16.16.2 Corticosteroids – 362
16.16.3 Pulsatile GnRH and Dopamine Agonists – 362
16.16.4 Laparoscopic Ovarian Drilling or Wedge
Resection – 362
16.18 Answers – 365
References – 365
Ovulation Induction
355 16
ment regimens used for ovulation induction in
Key Points women with these disorders.
55 The first-line treatment for ovulatory
disorders includes lifestyle modifica-
tions, if applicable. Case Vignette
55 The most effective and commonly used
aromatase inhibitor for ovulation Ovulation Induction- A 24-year-old
induction is letrozole. woman consults for infertility. She has
55 Administration of gonadotropin is irregular periods. She has noticed slow
more effective than oral ovulation- increase in facial hair since puberty and
inducing agents but is associated with mild acne. On physical examination, her
increased multiple pregnancy and ovar- body mass index (BMI) is 35 kg/m2. Initial
ian hyperstimulation. laboratory evaluation reveals a normal
55 Laparoscopic ovarian drilling or ovar- serum prolactin and TSH and mildly ele-
ian wedge resection should be rarely vated total testosterone. You diagnose
performed. polycystic ovary syndrome.
16.2 Clinical Presentation

16.1 Introduction and Classification
of Anovulatory Infertility
Ovulatory disorders are found in 18–25% of
couples who present with infertility. The diagnosis of an ovulatory disorder can be
Oligomenorrhea, defined as menstruation made by taking a thorough menstrual history,
occurring at intervals of 35 days to 6 months, including the age of menarche, the duration,
is the most common presenting symptom and the regularity of the menstrual cycle; for
among women with ovulatory dysfunction. example, oligomenorrhea or amenorrhea are
Some women may present with complete both suggestive of ovulatory problems.
amenorrhea. While there are multiple under- Testing to detect ovulation is relatively simple
lying etiologies for anovulation, polycystic and includes the measurement of basal body
ovary syndrome (PCOS) is by far the most temperature, mid-luteal serum progesterone
common. A wide range of interventions are levels, and documentation of ovulation by
available for ovulation induction in women serial ultrasonography examinations.
with ovulatory disorders, including lifestyle An appropriate clinical approach to ovula-
modification, oral and parenteral medication induction requires an understanding of
tions, and historically surgery. Oral ovulation- the causes of anovulation. Previously, ovula-
inducing agents include aromatase inhibitors tory disorders were classified by the World
and selective estrogen receptor modulators. If Health Organization into three categories of
treatment with oral medications is unsuccess- anovulation. However, this classification sys-
ful or not indicated, the next line of treatment tem is less commonly used, and four most
involved gonadotropin injections. common ovulatory disorders have been sug-
This chapter will review the clinical pre- gested. They are hypogonadotropic hypogo-
sentation and classification of ovulatory dis- nadism (HH), polycystic ovary syndrome
orders, as well as the indications, efficacy, and (PCOS), primary ovarian insufficiency (POI),
potential complications of the different treat- and hyperprolactinemia.
356 G. Mills and T. Tulandi
16.3 Hypogonadotropic of hyperandrogenism or polycystic ovarian

Hypogonadism morphology.
Obese women with PCOS can often see
16.3.1 reviously WHO Group I:
P improvement in their symptoms, including
restoration of spontaneous ovulation with
Hypogonadotropic weight loss. Therefore, lifestyle changes that
Hypogonadal Anovulation promote weight loss should be attempted
before treatment with ovulation induction
Hypothalamic causes of hypogonadotropic agents. Women with PCOS, regardless of their
hypogonadism (HH) are characterized by bio- weight, are also at increased risk of impaired
chemical findings of low serum estradiol and glucose tolerance. These women should be
low or low-normal serum follicle-stimulating screened before undergoing ovulation induc-
hormone (FSH) concentrations, secondary to tion due to the possible risks of pregnancy
decreased or inconsistent GnRH secretion. complications associated with impaired glu-
The most common cause of HH is func- cose tolerance.
tional hypothalamic amenorrhea (FHA), Less commonly, women presenting with
which is caused by eating disorders (such as eugonadotropic estrogenic anovulation have
anorexia nervosa), excessive exercise, signifi- late-onset congenital adrenal hyperplasia
cant weight loss, or stress. Women with FHA (CAH). This condition presents with signs and
usually present with complete amenorrhea symptoms comparable with PCOS. However,
(although oligo-ovulation can occur), and women with late-onset CAH have elevated
they account for 5–10% of cases of anovula- serum androgens and often present with more
tion. Before considering ovulation induction pronounced symptoms consistent with hyper-
with medications, lifestyle factors that con- androgenism including acne, hirsutism, and in
tribute to FHA should be reversed. some cases virilization.
Idiopathic HH, which usually presents as
primary amenorrhea, is a rare form of HH
which results from a complete congenital 16.5 Primary Ovarian Insufficiency
GnRH deficiency. When anosmia is also pres-
ent, this condition is called Kallmann syn- 16.5.1 reviously WHO Group III:
P
drome.
Hypergonadotropic
Hypoestrogenic
Anovulation
16.4 Polycystic Ovary Syndrome
Primary ovarian insufficiency (POI, previ-
16.4.1 reviously WHO Group II:
P ously referred to as premature ovarian failure)
16 Eugonadotropic Estrogenic occurs in 1% of women and accounts for
Anovulation 5–10% of cases of anovulation. Women with
POI have elevated levels of serum FSH and
Polycystic ovary syndrome (PCOS) consti- low or normal levels of serum estradiol in
tutes 70–85% of cases of anovulatory dys- association with primary or secondary amen-
function encountered in clinical practice. orrhea. In most cases of POI, the number of
Women with PCOS present with normal ovarian follicle is exhausted secondary to
serum estradiol and FSH concentrations, with accelerated follicle atresia of unknown etiol-
serum LH levels being either normal or ele- ogy. POI is also related to underlying genetic
vated. The diagnostic criteria for PCOS are conditions such as Turner syndrome and frag-
characterized by the Rotterdam criteria, of ile X carriers. Iatrogenic POI occurs after
which oligo- or anovulation is required, as treatment with gonadotoxic chemotherapy or
well as either clinical or biochemical evidence pelvic radiation therapy.
Ovulation Induction
357 16
Ovulation induction treatment in women management of anovulation, such as ovarian
with POI is often unsuccessful, and treatment drilling and wedge resection, has become out-
is primarily aimed at achieving estrogenic sta- dated and is no longer recommended.
tus through the administration of exogenous
estrogen to decrease the risk of osteoporosis
and cardiovascular disease. The most effective 16.8 Lifestyle Modifications
option for fertility treatments is in vitro fertil-
ization (IVF) with donor oocytes. The most common cause of ovulatory dys-
function in women of reproductive age is
polycystic ovary syndrome (PCOS). Aside
16.6 Hyperprolactinemic from affecting reproductive health, PCOS has
Anovulation a significant impact on a woman’s overall
health and is closely associated with obesity,
Hyperprolactinemia accounts for 5–10% of metabolic syndrome, and type 2 diabetes [1].
cases of anovulation. Elevated prolactin levels PCOS can manifest as a combination of men-
inhibit the release of GnRH, leading to strual irregularity and androgen excess, with
impaired gonadotropin secretion. Most or without the presence of multicystic ovarian
women will present with oligo- or anovulation morphology. Approximately 70% of women
and can have normal or decreased gonadotro- with PCOS are overweight or obese; however,
pin levels. The investigation and treatment of elevated body mass index (BMI) is not neces-
hyperprolactinemia are discussed in a separate sarily correlated with the severity of the PCOS
chapter. phenotype [2].
Hyperandrogenism in PCOS is closely asso-
ciated with insulin resistance, a relationship
16.7 Treatments for Ovulatory that appears to be independent of body mass
Disorders index [3]. Although the etiology of PCOS is
multifactorial, impaired insulin signaling and
There are various treatment options available hyperinsulinemia are believed to contribute to
in the management of ovulatory disorders. the pathogenesis of PCOS through impaired
The method of ovulation induction chosen insulin signaling within the GnRH neurons,
should be based on the underlying cause of gonadotropes, and the ovary, which ultimately
anovulation, as determined by a thorough his- impairs ovarian steroidogenesis and follicle
tory and physician examination of the patient development [2]. There is strong evidence that
and her partner. Consideration should also be improvement of insulin sensitivity, as well as
given to the efficacy, costs, risks, invasiveness, weight loss in women with elevated BMI, can
and potential complications associated with improve the clinical signs of PCOS and lead to
each treatment method. The first-line treat- the spontaneous resumption of ovulation [4].
ments should be those with the fewest risks Women with PCOS who are desiring preg-
and side effects, with more invasive and riskier nancy are at an increased risk of experiencing
treatment options reserved when first-line pregnancy-related morbidity including gesta-
treatments are not successful. Interventions tional diabetes, preeclampsia, hypertension,
may be as simple as lifestyle modifications, cesarean delivery, and pre-term delivery [5]. In
including weight loss and exercise, followed by order to mitigate these risks, it is important to
oral agents such as aromatase inhibitors or counsel these patients on the importance of
clomiphene citrate. Insulin-sensitizing agents improving their metabolic profile and encour-
can be added in conjunction with such thera- age weight loss in overweight women before
pies. More aggressive and invasive therapies achieving pregnancy. Such lifestyle changes, if
involve gonadotropin injections, which are adhered to beyond ovulation induction and
often combined with intrauterine insemina- pregnancy, can decrease the lifetime risk of
tion or in vitro fertilization. With the avail- developing metabolic syndrome and type 2
ability of these treatment options, surgical diabetes [6].
The first-line treatment for women with 45 hours, the effects of the medication are
anovulatory infertility, particularly if they are short lived. Therefore, as the dominant follicle
overweight or are diagnosed with PCOS, is grows and estradiol levels begin to rise, the
diet modification and increased physical activ- normal negative feedback effect of estradiol
ity to decrease weight and improve insulin occurs centrally; further FSH secretion is sup-
sensitivity. These changes can often lead to pressed, followed by atresia of the smaller
spontaneous resumption of ovulation, developing follicles. As a result, most ovula-
decrease the risks for metabolically associated tory events with the use of aromatase inhibi-
pregnancy complications, and improve long- tors are monofollicular, thereby lowering the
term health outcomes [6]. risk of multi-gestation pregnancies.
The short exposure and quick clearance of
letrozole offer additional advantages aside
16.9 Aromatase Inhibitors from ovulation induction. Because the pro-
duction of estrogen quickly resumes after the
Aromatase inhibitors were initially developed use of the aromatase inhibitor, there is less
to lower estrogen levels in women undergoing anti-estrogenic effects on the endometrium
breast cancer treatment [7]. Over the past 20 and the cervix when compared to clomiphene
years, aromatase inhibitors have been used as treatments [8]. The drug is also cleared from
an option for ovulation induction in women the system rapidly, often before a conception
who have failed to respond to the previous occurs, thereby limiting the exposure of a
first-line pharmacologic treatment, clomiphene potential early pregnancy [9].
citrate, and notably in women with PCOS. The
most effective and commonly used aromatase
inhibitor for ovulation induction is letrozole. 16.11 Dosage and Administration
Letrozole is given for 5 days, on cycle days

16.10 Pharmacology 3–7, following a spontaneous menstruation or
and Mechanism of Action a progestin-induced bleed. The starting dose is
2.5 mg daily, and if the cycle is ovulatory but
Aromatase is a cytochrome P450 enzyme that pregnancy does not occur, the same dose can
catalyzes the rate-limiting step in the produc- be administered again. However, if ovulation
tion of estrogens and is an ideal target for does not occur, the dose should be increased
selective inhibition because estrogen produc- to 5 mg per day, with the maximum dose being
tion is the terminal step in the steroid synthe- 7.5 mg per day. The most commonly pre-
sis pathway. Administration of an aromatase scribed dose is 5 mg daily for 5 days [10].
inhibitor to women in the early follicular
16 phase of the menstrual cycle results in the
suppression of systemic estradiol secretion. 16.12 Side Effects and Risks
Lower circulating estradiol levels release the
hypothalamus from the negative feedback Letrozole is now supported as the first-line
effect of estradiol, resulting in stronger GnRH treatment for ovulation induction by repro-
pulse release, a subsequent rise in follicle- ductive societies in North America and
stimulating hormone (FSH), increased follic- Europe, despite previous safety concerns.
ular development, and eventual increases in Previous concerns about congenital malfor-
estradiol production (as the effect of the aro- mations in children born after letrozole
matase inhibitor diminishes). administration have been disproven in multi-
Letrozole, a third-generation aromatase ple studies of over 1800 pregnancies. Side
inhibitor, is administered for a short duration effects of letrozole for ovulation induction are
of time, usually for 5 days in the early follicu- minimal and include hot flushes, dizziness,
lar phase. With a relatively short half-life of and fatigue. The risk of multiple pregnancy
Ovulation Induction
359 16
with letrozole is 3.4%, based on a large, multi- can have agonist or antagonist effects, depend-
center randomized trial. This is lower than the ing on the target tissue. The currently manu-
risk of multiple pregnancy seen with clomi- factured clomiphene citrate product used for
phene citrate (7.4%) [11]. ovulation induction is a mixture of two iso-
mers, enclomiphene and zuclomiphene, in an
approximate 3:2 ratio. Enclomiphene is the
16.13 Effectiveness more potent isomer and is responsible for the
ovulation induction effect of the medication.
Until very recently, clomiphene citrate was the It is also cleared more rapidly than zuclomi-
first-line oral ovulation induction medication, phene, by metabolism in the liver and via fecal
which was successfully used since the 1960s. excretion. Approximately 85% of the adminis-
Therefore, available data on the effectiveness of tered dose is eliminated from the body after
letrozole for ovulation induction is presented as 6 days, but traces can remain in circulation for
a comparison to clomiphene. In the largest ran- up to 6 weeks [14].
domized study to date, the cumulative live birth The mechanism of action of clomiphene
rates with letrozole was 27.5%, compared to citrate is believed to be at the level of the
19.1% with clomiphene [RR, 1.44; 95% CI, hypothalamus, where it binds to and depletes
1.10–1.87). The cumulative ovulation rate was the concentration of estrogen receptors. The
also higher with letrozole (62%) than with clo- depletion of estrogen receptors in the hypo-
miphene (48%; RR, 1.28; 95% CI, 1.19–1.37). A thalamus interferes with the negative feed-
Cochrane review conducted in 2018 reported a back mechanism of estrogen and is interpreted
higher live birth rate with letrozole compared to as low circulating estrogen. There is then a
clomiphene when followed by timed intercourse subsequent increase in the GnRH pulse fre-
(OR, 1.68; 95% CI, 1.42–1.99). There was little quency, leading to higher circulating levels of
to no difference in the rates of ovarian hyper- FSH and LH and an eventual increase in
stimulation syndrome (OHSS) (0.5% in both ovarian folliculogenesis and ovulation [15].
groups; RR, -0.00; 95% CI, -0.01–0.00) or mis- The effects of increased ovarian stimulation
carriage rates (19% with letrozole, 20% with clo- are expected to occur 5–12 days after the
miphene; OR, 0.69; 95% CI, 0.07–1.26) when administration of clomiphene citrate.
comparing letrozole and clomiphene use [12].
16.14.2 Dosage
16.14 Clomiphene Citrate and Administration
Clomiphene citrate is a selective estrogen The starting dose of clomiphene citrate is
receptor modulator (SERM). It was first 50–100 mg orally daily for 5 days starting on
described as an ovulation induction agent in days 2–5 of the menstrual cycle or a progestin-
the 1950s [13]. Since the 1960s, it has been induced bleed. The standard effective dose of
used as a first-line treatment for ovulation clomiphene citrate ranges from 50 mg daily to
induction until it was replaced by the more 250 mg daily, although doses in excess of
efficacious aromatase inhibitors. 100 mg daily are not recommended and seem
to add little to clinical pregnancy rates [16].
Response to clomiphene citrate can be evalu-
16.14.1 Pharmacology ated by ultrasound examination in the late fol-
and Mechanism of Action licular phase or by the use of urinary LH kits
to detect the presence of an LH surge and
Selective estrogen receptor modulators impending ovulation. A spontaneous menses
(SERMs) act as competitive inhibitors of at the expected time of the cycle is indicative
estrogen binding to estrogen receptors and of ovulation.
16.14.3 Side Effects and Risks they have been in clinical use since the 1950s.
Today, purified and recombinant forms of
Clomiphene citrate is generally well tolerated gonadotropins are available. Commonly used
with the most common side effects being mild compounds consist of either FSH or LH
and transient in nature. Mood swings and hot alone or a combination of both.
flushes are the most common side effects and Gonadotropins are administered either intra-
are temporary and short lived. Other less spe- muscularly or subcutaneously.
cific side effects include pelvic discomfort,
breast tenderness, and nausea, which can be
observed in 2–5% of patients taking the medi-
16.15.1 Pharmacology
cation. Visual symptoms, such as blurred or and Mechanism
double vision, scotomata, and light sensitiv- of Action
ity, are rare and reversible. There have been
reports of persistent visual symptoms and Exogenously administered gonadotropins
severe complications such as optic neuropathy promote ovarian follicular development
[17]. If visual disturbances occur, clomiphene through direct stimulation of the FSH and
citrate should be discontinued. LH receptors on the granulosa and theca
Clomiphene citrate treatment is associated cells of the ovary. Ovulation induction with
with an increased risk of multiple pregnancies gonadotropins should be accompanied by
because of the possibility of multifollicular the administration of an ovulation trigger
development. Most common multiple preg- with hCG. The alpha subunit of hCG is
nancies are twin pregnancies, with an incidence identical to that of LH, allowing hCG to
of around 8% in women taking clomiphene bind the LH receptor and mimic an endoge-
citrate for anovulation and 2.6–7.4% in women nous LH surge. Recombinant and human
with unexplained infertility. The rate of high- hCG is readily available, is easy to adminis-
order multiple pregnancies is much lower, in ter, is less expensive, and requires a smaller
the range of 0.08–1.1% [18]. OHSS rarely dose compared with recombinant LH; there-
occurs with clomiphene citrate. It appears that fore, it is the most commonly used com-
its use increases the risk of miscarriage, con- pound to trigger ovulation. A GnRH agonist
genital malformations, or ovarian cancer. can also be used to trigger ovulation, as the
initial “flare effect” of the gonadotropins
with its initial administration can also mimic
16.14.4 Effectiveness the LH surge. However, this method is not
efficacious in women with hypothalamic
Approximately 75–80% of patients with amenorrhea who have low endogenous LH
PCOS will ovulate with clomiphene citrate and FSH.
16 treatment. In ovulatory women, the concep- Gonadotropin administration is effective
in the treatment of hypogonadotropic hypo-
tion rate per cycle is up to 22% [10]. Over half
of the patients will ovulate with a 50 mg daily gonadal anovulation as it supplements the
dose, and those who do not may ovulate at lack of FSH and LH. In these patients, it is
higher doses using a step-up regime. Doses imperative that a preparation containing LH
can be increased by 50 mg with each anovula- is used or that recombinant LH is added to
tory cycle, to a maximum dose of 250 mg the treatment regime. LH stimulation of the
daily. Higher doses are often required in theca cells is necessary for the production of
patients with increased BMI [19]. androgens, which are then used as a substrate
for the granulosa cells to produce the estrogen
necessary for proper follicular maturation.
16.15 Gonadotropins Gonadotropins can also be effective in the
treatment of eugonadotropic anovulatory
Exogenous gonadotropins were first derived patients by augmenting the levels of endoge-
from the urine of menopausal women, and nous FSH and LH.
Ovulation Induction
361 16
16.15.2 Dosage and Administration to occur between 24 and 48 hours after the
hCG injection, with the average timing being
Gonadotropins are initiated between day 2 between 36 and 40 h hours post injection.
and day 5 of the menstrual or progesterone- Therefore, timed intercourse or intrauterine
induced bleed. In women with hypothalamic insemination is usually scheduled for
anovulation, however, treatment can be 24–36 hours after the trigger is administered
started at any time. Before initiation of gonad- [20].
otropins, a baseline ultrasound examination is
performed to exclude ovarian pathology that
could interfere with follicular development 16.15.3 Side Effects and Risks
and to evaluate endometrial thickness, partic-
ularly in women with anovulatory The most common complication of gonado-
PCOS. Gonadotropin dosage is based on the tropin treatment is multiple pregnancy.
patient’s age, ovarian reserve, and previous Multi-gestation pregnancies can occur in up
response to gonadotropins, but it is usually to 30% of gonadotropin-induced pregnan-
started at a relatively low dose and increased cies. In treatment cycles where numerous fol-
as necessary according to the patient’s licles are growing, cancellation or conversion
response [20]. to IVF with elective single blastocyst transfer
Initial starting doses range between 37.5 can be offered. In cases of high-order multi-
and 75 IU daily. Ultrasound examination is ple pregnancies, fetal reduction could be
performed after 4–5 days of administration offered. Another risk of gonadotropin treat-
and then every 1–3 days depending on the ment is ovarian hyperstimulation syndrome.
patient’s response to treatment. Once a mature In the presence of multiple developing folli-
follicle, around 17–19 mm in size, has devel- cles, the treatment cycle should be cancelled,
oped, an exogenous trigger (hCG or GnRH converted to IVF with or without a GnRH
agonist) is given to induce ovulation. Along agonist trigger and freezing all embryos, or to
with ultrasonographic follicle tracking, administer a lower dose of hCG at the time
response to gonadotropins can also be fol- of trigger [20].
lowed with estradiol levels. Although not Minor and common side effects of gonad-
measured routinely, estradiol levels can be otropin include injection site reaction such as
helpful in cases of atypical or prolonged erythema and discomfort. These are usually
responses to gonadotropins. self-limited and spontaneously resolve.
To reduce the occurrence of multiple Previous studies have raised concerns that
pregnancy, ovulation should not be triggered ovulation induction with gonadotropins may
if multiple dominant follicles are present or be associated with an increased risk of breast
developing. Ideally, ovulation trigger is given cancer and ovarian cancer, mainly borderline
when no more than two dominant follicles ovarian tumors. Recent studies have shown
over 16 mm are observed. Careful assess- mixed results.
ment and counselling on the risk of multiple
pregnancy should be undertaken if there are
additional follicles between 12 and 16 mm 16.15.4 Effectiveness
present in addition to the larger dominant
follicle, as these may still release a mature The overall pregnancy rate after ovulation
oocyte when triggered. HCG is administered induction with gonadotropins ranges from
in a single intramuscular or subcutaneous 15% to 20% per cycle. Success rates are depen-
injection of 5000–10,000 IU. Recombinant dent on the underlying pathology for anovula-
hCG is given at a dose of 250 mg subcutane- tion as well as individual prognostic factors,
ously, which corresponds to 6000–7000 IU including age of the patient. Women who are
of human hCG. Ovulation can be expected obese or insulin resistant may require an
increased amount of gonadotropins to achieve 16.16.2 Corticosteroids

ovulation [20].
Nonclassical (late-onset) congenital adrenal
hyperplasia (NCCAH) is a less common cause
16.16 Additional Treatment Options of eugonadotropic estrogenic oligo- or anovu-
lation. Ovulation induction in these patients is
16.16.1 Insulin-Sensitizing Agents best achieved through the use of glucocorti-
coid therapy. Prednisone is the most com-
The use of the insulin-sensitizing agent met- monly used glucocorticoid for ovulation
formin for the treatment of PCOS increased induction in NCCAH and should be started
in popularity when insulin resistance and at 5 mg/day. It can be augmented with stan-
hyperinsulinemia were discovered to play an dard doses of letrozole or clomiphene citrate
important role in the pathophysiology of the if ovulation does not resume with prednisone
condition. Early studies on metformin in alone. Alternatively, prednisone can be
PCOS demonstrated a small benefit for weight increased to 7.5 mg/day with or without the
loss in women with PCOS and found a resto- addition of oral ovulation induction agents
ration of menstrual function in approximately [23]. It is important that women using cortico-
50% of women with oligomenorrhea [21]. steroids in early pregnancy be followed closely
Metformin is a biguanide compound which by maternal fetal medicine or obstetrical med-
improves peripheral insulin sensitivity through icine subspecialists given their potential
stimulated glucose uptake by tissues. It also impact on early fetal development.
reduces gluconeogenesis in the liver and
impairs glucose absorption in the small intes-
tine. 16.16.3 Pulsatile GnRH
Metformin is not considered a first-line and Dopamine Agonists
treatment for ovulation induction in women
with PCOS. Compared with letrozole or clo- Pulsatile GnRH agonists can be administered
miphene citrate, treatment with metformin to women with hypogonadotropic anovula-
offers no advantage, either alone or in combi- tion. However, its use is not practical and is
nation with letrozole or clomiphene citrate, in rarely used today given the ready availability
terms of live birth rate (20). Although metfor- of exogenous gonadotropins. Women with
min has been used widely in the past for ovu- hyperprolactinemia can be treated with dopa-
lation induction and reduction of miscarriage mine agonists, the most common option being
in women with PCOS, the American Society cabergoline. Although ovulation will resume
for Reproductive Medicine recommends once prolactin levels normalize, dopamine
against the routine use of metformin for ovu- agonists are not considered ovulation-
16 lation induction in women with PCOS except
in women with glucose intolerance [22].
inducing agents.
Side effects of metformin include nausea,

vomiting, diarrhea, flatulence, GI upset, and
rarely lactic acidosis. Metformin is considered 16.16.4 Laparoscopic Ovarian
safe to use in pregnancy and is now recom- Drilling or Wedge
mended as the first-line treatment for gesta- Resection
tional diabetes and type 2 diabetes in
pregnancy. Therefore, while not recommended Ovarian surgery for ovulation induction in
for ovulation induction in women with PCOS, PCOS patients includes ovarian wedge resec-
metformin can safely be taken by women with tion and ovarian drilling [24]. These interven-
glucose intolerance who are attempting to tions are believed to be effective due to the
achieve pregnancy, including those undergo- destruction of ovarian androgen-producing
ing ovulation induction therapies. tissue. A subsequent fall in serum LH and
Ovulation Induction
363 16
androgen levels, as well as an increase in FSH comparable to gonadotropin use in patients
levels, is often observed after ovarian drilling who are resistant to oral induction agents.
procedures. These changes shift the adverse However, the multiple pregnancy rate is sig-
androgen-dominant intrafollicular milieu to nificantly higher with gonadotropins [20].
a more estrogenic-dominant one, which This procedure may be best suited for patients
restores the normal hormonal environment in whom frequent ultrasound monitoring is
by correcting the ovarian-pituitary feedback impractical or in a setting with limited
mechanisms. Consequently, the local and sys- resources. In our institution, laparoscopic
temic effects of ovarian drilling can promote ovarian drilling and ovarian wedge resection
follicular recruitment, maturation, and ovu- are no longer performed.
lation [25].
Potential complications of these proce- Conclusion
dures include the usual surgical and anesthet-
Anovulation is a common cause of infer-
ics risks, as well as post-operative adhesion
tility and usually presents as menstrual
formation and the reduction of ovarian
irregularity. A complete evaluation of the
reserve secondary to the destruction of
couple is mandatory to assess for systemic
healthy ovarian tissue. In order to limit the
illness and other factors to infertility. The
latter two complications, ovarian drilling is
first-line treatment for ovulatory disor-
often preferred over wedge resection. The typ-
ders should include lifestyle modifications,
ical indication for surgical treatment is clomi-
if applicable, followed by treatment with
phene citrate resistance in women with
ovulation-inducing agents. Selection of
anovulatory PCOS. Given the widespread use
the appropriate ovulation induction agent
of letrozole over clomiphene citrate, as well as
should be made according to the underly-
the availability of other effective methods for
ing pathology of anovulation, and it should
ovulation induction and IVF without the risk
follow a stepwise approach (. Table 16.1).
of affecting ovarian reserve, surgery should be
If conventional treatment is unsuccess-
used sparingly.
ful, patients can be treated with controlled
Ovarian drilling and wedge resection are
ovarian hyperstimulation or IVF.
effective and usually result in monofollicular
ovulation. Pregnancy and live birth rates are
.. Table 16.1 Treatment approaches to infertility secondary to PCOS-related anovulation
Intervention Advantages Disadvantages
First line Lifestyle modifications Low cost Minimal

including weight Reduced risk of treatment
control and exercise complications and pregnancy
Facilitates response to
ovulation induction
No increased risk of multiple
pregnancy
Ovulation induction Low cost Medication side effects
with oral agents: Easy administration Risk of multiple pregnancy
letrozole or clomiphene Limited monitoring
citrate
Second Ovulation induction Efficacious when first-line Higher cost
line with gonadotropins treatment fails Require ultrasound monitoring
Administered by injection
High risk of multiple pregnancy
Medication side effects
Third line In vitro fertilization High pregnancy rates Risks of procedure (including
Risk of multiple pregnancy can OHSS)
be controlled by elective single High cost
embryo transfer
Uncon- Laparoscopic ovarian One-time procedure Surgical risks
ventional drilling No increased risk of multiple High cost
pregnancy Risk of damaging ovarian reserve
No monitoring required Outdated
afterward
16.17 Review Questions pregnancy rate is most appropriate to

quote?
??1. Young woman with WHO class I A. <5%
anovulation is referred to you for fertil- B. 5–8%
ity treatments. Which is the most appro- C. 10–12%
16 priate treatment option(s)? D. Above 12% in young patients
A. Recombinant FSH alone ??3. The following statement about letrozole
B. Human menopausal gonadotro- is correct except:
phins A. A third-generation aromatase
C. Recombinant FSH and LH inhibitor.
D. Clomiphene citrate + recombinant B. It has a half-life of 5 days.
FSH C. The risk of multiple pregnancy is
E. Both B and C less than 5%.
F. Both B and D D. The risks of ovarian hyperstimula-
??2. When counseling a patient with PCOS tion syndrome with clomiphene or
using clomiphene citrate, what multiple letrozole are comparable.
Ovulation Induction
365 16
16.18 Answers 10. Al-Fadhli R, Sylvestre C, Buckett W, et al. A ran-
domized trial of superovulation with two different
doses of letrozole. Fertil Steril. 2006;85:161–4.
vv1. E https://doi.org/10.1016/j.fertnstert.2005.07.1283.
11. Legro RS, Brzyski RG, Diamond MP, et al.
vv2. B Letrozole versus clomiphene for infertility in the
polycystic ovary syndrome. N Engl J Med.
2014;371:119–29. https://doi.org/10.1056/
vv3. B
NEJMoa1313517.
12. Eskew AM, Bedrick BS, Hardi A, et al. Letrozole
compared with clomiphene citrate for unexplained
References infertility: a systematic review and meta-analysis.
Obstet Gynecol. 2019;133:437–44. https://doi.
org/10.1097/AOG.0000000000003105.
1. Dehghan M, Mente A, Zhang X, et al. Associations
13. GREENBLATT RB, BARFIELD WE, JUNGCK
of fats and carbohydrate intake with cardiovascu-
EC, RAY AW. Induction of ovulation with
lar disease and mortality in 18 countries from five
MRL/41. Preliminary report. JAMA.
continents (PURE): a prospective cohort study.
1961;178:101–4. https://doi.org/10.1001/
Lancet. 2017; https://doi.org/10.1016/S0140-
jama.1961.03040410001001.
6736(17)32252-3.
14. Glasier AF, Irvine DS, Wickings EJ, et al. A com-
2. Rojas J, Chávez M, Olivar L, et al. Polycystic ovary
parison of the effects on follicular development
syndrome, insulin resistance, and obesity: navigat-
between clomiphene citrate, its two separate iso-
ing the pathophysiologic labyrinth. Int J Reprod
mers and spontaneous cycles. Hum Reprod.
Med. 2014;2014:719050. https://doi.
1989;4:252–6. https://doi.org/10.1093/oxford-
org/10.1155/2014/719050.
journals.humrep.a136882.
3. Randeva HS, Tan BK, Weickert MO, et al.
15. Kettel LM, Roseff SJ, Berga SL, et al.
Cardiometabolic aspects of the polycystic ovary
Hypothalamic-pituitary-ovarian response to clo-
syndrome. Endocr Rev. 2012;33:812–41. https://
miphene citrate in women with polycystic ovary
doi.org/10.1210/er.2012-1003.
syndrome. Fertil Steril. 1993;59:532–8.
4. Legro RS, Dodson WC, Kris-Etherton PM, et al.
16. Dehbashi S, Vafaei H, Parsanezhad MD, Alborzi
Randomized controlled trial of preconception inter-
S. Time of initiation of clomiphene citrate and
ventions in infertile women with polycystic ovary
pregnancy rate in polycystic ovarian syndrome. Int
syndrome. J Clin Endocrinol Metab. 2015;100:4048–
J Gynaecol Obstet Off organ Int Fed Gynaecol
58. https://doi.org/10.1210/jc.2015-2778.
Obstet. 2006;93:44–8. https://doi.org/10.1016/j.
5. Mills G, Badeghiesh A, Suarthana E, et al.
ijgo.2005.10.015.
Polycystic ovary syndrome as an independent risk
17. Choi S-H, Shapiro H, Robinson GE, et al.
factor for gestational diabetes and hypertensive
Psychological side-effects of clomiphene citrate

disorders of pregnancy: a population-based study
and human menopausal gonadotrophin. J
on 9. 1 million pregnancies. 2020:1–9. https://doi.
Psychosom Obstet Gynaecol. 2005;26:93–100.
org/10.1093/humrep/deaa099.
https://doi.org/10.1080/01443610400022983.
6. Fauser BCJM, Tarlatzis BC, Rebar RW, et al.
18. Fauser BCJM, Devroey P, Macklon NS. Multiple
Consensus on women’s health aspects of polycystic
birth resulting from ovarian stimulation for subfer-
ovary syndrome (PCOS): the Amsterdam ESHRE/
tility treatment. Lancet (London, England).
ASRM-Sponsored 3rd PCOS Consensus
2005;365:1807–16. https://doi.org/10.1016/S0140-
Workshop Group. Fertil Steril. 2012;97:28–38.e25.
6736(05)66478-1.
7. Mitwally MF, Casper RF. Use of an aromatase
Reproductive Medicine. Use of clomiphene citrate
inhibitor for induction of ovulation in patients
in infertile women: a committee opinion. Fertil
with an inadequate response to clomiphene citrate.
Steril. 2013;100:341–8. https://doi.org/10.1016/j.
Fertil Steril. 2001;75:305–9. https://doi.
fertnstert.2013.05.033.
org/10.1016/s0015-0282(00)01705-2.
20. Committees P, Society A, Endocrinology R. Use
8. Franik S, Kremer JAM, Nelen WLDM, et al.
of exogenous gonadotropins for ovulation induc-
Aromatase inhibitors for subfertile women with
tion in anovulatory women: a committee opinion.
polycystic ovary syndrome: summary of a
Fertil Steril. 2020;113:66–70. https://doi.
Cochrane review. Fertil Steril. 2015;103:353–5.
org/10.1016/j.fertnstert.2019.09.020.
21. Nestler JE. Metformin for the treatment of the
9. Casper RF, Mitwally MFM. Review: aromatase
polycystic ovary syndrome. N Engl J Med.
inhibitors for ovulation induction. J Clin
2008;358:47–54. https://doi.org/10.1056/
Endocrinol Metab. 2006;91:760–71. https://doi.
NEJMct0707092.
org/10.1210/jc.2005-1923.
22. Penzias A, Bendikson K, Butts S, et al. Role of 24. Felemban A, Tan SL, Tulandi T. Laparoscopic
metformin for ovulation induction in infertile treatment of polycystic ovaries with insulated nee-
patients with polycystic ovary syndrome (PCOS): a dle cautery: a reappraisal. Fertil Steril.
guideline. Fertil Steril. 2017;108:426–41. https:// 2000;73:266–9. https://doi.org/10.1016/s0015-
doi.org/10.1016/j.fertnstert.2017.06.026. 0282(99)00534-8.
23. Speiser PW, Arlt W, Auchus RJ, et al. Congenital 25. Farquhar C, Brown J, Marjoribanks J. Laparoscopic
adrenal hyperplasia due to steroid 21-hydroxylase drilling by diathermy or laser for ovulation induc-
deficiency: an Endocrine Society Clinical Practice tion in anovulatory polycystic ovary syndrome.
Guideline. J Clin Endocrinol Metab. 2018;103:4043– Cochrane Database Syst Rev. 2012:CD001122.
88. https://doi.org/10.1210/jc.2018-01865. https://doi.org/10.1002/14651858.CD001122.pub4.
16
367 17
Assisted Reproductive
Technology: Clinical
Aspects
Pardis Hosseinzadeh, M. Blake Evans, and Karl R. Hansen
Contents

17.1.1 revalence – 369
P
17.1.2 Indications for ART – 370
17.2 Evaluation Prior to IVF – 370

17.2.1 istory and Physical Exam – 370
H
17.2.2 Ovarian Reserve Testing – 371
17.2.3 Uterine Evaluation – 371
17.2.4 Sperm Testing – 372
17.2.5 Optimizing IVF Outcomes – 372
17.3 Process of IVF – 372

17.3.1 varian Stimulation – 372
O
17.3.2 Gonadotropins – 373
17.3.3 Cycle Timing – 373
17.3.4 Ovulation Prevention – 374
17.3.6 Microdose, or “Flare,” Protocols – 374
17.3.7 Gonadotropin-Releasing Hormone Antagonists – 375
17.3.8 Ovulation Trigger – 376
17.3.9 Fertilization Methods – 376
17.3.10 Luteal Phase Hormonal Support – 377
17.3.11 Embryo Transfer – 377
17.3.12 Embryo Transfer Technique – 378
17.3.13 Cryopreservation of Embryos – 378

https://doi.org/10.1007/978-3-030-99596-6_17
17.4 Special Considerations – 379
17.4.1 isposition of Embryos – 379
D
17.4.2 Third-Party Reproduction – 379
17.4.3 Oocyte Donation – 379
17.4.4 Indications for Oocyte Donation – 379
17.4.5 Evaluation of the Oocyte Donor – 380
17.4.6 Sperm Donation – 380
17.4.7 Indications for Sperm Donation – 380
17.4.8 Evaluation of the Sperm Donor – 380
17.4.9 Embryo Donation – 381
17.4.10 Gestational Carriers – 381
17.4.11 IVF Outcomes – 381
17.4.12 Potential Adverse Outcomes – 381
17.4.13 Risk of Cancer in Women Undergoing IVF – 382
17.4.14 Obstetrical Complications – 382
17.4.15 Risks to the Offspring – 383
17.4.16 Controversies – 384
17.6 Answer – 386
References – 386
Assisted Reproductive Technology: Clinical Aspects
369 17
According to data from the National
Key Points Survey of Family Growth (NSFG) conducted
55 Assisted reproductive technology from June 2006 through June 2010, 6% (or an
(ART) is a complex series of procedures estimated 1.5 million US couples) were infer-
used to treat infertility in couples who tile. Additionally, 12% of reproductive-aged
have failed less invasive fertility treat- women reported impaired fecundity [7].
ments or wish to prevent certain genetic Challenges to human fertility may arise from
problems in the offspring. many conditions caused by genetic or struc-
55 In vitro fertilization (IVF) is the most tural abnormalities, infectious or environmen-
effective and commonly used form of tal agents, and certain behaviors. Natural
modern ART, which involves collecting aging also limits human fertility. The recent
mature eggs from the ovaries and fertil- decline in the US birth and fertility rates is
izing them with sperm in a lab followed mainly attributed to delayed childbearing age
by transfer of the fertilized egg or in women due to greater aspiration for
embryo into the uterus. advanced education and marriage later in life.
55 Most common indications for IVF These trends have underscored the limits to
include, but are not limited to, disorders natural fertility, and today, Americans are
of ovulation, damaged or blocked fal- increasingly aware of and are concerned about
lopian tubes, male factor infertility, infertility. Efforts to treat tubal factor and
unexplained infertility, same-sex cou- later other causes of infertility lead to the
ples, and fertility preservation for can- development and refinement of assisted
cer or other medical problems. reproductive technology (ART), which has
55 Risks associated with IVF include ovar- changed the course of human reproduction.
ian hyperstimulation syndrome, multi- Based on data presented from the NSFG
ple gestation, preterm delivery, low survey, 12% of women aged 15–44 in 2006–
birth weight, ectopic pregnancy, and 2010 (7.3 million women), or their partners,
complications associated with the egg had ever used infertility services. Among
retrieval procedure. women aged 25–44, 17% (6.9 million women)
had ever used any infertility service [8].
Among these women, the most common ser-
vices were advice on the timing of intercourse
17.1 Introduction (29%), infertility testing (27%), and ovulation
induction drugs (20%) [8]. Intrauterine insem-
17.1.1 Prevalence ination (IUI) was used by 7.4% of these
women, 3.2% had undergone surgery or treat-
Infertility is a significant public health prob- ment for obstructed fallopian tubes, and 3.1%
lem in the USA that affects women, men, and had ever used ART [2]. The NSFG report
couples. Even though perceived as a quality- indicates that infertility treatment other than
life issue, both the World Health ART, such as ovarian stimulation followed by
of-
Organization and the American Society for natural conception or IUI, is much more com-
Reproductive Medicine (ASRM) [1, 2] define mon than ART. Although the scientific litera-
infertility as a disease of the reproductive sys- ture indicates that the efficacy of these
tem. Infertility has public health consequences treatments is much lower than that of
beyond the ability to have children, including ART. While it is difficult to ascertain the
psychological distress, social stigmatization, denominator for patients where ART has been
economic strain, and marital discord. recommended, it is very likely that more
Furthermore, infertility is associated with an patients would benefit from ART. Lower rates
increased risk of subsequent chronic health of IVF utilization have been correlated with a
conditions [3–6]. lack of insurance coverage and decreased
370 P. Hosseinzadeh et al.
availability of physicians providing this ser- all contributing causes at once. Furthermore,
vice. Despite these social factors, approxi- IVF may be recommended for patients with
mately 248,000 cycles of in vitro fertilization age-related or unexplained infertility diagno-
(IVF) are performed each year in the USA [9]. ses when other treatment options fail.
Some women or couples may have an indi-
cation for a fertility preservation procedure,
Case Vignette which involves harvesting oocytes, with or
without embryo creation, for later use. This
ART Clinical- A 30-year-old woman with a may be performed prior to receiving gonado-
diagnosis of infertility and polycystic ovary toxic medications such as chemotherapy. This
syndrome consults you for in vitro fertiliza- treatment is also gaining acceptance for pur-
tion (IVF). She has failed multiple cycles of poses of deferred childbearing. In patients
ovulation induction with letrozole and clo- with a planned fertility-threatening treatment,
miphene. The semen parameters are nor- the process can be expedited, requiring approx-
mal. Imaging for tubal disease was negative. imately 2–3 weeks from the time of medication
initiation to oocyte retrieval [10, 11].
17.1.2 Indications for ART

17.2 Evaluation Prior to IVF
It is important to understand which individu-
als or couples would most benefit from 17.2.1 History and Physical Exam
ART. Of note, the term “ART” has historically
been used to describe all treatments involving Prior to starting IVF, individuals and couples
the handling of sperm and oocytes, although should be thoroughly evaluated to help maxi-
currently more than 99% of ART procedures mize their chances for a healthy pregnancy.
are in vitro fertilization (IVF) procedures. The Ideally, the couple should both be present dur-
term “IVF” will be used throughout the rest of ing the first office visit. Individual or each part-
this chapter. IVF was first developed as a ner’s detailed past medical, surgical, family,
method to overcome infertility resulting from and social history should be reviewed, and any
irreversible tubal factor but now is applied special considerations followed up as appropri-
much more broadly for the treatment of almost ate. Chronic diseases, including hypertension,
all causes of infertility. Currently, IVF is com- diabetes, thyroid, and autoimmune disorders,
monly used in the treatment of individuals or should be optimally controlled. Lifestyle and
couples with severe male factor infertility or environmental factors influence fertility and
severe tubal factor infertility resulting from deserve consideration when relevant. For
previous infection, severe endometriosis, or instance, substance abuse, particularly tobacco
sterilization procedure. In addition, there are use, is one factor over which couples have con-
other situations in which IVF may be the first- trol. Infertility is more prevalent in reproduc-
line treatment, such as women or men who are tive-aged women who smoke, and the time to
17 single or homosexual-partnered males using a conception is longer compared to nonsmoking
gestational carrier and any individual or cou- women. Additionally, the effects of passive
ple using donor oocytes or previously frozen smoke exposure is only slightly less than active
oocytes. Another indication for IVF as a first- smoking [12]. Therefore, couples attempting to
line treatment is in couples who are carriers of conceive should be encouraged to quit smok-
autosomal or sex-linked genetic disorders or ing. Other forms of substance abuse such as
balanced chromosomal translocations. In marijuana and cocaine use can adversely affect
these cases, IVF with preimplantation genetic fertility. Marijuana use may interfere with ovu-
testing (PGT) can decrease the risk of deliver- lation in women [13] and also decrease fecun-
ing an affected child. IVF is also often the best dity [14]. In men, marijuana use has been
treatment for couples with multiple causes associated with lower sperm concentration,
relating to their infertility in order to overcome motility, viability, morphology, and impaired
371 17
capacitation and fertilization [14, 15]. In both include both biochemical and ultrasono-
women and men, even modest alcohol con- graphic measures. An anti-Müllerian hor-
sumption has been associated with lower preg- mone (AMH) level is drawn, and in some
nancy rates in IVF cycles [16]. Some studies patients, a basal (cycle day 3) follicle-
have suggested that women ingesting greater stimulating hormone (FSH) and estradiol are
than 200 mg caffeine per day may delay con- obtained as well [21]. Exceptions to drawing
ception [17] or increase the risk of pregnancy “day 3” labs may include young patients with
loss [18]. a high AMH and fertility preservation patients
If review of the history reveals conditions undergoing an expedited cycle. Measuring an
that may affect the patient or the pregnancy, a antral follicle count with transvaginal ultra-
pre-pregnancy consultation with a maternal- sound also gives an assessment of ovarian
fetal medicine specialist may be warranted to reserve. A selection of all or some of these
discuss the risks involved in becoming preg- tests assists with dosing of gonadotropins and
nant as well as management during pregnancy. protocol selection.
In general, the patient should be offered Since none of the mentioned ovarian
screening for conditions that could affect the reserve tests are perfect predictors of ovarian
health of the pregnancy. The patient’s blood response, various combinations of ovarian
type should be confirmed, and if her blood reserve tests have been developed in the desire
type is Rh negative, she should be counseled to improve diagnostic performance. However,
on the indications for and benefits of RhoGam as these tests are highly correlated, models
administration during pregnancy. She also combining tests do not perform significantly
should be screened for immunity to rubella better than individual tests such as the AFC
and varicella and, if non-immune, offered [22]. Thus, the use of combined tests will not
vaccination prior to pregnancy. In addition, only increase the cost of testing but generally
the patient and her partner (if applicable) will not improve clinical decision-making.
should be tested for hepatitis B and C, human
immunodeficiency virus (HIV), gonorrhea,
chlamydia, and syphilis. A careful family his- 17.2.3 Uterine Evaluation
tory and review of ethnic background will
also inform whether additional tests such as Abnormalities of the uterus are an uncom-
cystic fibrosis, Tay-Sachs disease, and hemo- mon cause of infertility, but a cavity evalua-
globin electrophoresis (for sickle trait or thal- tion is essential if an embryo transfer is
assemia) may be recommended [19]. Another anticipated. The anatomic uterine abnormali-
option is for couples to consider Universal ties that may adversely affect fertility include
Genetic Carrier Screening. This testing offers congenital malformations, leiomyomas, intra-
the additional advantages of identifying cou- uterine adhesions, and endometrial polyps.
ples at risk for having children with genetic There are three commonly used methods
disease prior to pregnancy [20]. for evaluation of the uterine cavity: hystero-
Ultimately, it is important to discuss and salpingogram (HSG), transvaginal ultrasound
set achievable goals for the management of (TVUS) with saline infusion sonogram (SIS),
infertility personalized for each individual or and hysteroscopy.
couple. This can help increase patient compli- The best options include a SIS (injecting
ance and manage expectations. sterile saline into the uterine cavity under
ultrasonographic guidance) and hysteroscopy
(using a small lighted scope while using a dis-
17.2.2 Ovarian Reserve Testing tension medium such as normal saline, to
look directly into the uterine cavity).
Ovarian reserve testing is typically performed Hysteroscopy serves as the gold standard
to estimate the expected response to gonado- method for both diagnosis and treatment of
tropin stimulation. Ovarian reserve tests intrauterine pathology that may adversely
affect fertility. Although definitive, hysteros- without hydrosalpinges [26, 27]. Laparoscopic
copy has limited diagnostic advantages over salpingectomy or a tubal transection prior to
SIS and generally can be reserved for treat- IVF significantly improves pregnancy rates in
ment of abnormalities identified by less inva- women with hydrosalpinges [28], and limited
sive and costly methods. evidence suggests improved pregnancy rates
HSG is a procedure wherein radio-opaque in natural conception [29].
contrast is injected through the cervix into the Another aspect is optimizing thyroid func-
uterine cavity under fluoroscopy to evaluate tion prior to IVF. Suboptimal thyroid func-
the fallopian tubes and uterine cavity. It is less tion is associated with adverse pregnancy
sensitive (50%) and has a lower positive pre- outcomes, including an increased risk of mis-
dictive value (30%) compared to SIS and hys- carriage, preterm birth, and impaired neuro-
teroscopy [23]. Because HSG cannot reliably logical development in the offspring [30, 31].
differentiate a septate from a bicornuate Hypothyroidism denotes deficient production
uterus, further evaluation with pelvic MRI or of thyroid hormones and can be overt or sub-
3D ultrasonography may be necessary [24]. clinical. Overt hypothyroidism is character-
Although the benefit of optimizing the ized by an elevated thyroid-stimulating
uterine cavity requires further study, this is hormone (TSH) concentration and a
generally considered a standard practice prior decreased free T4 and is often associated with
to IVF. Many offices also perform a “mock,” clinical findings such as fatigue, constipation,
or practice, embryo transfer prior to the actual cold intolerance, muscle cramps, weight gain,
embryo transfer in order to anticipate any dif- dry skin, hair loss, and prolonged deep tendon
ficulties and increase the chances for an atrau- reflexes. Overt hypothyroidism decreases fer-
matic embryo transfer [20]. tility, presumably due to ovulatory dysfunc-
tion, and thyroid hormone should be
administered prior to pregnancy to normalize
17.2.4 Sperm Testing the thyroid axis. Subclinical hypothyroidism is
defined as an elevated serum TSH concentra-
If a male infertility factor exists, it frequently tion (TSH > 4.5–5 mIU/L depending on local
will be revealed by an abnormal semen analy- standards) with free T4 level within the nor-
sis. Semen parameters can vary widely over mal reference range [32]. Thyroid function
time, and if abnormal, another semen analysis should be optimized in infertile women with
should be obtained after at least 4 weeks [25]. subclinical hypothyroidism.
Prior to IVF, a recent semen analysis is indi-
cated to assess whether intracytoplasmic
sperm injection (ICSI) is necessary and 17.3 Process of IVF
whether a sperm extraction technique may be
needed. 17.3.1 Ovarian Stimulation
Numerous regimens have been proposed for

17 17.2.5 Optimizing IVF Outcomes ovarian stimulation, ranging from no stimula-
tion (natural cycle IVF) to minimal stimula-
The reason for extensive evaluation prior to tion with clomiphene citrate or sequential
IVF is that there are areas of a patient’s health treatment with clomiphene citrate and from
that can be optimized prior to IVF. One low-dose exogenous gonadotropins to high-
important example is the identification of a dose exogenous gonadotropins. Currently
hydrosalpinx on HSG or ovarian stimulation using exogenous gonado-
TVUS. Hydrosalpinges adversely affect IVF tropins in combination with a gonadotropin-
outcomes and have been shown to decrease releasing hormone (GnRH) analogue has
pregnancy, implantation, and delivery rates almost entirely replaced the other regimens
by approximately 50% compared to women due to higher pregnancy rates.
373 17
There are three basic elements to a conven- proportions of FSH and LH may have an
tional ovarian stimulation protocol for IVF; impact on the outcomes of ovarian stimula-
the first is exogenous gonadotropins to stimu- tion, with suggested optimal LH to FSH ratio
late multi-follicular growth, the second is of 0.30–0.60 to mitigate the risk of premature
GnRH antagonist or agonist to prevent pre- progesterone effect on the endometrium in
mature ovulation, and the third is LH activity fresh embryo transfer cycles [35]. Monitoring
in the form of human chorionic gonadotropin the response to ovarian stimulation is accom-
(hCG) or GnRH agonist to trigger the final plished with a combination of frequent trans-
oocyte maturation. vaginal ultrasound examinations, with serum
estradiol and progesterone measurements.
17.3.2 Gonadotropins
17.3.3 Cycle Timing
Gonadotrophin preparations available for use
include human menopausal gonadotrophin Oral contraceptive pills (OCPs) are often used
(hMG) (a urinary product with follicle- prior to an IVF cycle to control the onset of
stimulating hormone (FSH) and luteinizing the menses and therefore allow optimized
hormone (LH) activity), purified FSH, highly scheduling of the stimulation cycle. Once on
purified FSH, and various recombinant FSH OCPs, patients are typically instructed to stop
and LH preparations. at least 5 days before the scheduled start. This
In a natural cycle, FSH and LH act in con- provides more flexibility with the timing of
cert to stimulate folliculogenesis and ovula- appointments, which is more convenient for
tion. FSH stimulates growth of follicles and both the patient and the provider as well as
upregulates aromatase activity (an enzyme facilitating cycle batching for some clinics.
that converts testosterone to estrogen). Pretreatment with OCPs may also help syn-
Administration of exogenous FSH prevents chronize the follicular cohort by attenuating
the physiologic decrease in FSH in a natural the FSH rise before stimulation begins.
cycle when the dominant follicle is selected. However, as always, convenience and poten-
This allows for multi-follicular growth during tial biological benefits should be weighed
controlled ovarian hyperstimulation. LH acts against any possible adverse effects from the
on the theca cells to increase androgen pro- intervention.
duction, which is the substrate for estradiol OCP priming in women undergoing ovar-
synthesis by the granulosa cells in the develop- ian stimulation with antagonist protocol has
ing follicles. LH causes luteinization of the been suggested to be associated with longer
follicle(s) and the synthesis/secretion of a duration of stimulation and higher gonado-
large amount of progesterone from the corpus tropin administration without an increase in
luteum [33]. Therefore, these gonadotropins cumulus oocyte complexes and lower ongoing
are used alone or in combination in the ovar- pregnancy and live birth rates [36]. However,
ian stimulation process. The data from a 2017 data from a recent study indicates that OCP
meta-analysis have shown that although the administration for an interval of 12- to 30-day
administration of FSH alone results in a treatment period with a 5-day washout period
higher number of oocytes retrieved than does not affect clinical pregnancy or live birth
FSH + LH or hMG protocols, the embryo rates in patients undergoing IVF cycles using
number, implantation, and pregnancy rates an antagonist protocol [37].
were higher in the FSH + hMG protocols [34]. Patients over the age of 35 who undergo
In light of evidence suggesting that the use of ovarian pretreatment with OCPs may require
hMG may increase live birth rates, many clin- a longer duration of stimulation with gonado-
ics favor the combined stimulation with FSH tropins [38]. In low responder patients, there is
and hMG (or alternative form of LH activity) limited evidence to support that short-term
over stimulation with FSH alone. In the com- suppression with OCPs may improve the
bination protocols, variations in the relative response [39].
If women have contraindications to the stimulation cycles were cancelled because of a

use of combined OCPs or history of intoler- premature LH surge and ovulation [41]. There
ance due to side effects, an IVF cycle may be are three standard IVF protocols to physio-
started with menses or the use of progesterone- logically prevent or delay an LH surge.
only pills. In women who are amenorrheic or
oligomenorrheic, withdrawal bleeding may be
induced using progesterone or a progestin. 17.3.5 Gonadotropin-Releasing
Additionally, fertility preservation patients in Hormone Agonists
need of imminent cancer treatments may need
to start stimulation as soon as possible. In this GnRH agonists initially stimulate LH and
setting, gonadotropins can be administered as FSH release, also known as the “flare” effect,
a “random start” protocol, regardless of and within 2 weeks will suppress gonadotropin
where the patient is in her menstrual cycle release [42], owing to downregulation of
[11]. There is good evidence that the timing of gonadotropin-releasing hormone receptors at
cycle start does not affect outcomes when the level of the pituitary. In a typical cycle,
embryo cryopreservation is planned, even GnRH agonist treatment starts during the mid-
when gonadotropins are started in the luteal luteal phase, when endogenous gonadotropin
phase [40]. levels are low and the “flare” effect is least likely
to stimulate a new cohort of follicular growth.
In the USA, the most popular GnRH ago-
17.3.4 Ovulation Prevention nist is leuprolide acetate, given subcutane-
ously starting with 1.0 mg daily for
As previously mentioned, the goal of ovarian approximately 10 days or until onset of men-
stimulation for IVF is to harvest a cohort of ses or gonadotropin stimulation, decreasing
mature oocytes before spontaneous ovulation to 0.5 mg daily thereafter until the ovulation
takes place. If premature ovulation occurs, the trigger (. Fig. 17.1).
oocytes cannot be harvested, and the cycle
will be cancelled. Estradiol levels during con-
trolled ovarian hyperstimulation usually far 17.3.6 Microdose, or “Flare,”
exceed the threshold that triggers an LH surge Protocols
in a natural cycle. The introduction of long-
acting GnRH agonists in the late 1980s trans- Microdose Lupron is an alternative stimula-
formed the approach to ovarian stimulation in tion regimen that utilizes a smaller dose of the
ART by providing the means to suppress GnRH agonist leuprolide acetate just 2–3 days
endogenous pituitary gonadotropin secretion before the start of ovarian stimulation medi-
and thereby prevent a premature LH surge cations. In a typical standard microdose pro-
during exogenous gonadotropin stimulation tocol, leuprolide acetate (usually 40
[41]. Prior to that time, more than 20% of micrograms divided into twice daily) is admin-
17
HCG Retrieval
Ovulation GnRH Agonist
Gonadotropins
Menses
.. Fig. 17.1 GnRH agonist long protocol

375 17
istered starting on cycle day 1 or 2 and con- in ART. Their main advantage is that antago-
tinuing daily until the trigger. The trigger nists block the GnRH receptor in a dose-
must be an hCG as the GnRH receptors on dependent competitive fashion and have no
the pituitary are fully occupied, and a GnRH flare effect. Since gonadotropin suppression is
agonist trigger would not work appropriately immediate, and because local GnRH recep-
(. Fig. 17.2). The goal is to minimize the tors within the ovary may lead to decreased
suppressive effect and to take advantage of aromatase activity [47], treatment duration
the initial “flare” phase to complement the and total dose for gonadotropin usage are
exogenous gonadotropin injections. After decreased [48]. A multicenter IVF trial com-
5–7 days of administration, longer-term treat- pared the GnRH agonist protocol with the
ment will result in pituitary suppression and GnRH antagonist protocol and found a mean
thus prevents premature ovulation [43]. duration of 19 days of injections with the
Minimizing excessive ovarian suppression GnRH agonist, compared to only 4 days with
while capitalizing on the initial stimulatory the GnRH antagonist protocol [49]. The treat-
effect has led this regimen to gain popularity ment protocol may be fixed and begin antago-
for poor responders. However, data from mul- nist after 5–6 days of gonadotropin
tiple studies including a meta-analysis regard- stimulation or individualized, starting antag-
ing superiority of this protocol for poor onist when the lead follicle reaches approxi-
responders are conflicting [44–46]. mately 13–14 mm in diameter [50, 51]
(. Fig. 17.3). The minimum usual dose to
prevent ovulation is 250 μg/day.
17.3.7 Gonadotropin-Releasing A 2017 meta-analysis compared GnRH
Hormone Antagonists antagonist with long agonist protocols in cou-
ples undergoing IVF while accounting for
The development of GnRH antagonists pro- patient diagnosis [52]. According to this study,
vided another option for ovulation prevention in a general IVF population, GnRH antago-
Retrieval
HCG
Gonadotropins
Microdose Lupron
Menses
.. Fig. 17.2 Microdose Lupron or “flare” protocol
HCG and/or GnRH

agonist
Retrieval
GnRH
Antagonist
OCPs
Gonadotropins
Menses
.. Fig. 17.3 Antagonist protocol

nist protocols are associated with lower ongo- hCG trigger, known as a “dual trigger.”
ing pregnancy rates when compared to long Several studies, including a 2020 randomized
protocol agonists but also with lower ovarian clinical trial, suggests improved IVF out-
hyperstimulation syndrome (OHSS) rates comes, pregnancy, and live birth rates with the
[52]. The number needed to treat in the antag- dual trigger compared to hCG alone [61–63].
onist treatment group to prevent one case of
OHSS was 40. In couples with PCOS and
poor responders, GnRH antagonists do not 17.3.9 Fertilization Methods
seem to compromise ongoing pregnancy rates
and are associated with less OHSS [52]. The two methods most commonly used to
achieve fertilization are conventional IVF and
intracytoplasmic sperm injection (ICSI). In
17.3.8 Ovulation Trigger conventional IVF, each oocyte is incubated
with 50–100,000 motile sperm for an interval
Once a cohort of follicles reaches maturity, of 12–18 hours, whereas with ICSI, a single
urinary human chorionic gonadotropin selected sperm is injected directly into an
(hCG, 5000–10,000 international units) is typ- oocyte to attempt fertilization. Whether to
ically administered to mimic the LH surge fertilize the oocytes with conventional IVF or
and triggers the final steps of oocyte develop- ICSI is a decision that should be made prior
ment. A total of 250 μg of recombinant hCG to the initiation of the IVF cycle. In general,
can also be used to trigger ovulation and has ICSI is used when there is a known male fac-
been shown to have comparable outcomes tor or when concern for poor fertilization with
with urinary hCG [53]. Oocyte retrieval is per- conventional IVF exists. ICSI is the treatment
formed prior to ovulation, 34–36 h after the of choice for male factor infertility, as it does
trigger injection. hCG has a relatively long not require sperm to undergo the acrosome
half-life and remains elevated in the serum for reaction or to fuse with the oocyte membrane
up to 6 days [54]. For this reason, it may exac- and may overcome the negative effects of
erbate symptoms of ovarian hyperstimulation abnormal semen characteristics and sperm
syndrome in patients at risk. Alternatively, a quality on fertilization [64].
single bolus of GnRH agonist may be used to ICSI without male factor infertility may
trigger ovulation in GnRH antagonist proto- be of benefit for fertilization in selected
col cycles. GnRH agonist triggers an endoge- patients undergoing IVF with preimplanta-
nous LH surge, which has a considerably tion genetic testing for monogenic disease
shorter half-life than the endogenous LH (PGT-M), c oupled with previous failed fertil-
surge that occurs in a natural cycle [55]. This ization with conventional fertilization,
short LH surge is inadequate to support the in vitro matured oocytes, and previously
corpora lutea and limits the production of cryopreserved oocytes [65]. The number
vascular endothelial growth factor, which is needed to treat to prevent one case of unex-
the key mediator leading to increased vascular pected fertilization failure is approximately
17 permeability, the hallmark of OHSS [56]. 30 cases of ICSI, when considering ICSI for
Although initial studies reported decreased non-male factor infertility [65]. However,
implantation and live birth outcomes with regarding patients with unexplained infertil-
GnRH agonist trigger [57, 58] when com- ity, a prior meta-analysis indicates that the
pared to conventional hCG, most recent stud- number needed to treat to prevent one case of
ies have reported comparable reproductive unexpected fertilization failure is 5 [66].
outcome and live birth rate in the presence of ICSI for unexplained infertility is associ-
adequate luteal support [59, 60]. GnRH ago- ated with increased fertilization rates and
nist trigger may also be ideal in situations decreased risk of failed fertilization; however,
when no fresh transfer is planned. GnRH it has not been shown to improve live birth
agonist can also be used in combination with outcomes [65].
377 17
17.3.10 uteal Phase Hormonal
L to progesterone supplementation alone [71].
Support Although estrogen is commonly administered
after a GnRH-only trigger due to rapid lute-
Controlled ovarian stimulation cycles are olysis, the optimal luteal support protocol is
associated with disruption of the luteal phase uncertain [72].
due to multiple mechanisms. Co-treatment
with GnRH agonist or antagonist will result
in suppressed endogenous LH levels during 17.3.11 Embryo Transfer
the luteal phase. Insufficient LH levels may be
inadequate to stimulate and maintain estro- Although embryos can be successfully trans-
gen and progesterone production by the cor- ferred anytime during preimplantation devel-
pora lutea required to promote endometrial opment, the transfer is most commonly
development in preparation for implantation. performed on day 3 or day 5 following the
Additionally, the disrupted follicle with the oocyte retrieval. In general, the goal of IVF is
aspiration of granulosa cells may also limit to maximize success rates while minimizing
the capacity of the new corpora lutea to syn- multiple gestation pregnancy rates. Transfer
thesize and secrete hormones. In order to of a single day 5 blastocyst has been advo-
overcome these luteal deficiencies, exogenous cated as a method to minimize the risk of
progesterone and, in some cases, estradiol are multiple gestation pregnancy while maintain-
administered in the luteal phase to support ing satisfactory pregnancy rates. However, for
endometrial development, implantation, and some patients, none of the day 3 embryos will
early pregnancy. continue to grow to the blastocyst stage. In a
Progesterone supplementation generally reputable lab, this is more reflective of embryo
begins on the day of or day after oocyte quality than the laboratory environment. The
retrieval [65, 67]. Progesterone can be admin- possibility of having no embryos to transfer is
istered orally, vaginally, or by intramuscular a risk with the decision to defer embryo trans-
(IM) injections. Oral progesterone supple- fer on day 3 and proceed to the blastocyst
mentation is the least common method due to stage, and appropriate counseling is necessary.
intense hepatic metabolism during the first The transfer of more than one embryo
pass through the liver. This effect cannot be increases the chance of pregnancy but also
overcome by simply increasing the dose of increases the risk of multiple gestation to a
progesterone administered, since it produces a much greater degree. This is especially
degree of somnolence unacceptable to most important to consider in younger patients

patients. Although success rates with intra- when the pregnancy rates are only increased
muscular versus vaginal route are reported to by approximately 5% with more than one
be similar in a fresh embryo transfer, recent embryo transferred, but the risk of multiples
data shows that exclusively using vaginal pro- can be as high as 40% [73]. ASRM has issued
gesterone in frozen embryo transfer cycles is guidelines in 2017 for the number of embryos
associated with a significant decrease in live to be transferred based on the age of the
birth rates and using intramuscular progester- woman, presence or absence of favorable
one with or without vaginal progesterone sup- characteristics, stage of embryo development,
plementation is recommended [68]. Even and if known, euploid status [74]
though stopping luteal phase support after a (. Table 17.1). The following criteria have
positive pregnancy test does not seem to be been characterized as favorable prognosis:
associated with lower live birth rates [69], first cycle of IVF, good embryo quality, excess
many clinics continue luteal support until embryos for cryopreservation, or previous
8–10 weeks of gestation [70]. successful IVF. Additional favorable criteria
Estradiol is also commonly administered for FET cycles include the availability of vitri-
for luteal phase support; however, there is no fied, euploid, day 5, or day 6 blastocysts for
evidence that it improves outcomes compared transfer [74].
.. Table 17.1 Recommended limits on the number of embryos to transfer
Prognosis <35 years 35–37 years 38–40 years 41–42 years
Cleavage stage
Euploid 1 1 1 1
Favorable 1 1 ≤3 ≤4
All others ≤2 ≤3 ≤4 ≤5
Blastocysts
Euploid 1 1 1 1
Favorable 1 1 ≤2 ≤3
All others ≤2 ≤2 ≤3 ≤3
Reproduced from “Recommendations on the limits to the number of embryos to transfer: a committee opin-
ion” with permission [74]
17.3.12 Embryo Transfer Technique .. Table 17.2 Interventions that are supported
by the literature to improve pregnancy rates
Embryo transfer is the final, and one of the versus interventions without clear benefit [75]
most important, step in the process of
IVF. The basic steps of an embryo transfer Interventions supported Interventions have
by the literature for been shown not to be
include placing a speculum in the vagina,
improving pregnancy beneficial for
inserting a catheter into the uterus under rates improving pregnancy
ultrasound guidance versus blind placement, rates
and injecting the embryo in the upper or mid-
Abdominal ultrasound Acupuncture
dle third of the uterine cavity. The optimal
guidance for embryo Analgesics, massage,
technique for embryo transfer has been stud- transfer general anesthesia,
ied, as there is large variation in techniques. In Removal of cervical whole-systems
an effort to standardize the embryo transfer mucus traditional Chinese
process, the ASRM has published guidelines Use of soft embryo trans- medicine
fer catheters Prophylactic
and a standard embryo transfer protocol tem-
Placement of embryo antibiotics to improve
plate [75, 76]. transfer tip in the upper embryo transfer
. Table 17.2 summarizes various com- or middle (central) area outcomes
mon practice techniques and whether their of the uterine cavity, Waiting after
efficacy is supported by the literature. greater than 1 cm from expulsion of embryos
the fundus, for embryo for any specific period
17 expulsion of time before
Immediate ambulation withdrawing the
17.3.13 Cryopreservation once the embryo transfer embryo transfer
of Embryos procedure is completed catheter
Cryopreservation of embryos is now an inte-

gral aspect of modern ART. Cryopreservation plantation genetic testing (PGT) as results
allows for future use of the embryos that are typically take up to 2 weeks to return and is an
not being transferred in a fresh cycle and thus effective strategy to reduce the risk of ovarian
significantly increases cumulative pregnancy hyperstimulation syndrome (OHSS) [77].
rate per egg retrieval. Additionally, cryo- Cryopreservation has two main steps:
preservation is essential for cycles with preim- freezing and thawing/warming. Two cryo-
379 17
preservation methods are routinely used: the rier from individuals other than the intended
slow-freeze technique and vitrification. Slow- parent/parents, enables an infertile individual
freezing is the process of gradual decrease in or couple to become a parent/parents. Patients
temperature to −30° C to –110° C before stor- who are intending to use third-party repro-
age in liquid nitrogen. In the vitrification tech- duction will need to go through additional
nique, embryos are immersed in liquid testing and counseling, including a psycho-
nitrogen and are flash frozen following treat- logical evaluation. Because laws regarding
ment with high concentration cryoprotectants third-party reproduction are different from
[78]. The improvement obtained with the one state to another, all couples are advised to
introduction of verification has several impor- consult with an attorney knowledgeable in
tant clinical implications in ART. Vitrification reproductive and family law in their individ-
is associated with consistently higher embryo ual state(s). Additionally, potential donors
survival rates (90–100%) and yields higher and recipients should be made aware that laws
implantation and pregnancy rates compared may change and anonymity cannot be guar-
to slow-freezing protocols [79]. anteed for the future.
17.4 Special Considerations 17.4.3 Oocyte Donation
17.4.1 Disposition of Embryos The first pregnancy achieved with oocyte

donation was reported in 1984, 6 years after
Cryopreservation of embryos has produced the first human IVF baby [81]. Oocyte dona-
important legal, ethical, and practical consid- tion is now commonly utilized in IVF using
erations regarding the disposition of embryos. oocytes retrieved from a healthy young
The disposition of embryos must be clear donor after ovarian stimulation. Donor
before initiation of the IVF process and embryo oocytes may be obtained from a donor
creation. Generally, there are five choices for undergoing a fresh stimulation cycle or from
embryo disposition: warm and transfer for a cryobank. Following fertilization with the
intended parent’s pregnancy attempt, donate sperm of the recipient’s partner, an appro-
to another individual/couple, donate for priate number of the resulting embryos are
research (or clinical training), warm and dis- transferred to the uterus of the recipient.
card, and maintain indefinitely in cryostorage Oocyte donors may be anonymous or known
(this option is no longer typically offered). to the recipients. Fresh oocyte donors are
In particular, the wishes of a patient or cou- typically recruited through an agency or are
ple must be clear regarding the possible situa- a known friend or family member of the
tion of death of one or both of the intended intended parents.
parents, divorce, separation, failure to pay
storage charges, inability to agree on disposi-
tion in the future, or prolonged lack of contact 17.4.4 Indications for Oocyte
with the program. For this reason, the ASRM Donation
has a committee opinion dedicated to this sub-
ject, stating that programs should develop Oocyte donation is often used for women with
written policies to optimize disposition ovarian insufficiency, genetically transmitted
dilemma and reduce potential liabilities [80]. disease, significantly decreased ovarian
reserve, advanced reproductive age, and per-
sistent poor oocyte quality in prior IVF cycles
17.4.2 Third-Party Reproduction [82]. Oocyte donation is also an option for
single men or same-sex male couples who
Third-party reproduction, which is the use of choose to build their families through assisted
oocytes, sperm, embryos, or a gestational car- reproduction.
17.4.5 Evaluation of the Oocyte 17.4.6 Sperm Donation

Donor
Donor insemination has been practiced since
Donors, both anonymous and known, are the early 1900s. Sperm donation may also be
screened for eligibility with extensive testing used in the context of IVF. Current FDA and
according to FDA and ASRM guidelines [82]. ASRM guidelines recommend that in any
Psychological evaluation and counseling by a case of therapeutic sperm donation, the sperm
qualified mental health professional is strongly be quarantined for 6 months before being
recommended for the donor and her partner used, with FDA testing performed at the time
(if applicable). A complete personal, medical, of specimen collection and following the
and family history as well as their sexual and quarantine, as this decreases the risk of trans-
substance abuse history should be obtained. mission of communicable diseases such as
Oocyte donors should be of legal age and human immunodeficiency virus [83].
preferably between the ages of 21 and 34.
Proven fertility in the donor is desirable but
not required. Appropriate genetic screening 17.4.7 Indications for Sperm
should be performed based on ethnic back- Donation
ground and current recommendations.
In the USA, the Federal Drug In heterosexual couples, therapeutic donor
Administration (FDA) requires following sperm is indicated when severe male factor
tests be performed within 30 days of oocyte (azoospermia or severe oligospermia) exists
collection: and sperm cannot be successfully recovered
(a) HIV-1 antibody as well as nucleic acid test via invasive sperm retrieval methods. In addi-
(NAT) (spell out the first time listed) tion, sperm donation may be indicated in
(b) HIV-2 antibody cases of severe male factor infertility with his-
(c) Hepatitis C antibody and NAT tory of fertilization failure in prior IVF cycles
(d) Hepatitis B surface antigen or if the male partner is a carrier of a genetic
(e) Hepatitis B core antibody (IgG and IgM) disease [83]. Single women and same-sex
(f) Serologic test for syphilis female couples may choose to use sperm
(g) Neisseria gonorrhoeae and Chlamydia tra- donation to achieve pregnancy.
chomatis on urine or a swab obtained
from the cervix, urethral meatus, or
vagina 17.4.8 Evaluation of the Sperm
Donor
If all parties have satisfactory evaluations, the
fresh oocyte donor undergoes ovarian stimu- Similar to oocyte donation, the sperm donor
lation. The recipient’s uterus is typically pre- can be known or anonymous to the intended
pared with exogenous estrogen and parent/parents. ASRM recommends the
17 progesterone to receive the embryo(s). Many
regimens for endometrial preparation have
anonymous donors to be in the age range of
18–40 years. The ASRM also recommends
been described, and successful pregnancies that all donors be tested for communicable
have also been reported in natural cycles diseases similar to oocyte donors, although
where donor oocytes were used to create the the FDA requires that only anonymous
embryos. The use of donor oocytes for IVF donors be tested. A thorough medical history
consistently results in high pregnancy rates is reviewed, with focus on sexual history,
when young, healthy, fertile women donate genetic issues, or psychological factors that
their oocytes, with pregnancy rates from 51 to would preclude them from being donors. A
58% per IVF cycle [83]. semen analysis is performed, and a test sam-
381 17
ple will evaluate the post-freezing/thawing singleton live birth rate. Pregnancy or live
parameters. The sperm donor is again birth rates may be calculated as a percentage
screened for communicable diseases 6 months of per cycle starts, per retrieval, or per embryo
after the semen sample is frozen to ensure that transfer. This statistic for a specific fertility
the results of screening are negative [83]. clinic as well as cumulative national data can
be accessed on the Society for Assisted
Reproductive Technology (SART) website
17.4.9 Embryo Donation and is available to the public [84]. In the USA,
these data are collected on an annual basis
Embryo donation entails transfer of and reported by the CDC.
embryos created by infertile couples who . Table 17.3 highlights the most recent
underwent IVF previously to another infer- National Data Summary statistics for fresh
tile patient once they achieve a pregnancy cycles, cycles of previously frozen embryos,
and do not desire another pregnancy or have fresh and frozen donor oocyte, as well as fro-
other reasons for choosing not to use their zen donor embryo cycles. The recent SART
embryos. Indications include untreatable report is useful in that it notes the available
infertility or genetic disorders that involve data as well as limitations in the reporting
one or both of the partners. The evaluation process, such as cancelled cycles and delay to
process is similar to recipients of oocyte or having outcome data (e.g., in embryo banking
sperm donation. Pregnancy rates following and fertility preservation treatments).
embryo donation depends on a number of On the basis of long-term national data,
factors, such as age of the women at the time SART has also developed an online calculator
of the oocyte retrieval, the quality of the that provides individualized estimated chance
embryos, and the number of embryos trans- of live birth rate based on patient’s age, height,
ferred [83]. weight, and infertility diagnosis [75]. This
calculator also provides information on the
live birth rates and the chance of a multiple
17.4.10 Gestational Carriers birth (twins, triplets, or quadruplets) when
two embryos are transferred as well as cumu-
A gestational carrier is a woman who carries lative live birth rate following one, two, and
a pregnancy for the intended parent/parents. three fresh IVF cycles. It also provides esti-
It is both medically and emotionally complex mated success rates if a patient uses her own
and involves legal and ethical issues as well. oocytes versus donor oocytes.
Common indications include women who
lack a uterus (either due to congenital
absence or surgical removal), patients with 17.4.12 Potential Adverse
recurrent pregnancy loss related to uterine Outcomes
factor (such as severe Asherman syndrome),
or patients with a medical contraindication 17.4.12.1 Ovarian Hyperstimulation
to pregnancy [83]. Syndrome
One of the most serious side effects of con-
trolled ovarian stimulation is ovarian hyper-
17.4.11 IVF Outcomes stimulation syndrome (OHSS). The incidence
of mild to moderate OHSS is estimated to be
17.4.11.1 Success Rates 3–6% [85], while the severe form may occur in
IVF outcomes have improved throughout the 0.9–1.4% of all cycles [86]. The pathophysiol-
years since its introduction. Although many ogy of OHSS is not fully understood, but
endpoints have been used to express IVF suc- increased capillary permeability (as a result of
cess rates, the most common are clinical preg- hCG-induced vasoendothelial growth factor
nancy and live birth rates and, more recently, production) with the resulting third space
.. Table 17.3 Society for assisted reproductive technology 2016 live birth rates per intended retrievala [84]
Oocyte source Age of woman

<35 35–37 38–40 41–42 >42
Fresh, patient’s 40.5% 24% 15.5% 8% 3.2%

own oocytes
Frozen, patient’s 45.7% 37.5% 42.7% 37.9% 27.7%
own oocytes
Fresh, donor 54.6% (all ages)
oocytes
Frozen, donor 44.9% (all ages)
oocytes
Frozen, donor 42.7% (all ages)
embryo
aThe primary outcome is the outcome for the first embryo transfer following an oocyte retrieval (fresh or
frozen) within a year of the oocyte retrieval cycle start
fluid shift is its main feature. OHSS may be [87]. For patients who develop severe symp-
characterized as early onset (1–9 days after toms, hospitalization may be necessary for
oocyte retrieval, usually as a result of the hCG close fluid and electrolyte management, anti-
trigger) or late onset (10 or more days after emetics, anticoagulation, and occasionally
oocyte retrieval due to endogenous hCG pro- paracentesis [90].
duction if pregnancy occurs) [72]. Symptoms
can include increased ovarian size, nausea,
vomiting, bloating, accumulation of fluid in 17.4.13 isk of Cancer in Women
R
the abdomen, breathing difficulties, hemocon- Undergoing IVF
centration, and in the most severe cases,
venous thromboembolic disease, kidney fail- Infertility and nulliparity are risk factors for
ure, and death. Options to decrease the risk of breast, ovarian, and endometrial cancer [91].
OHSS include cycle cancellation, administra- Although some reports have suggested an
tion of the dopamine agonist, cabergoline, increased risk of cancer in patients who use
0.5 mg for 8 days following the trigger, coast- fertility medications, most recent studies have
ing (withholding the gonadotropins for reported no relationship between cancer and
1–3 days), GnRH antagonist “rescue” [87–89], ovarian stimulation in women who underwent
use of GnRH agonist only or dual trigger IVF treatment [92, 93]. Larger studies with
(GnRHa combined with low-dose hCG) in appropriate follow-up are needed to examine
17 GnRH antagonist cycles, and freeze-only the long-term effect that fertility medications
cycles [90]. The relative risk of severe compli- may have on cancer rates, although to date
cations is higher if pregnancy occurs, which is there are no compelling data.
why a fresh transfer is usually not performed
in patients at high risk. Mild or moderate
cases of OHSS may be managed outpatient
17.4.14 Obstetrical Complications
with supportive therapy that involves oral
hydration with electrolyte rich fluids, moder-
Pregnancies that occur through IVF are asso-
ate ambulation, with daily weight, abdominal
ciated with an increased risk of certain com-
circumference, and urinary output measure-
plications, including gestational hypertension,
ments while also monitoring liver and kidney
gestational diabetes, placental abnormalities,
function and assessing for hemoconcentration
383 17
preterm delivery, low birth weight, and con- of imprinting disorders, theoretically due to
genital malformations [94]. Some of these laboratory manipulations that occur during
risks may be related to the older age of women meiosis [96]. Because imprinting disorders are
undergoing IVF or the underlying cause of quite rare, a causal relationship with IVF is
subfertility. Some risks may also be due to the difficult to determine.
IVF procedure itself, although further studies Another important question is whether
are needed to determine whether these risks the ICSI procedure, in particular, affects the
are associated with the process of IVF per se risk of congenital malformations and long-
or rather the underlying cause of subfertility. term health of the offspring. The invasive
IVF also increases the risk of multiple gesta- nature of ICSI circumvents natural selection
tion pregnancy. SART data from 2017 mechanisms, and the ICSI process, as well as
reported that, of live births in women under the underlying related infertility conditions
35 years undergoing IVF with their own eggs, that lead to the need of ICSI, has raised con-
86.9% had a singleton birth, 12.8% had a twin cerns regarding this matter. There have been
birth, and 0.3% had triplets or more [9]. some reports of the possible increased risk of
Multiple gestation also imposes additional
congenital and urogenital malformations, epi-
risks of pregnancy, both to the patient and the genetic disorders, chromosomal abnormali-
offspring. ties, infertility, cancer, delayed psychological
and neurological development, and impaired
cardiometabolic profile compared with natu-
17.4.15 Risks to the Offspring rally conceived children [97, 98]. Taken
together, the literature suggests that infertile
Numerous studies have been conducted to couples may have a higher risk of having chil-
assess the overall health of children conceived dren with congenital malformations. It is
via IVF, and the majority of studies have been unclear whether the process of IVF itself
reassuring. A major problem with studies increases this risk. Indeed, if additional risk is
done thus far has been comparing a group of present, the effect size is small.
infertile couples with pregnancies achieved The vast majority of risks to the offspring
through IVF to a group of normally fertile are related to multiple gestation pregnancy
couples with unassisted conceptions. and preterm delivery and the comorbidities
Interestingly, a recent study has addressed this that are associated with prematurity. It has
issue [95]. This study compared health of chil- been shown that singletons conceived with
dren of fertile couples with children of subfer- IVF tend to be born slightly earlier than natu-
tile couples with and without ART treatment. rally conceived babies (39.1 weeks compared
Results from this study showed that prematu- to 39.5 weeks) and IVF twins are not born
rity was more common in subfertile couples earlier than naturally conceived twins. There
with or without ART treatments when com- may be a slight increase in low birth weight of
pared to fertile couples [95]. When stratified IVF singletons conceived following fresh
by gestational age (GA), infants of subfertile embryo transfer compared to naturally con-
mothers with or without ART were at greater ceived singletons [94].
risk for congenital malformations [95]. Monochorionic twinning occurs in
Additionally, when comparing infants born to approximately 2–3% of IVF pregnancies,
subfertile mothers without ART treatments, which is higher than the spontaneous rate of
infants born to ART-treated mothers were at 0.4% for in vivo conceptions [99]. This further
lower risk for being small for GA and having increases the risk to the pregnancy, as compli-
congenital malformations and cardiovascular cations such as twin-twin transfusion may
conditions and at higher risk for infectious occur (in up to 20% of monochorionic diam-
disease conditions [95]. niotic gestations) as well as umbilical cord
A number of studies also suggest that entanglement (in monochorionic monoamni-
ART may be associated with an increased risk otic gestations).
17.4.16 Controversies outcomes [104, 105]. In addition, it is not yet

clear which specific groups of patients might
17.4.16.1 Freeze-Only specifically benefit from the use of a freeze-
with Cryopreserved only versus fresh transfer.
Transfer Versus Fresh Data from a recent systematic review and
Embryo Transfer meta-analysis suggests that a significantly
higher probability of live birth occurs in high
As stated earlier, with the development and but not normal responders after FET when
refinement of vitrification techniques and compared to fresh embryo transfer [106]. A
improved embryo survival, the pregnancy cost-effective analysis performed alongside an
rates following frozen embryo transfer (FET) RCT, with the effectiveness measure being live
have approached, if not exceeded, fresh trans- birth rate, showed that there is low probability
fer. According to the most recent national of the freeze-only strategy being more cost-
SART report in 2016, the live birth rate fol- effective than fresh transfer for women, except
lowing FET was higher in all age groups than those with PCOS [107].
the corresponding rates following fresh Based on the available literature, common
embryo transfer among patients undergoing scenarios to consider implementing a freeze-
an autologous cycle [84]. Accordingly, there only strategy include patients at risk of OHSS,
has been a shift in practice toward favoring premature progesterone elevation (discussed
IVF with FET in the recent years the USA later), and in those undergoing PGT. Otherwise,
[100]. As FET has become more common, the use of FET for other clinical scenarios is
freeze-only protocols have emerged in which unlikely to offer meaningful improvements in
all good-quality embryos are electively frozen outcomes that outweigh the added cost of
and transferred in a later natural or medicated treatment.
cycle.
Improved outcomes resulted from FET are 17.4.16.2 Preimplantation Genetic
attributed to reduction in OHSS rates, allow- Testing
ing for preimplantation genetic testing (PGT) Preimplantation genetic testing (PGT)
of embryos, as well as overcoming embryo- involves the removal of one or more cells from
endometrial asynchrony, due to either delayed the dividing embryo to test for genetic con-
blastulation or premature progesterone eleva- tent. PGT is subdivided into PGT-M (for
tion. In addition, there is increasing evidence monogenic disorder), PGT-SR (structural
that FET may lead to more favorable perinatal rearrangements), and PGT-A (aneuploidy
and live birth outcomes, including a lower risk screening). For the purpose of this section, we
of preterm birth, low birth weight, placenta will focus on the clinical outcomes following
previa, and placental abruption. However, this embryo biopsy and selection with PGT-A.
may be at the cost of increased rates of pre- The high incidence of chromosomal
eclampsia, large for gestational age, and high abnormalities observed with increasing mater-
birth weight [101, 102]. The risk for these com- nal age is the major cause of miscarriage and
17 plications may be related to the method of IVF failure [84]. Most aneuploidies take place
endometrial preparation (i.e., natural cycle in the process of meiosis in the female partner
versus programed) [103]. It should be consid- and contribute to rapidly declining IVF suc-
ered that the use of a freeze-only strategy may cess and live birth rates in women over the age
be more expensive due to the costs of embryo of 35. In contrast, IVF cycles with the transfer
cryopreservation, endometrial priming, extra of a euploid embryo have similar implanta-
medication use, and ultrasound monitoring tion rates regardless of maternal age [84].
for FET. However, there is increasing evidence Thus, PGT-A has been proposed as a method
that in a planned freeze-only cycle, pituitary to select embryos with the highest potential of
suppression with progesterone in lieu of a ongoing implantation.
GnRH antagonist is more cost-effective by In contemporary IVF practice, trophecto-
approximately $2000 and with comparable derm biopsy with single nucleotide polymor-
385 17
phism (SNP) array, array comparative 17.4.16.3 Management
genomic hybridization (aCGH), quantitative of Prematurely Elevated
real-time polymerase chain reaction (qPCR), Progesterone in IVF Cycle
or next-generation sequencing (NGS) are rou- Despite the utilization of GnRH analogues
tinely used for aneuploidy detection. Several, and GnRH antagonists to suppress the pitu-
mainly single-center, RCTs performed in the itary and prevent ovulation, premature pro-
past decade have shown significant improve- gesterone elevation has been reported to still
ment in ongoing pregnancy rates per embryo occur in 5–38% of IVF cycles [112–115].
transfer procedure following PGT-A [108– Premature progesterone elevation can lead to
110]. However, data from a recent multicenter asynchrony between the embryo and the
randomized controlled trial (the STAR study) endometrium and thus adversely affect
demonstrated that the use of trophectoderm implantation rates [116–119]. In the late 1980s,
biopsy at the blastocyst stage and NGS-based Hamori et al. and Feldberg et al. first reported
PGT-A to select euploid embryos for single a concern of prematurely elevated progester-
vitrified-warmed blastocyst transfer signifi- one in IVF cycles leading to decreased preg-
cantly improved ongoing pregnancy rates and nancy rates [120, 121]. Shortly thereafter,
live birth rates per transfer in women aged Schoolcraft et al. and Fanchin et al. found
35–40 years, but not in women aged that a prematurely elevated progesterone level
25–34 years [111]. Additionally, there was no on the day of hCG trigger led to decreased
difference in outcomes in any age group on an pregnancy rates in IVF cycles [122, 123].
intent to treat basis. Furthermore, preliminary evidence continued
Possible explanations for the lack of to support that prematurely elevated proges-
improvement in outcomes following transfer terone levels on the day of hCG trigger led to
of euploid embryos in the STAR trial include decreased pregnancy rates as demonstrated by
the following: (1) trophectoderm biopsy may Bosch et al. (>4000 IVF cycles) using a pro-
reduce an embryo’s potential for implantation gesterone threshold of 1.5 ng/mL [114] and
more than previously realized, or (2) testing Xu et al. (>10,000 IVF cycles) [124] using a
results from the trophectoderm may not be progesterone threshold of 1.75 ng/mL and
representative of the embryo as a whole, thus confirmed by a large meta-analysis by Venetis
resulting in discarding embryos that have the et al. (>60,000 IVF cycles) [125].
potential for pregnancy due to being deemed Recently, several studies have clearly
abnormal. PGT is inherently imperfect. It is shown that a progesterone level using thresh-
an invasive procedure, and errors may occur olds of 1.5 and 2.0 ng/mL on the day of trig-
during the genetic analysis of a small amount ger leads to decreased pregnancy rates, and a
of DNA collected. This may lead to indeter- freeze-all approach of the embryos should be
minate results or, in some instances, discard- considered without performing a fresh embryo
ing of a normal embryo following erroneous transfer [126–130]. Although the evidence
abnormal results. More importantly, finding supports that premature progesterone eleva-
trophectoderm mosaicism with limited data tion decreases pregnancy rates, the definition
on implantation potential may create more of the progesterone threshold has not been
questions than answers and lead to lengthy clearly defined and has changed over the years
consultation with the patient (and a genetic [104]. A publication by Hill et al. performed a
counselor) on whether to consider those threshold and cost analysis of 7608 IVF cycles
embryos for transfer [112]. Ultimately, it is demonstrating that freezing embryos in lieu
important to counsel patients about the use of of a fresh embryo transfer is cost-effective, if
PGT and its clinical efficacy in an individual- the progesterone on the day of trigger is
ized manner regarding potential benefits and 1.5 ng/mL or above, with a number needed to
cost-effectiveness of PGT in a case-by-case treat of 13 [131]. At these thresholds, elevated
basis rather than a universal approach.
progesterone on the day of trigger showed a References

decrease in live birth rate of up to 20% when
the progesterone was at 2.0 ng/mL on the day 1. Practice Committee of the American Society for
of trigger. In conclusion, an elevated proges- Reproductive M. Definitions of infertility and
recurrent pregnancy loss: a committee opinion.
terone on the day of trigger demonstrates a
Fertil Steril. 2013;99(1):63.
clinically significant negative impact in IVF 2. Zegers-Hochschild F, et al. International
cycles, and those at risk for fresh transfer fail- Committee for Monitoring Assisted
ure should be counseled of the risks versus Reproductive Technology (ICMART) and the
benefits in proceeding with a transfer. World Health Organization (WHO) revised glos-
sary of ART terminology, 2009. Fertil Steril.
2009;92(5):1520–4.
3. Eisenberg ML, et al. Relationship between semen
17.5 Review Questions production and medical comorbidity. Fertil
Steril. 2015;103(1):66–71.
??1. About what percentage of US couples 4. Kurabayashi T, et al. Ovarian infertility is associ-
ated with cardiovascular disease risk factors in
have impaired fertility?
later life: a Japanese cross-sectional study.
A. 10% Maturitas. 2016;83:33–9.
B. 12% 5. Meczekalski B, et al. Functional hypothalamic
C. More than 25% amenorrhea and its influence on women’s health.
D. Less than 5% J Endocrinol Investig. 2014;37(11):1049–56.
6. Tobias DK, et al. History of infertility and risk of
??2. What is the recommended number of
type 2 diabetes mellitus: a prospective cohort
cleavage stage embryos to be trans- study. Diabetologia. 2015;58(4):707–15.
ferred in a 34-year-old female? 7. Chandra A, Copen CE, Stephen EH. Infertility
A. 2 and impaired fecundity in the United States,
B. 3 or less 1982–2010: data from the National Survey of
Family Growth. Natl Health Stat Report.
C. 1
2013(67):1–18, 1 p following 19.
D. Up to 4 8. Chandra A, Copen CE, Stephen EH. Infertility
??3. Which of the following obstetrical com- service use in the United States: data from the
plications has not been associated with National Survey of Family Growth, 1982-2010.
IVF? Natl Health Stat Report. 2014;73:1–21.
9. Society for Assisted Reproductive Technology.
A. Gestational hypertension
SART national summary report 2017. 2017;
B. Abnormalities of the placenta Available from: https://www.sartcorsonline.com/
C. Low birth weight rptCSR_PublicMultYear.aspx?ClinicPKID=0.
D. Oligohydramnios 10. Sonmezer M, et al. Random-start controlled
??4. Which of the following is not the role ovarian hyperstimulation for emergency fertility
preservation in letrozole cycles. Fertil Steril.
of GnRH analogues in ovarian stimula-
2011;95(6):2125 e9-11.
tion protocols? 11. Cakmak H, et al. Effective method for emergency
A. Prevention of OHSS fertility preservation: random-start controlled
B. Induction of oocyte maturation ovarian stimulation. Fertil Steril.
C. Prevention of premature ovulation 2013;100(6):1673–80.
17 D. Improving oocyte quality 12. Hull MG, et al. Delayed conception and active
and passive smoking. The Avon Longitudinal
Study of Pregnancy and Childhood Study Team.
Fertil Steril. 2000;74(4):725–33.
17.6 Answer 13. Mueller BA, et al. Recreational drug use and the
risk of primary infertility. Epidemiology.
1990;1(3):195–200.
vv1. B
14. Mumford SL, et al. Cannabis use while trying to
conceive: a prospective cohort study evaluating
vv2. C associations with fecundability, live birth and
pregnancy loss. Hum Reprod; 2021;36(5):
vv3. D 1405−15.
15. Payne KS, et al. Cannabis and male fertility: a
systematic review. J Urol. 2019;202(4):674–81.
vv4. D
387 17
16. Klonoff-Cohen H, Lam-Kruglick P, Gonzalez 31. Taylor PN, et al. TSH levels and risk of miscar-
C. Effects of maternal and paternal alcohol con- riage in women on long-term levothyroxine: a
sumption on the success rates of in vitro fertiliza- community-based study. J Clin Endocrinol
tion and gamete intrafallopian transfer. Fertil Metab. 2014;99(10):3895–902.
Steril. 2003;79(2):330–9. 32. Thyroid disease in pregnancy: ACOG practice
17. Caan B, Quesenberry CP Jr, Coates bulletin, number 223. Obstet Gynecol.
AO. Differences in fertility associated with caf- 2020;135(6):e261–74.
feinated beverage consumption. Am J Public 33. Hillier SG. Paracrine control of follicular estro-
Health. 1998;88(2):270–4. gen synthesis. Semin Reprod Endocrinol.
18. Cnattingius S, et al. Caffeine intake and the risk 1991;9(4):332–40.
of first-trimester spontaneous abortion. N Engl J 34. Santi D, et al. Efficacy of follicle-stimulating hor-
Med. 2000;343(25):1839–45. mone (FSH) alone, FSH + luteinizing hormone,
19. Hussein N, et al. Preconception risk assessment human menopausal gonadotropin or FSH +
for thalassaemia, sickle cell disease, cystic fibrosis human chorionic gonadotropin on assisted repro-
and Tay-Sachs disease. Cochrane Database Syst ductive technology outcomes in the “personal-
Rev. 2018;3:CD010849. ized” medicine era: a meta-analysis. Front
20. Society for Assisted Reproductive Technology. Endocrinol (Lausanne). 2017;8:114.
Patient Evaluation. 2021; Available from: https:// 35. Werner MD, et al. Defining the “sweet spot” for
www.sart.org/patients/sart-patient-evaluation/. administered luteinizing hormone-to-follicle-
21. Practice Committee of the American Society for stimulating hormone gonadotropin ratios during
Reproductive Medicine. Electronic address, a.a.o. ovarian stimulation to protect against a clinically
and M. Practice Committee of the American significant late follicular increase in progesterone:
Society for Reproductive. Testing and interpret- an analysis of 10,280 first in vitro fertilization
ing measures of ovarian reserve: a committee cycles. Fertil Steril. 2014;102(5):1312–7.
opinion. Fertil Steril. 2020;114(6):1151–7. 36. Farquhar C, et al. Oral contraceptive pill, proges-
22. Verhagen TE, et al. The accuracy of multivariate togen or oestrogen pretreatment for ovarian stim-
models predicting ovarian reserve and pregnancy ulation protocols for women undergoing assisted
after in vitro fertilization: a meta-analysis. Hum reproductive techniques. Cochrane Database Syst
Reprod Update. 2008;14(2):95–100. Rev. 2017;5:CD006109.
23. Soares SR, Barbosa dos Reis MM, Camargos 37. Montoya-Botero P, et al. The effect of type of
AF. Diagnostic accuracy of sonohysterography, oral contraceptive pill and duration of use on
transvaginal sonography, and hysterosalpingog- fresh and cumulative live birth rates in IVF/ICSI
raphy in patients with uterine cavity diseases. cycles. Hum Reprod. 2020;35(4):826–36.
Fertil Steril. 2000;73(2):406–11. 38. Schmitz C, et al. Does the degree of hypothalamic-
24. Practice Committee of the American Society for pituitary-ovarian recovery after oral contracep-
Reproductive M. Diagnostic evaluation of the tive pills affect outcomes of IVF/ICSI cycles
infertile female: a committee opinion. Fertil receiving GnRH-antagonist adjuvant therapy in
Steril. 2015;103(6):e44–50. women over 35 years of age? J Assist Reprod
25. Schlegel PN, et al. Diagnosis and treatment of Genet. 2012;29(9):877–82.
infertility in men: AUA/ASRM guideline part 39. Tarlatzis BC, et al. Clinical management of low
II. Fertil Steril. 2021;115(1):62–9. ovarian response to stimulation for IVF: a sys-
26. Zeyneloglu HB, Arici A, Olive DL. Adverse tematic review. Hum Reprod Update.
effects of hydrosalpinx on pregnancy rates after 2003;9(1):61–76.
in vitro fertilization-embryo transfer. Fertil Steril. 40. Alexander VM, et al. Ovarian stimulation for fer-
1998;70(3):492–9. tility preservation in women with cancer: a sys-
27. Camus E, et al. Pregnancy rates after in-vitro fer- tematic review and meta-analysis comparing
tilization in cases of tubal infertility with and random and conventional starts. J Gynecol
without hydrosalpinx: a meta-analysis of pub- Obstet Hum Reprod. 2021;50(8):102080.
lished comparative studies. Hum Reprod. 41. Porter RN, et al. Induction of ovulation for in-
1999;14(5):1243–9. vitro fertilisation using buserelin and gonadotro-
28. Melo P, et al. Surgical treatment for tubal disease pins. Lancet. 1984;2(8414):1284–5.
in women due to undergo in vitro fertilisation. 42. Kumar P, Sharma A. Gonadotropin-releasing
Cochrane Database Syst Rev. 2020;10:CD002125. hormone analogs: understanding advantages and
29. Sagoskin AW, et al. Salpingectomy or proximal limitations. J Hum Reprod Sci. 2014;7(3):170–4.
tubal occlusion of unilateral hydrosalpinx 43. Padilla SL, et al. Use of the flare-up protocol with
increases the potential for spontaneous preg- high dose human follicle stimulating hormone
nancy. Hum Reprod. 2003;18(12):2634–7. and human menopausal gonadotropins for
30. Hollowell JG Jr, Garbe PL, Miller DT. Maternal in vitro fertilization in poor responders. Fertil
thyroid deficiency during pregnancy and subse- Steril. 1996;65(4):796–9.
quent neuropsychological development of the 44. Pandian Z, et al. Interventions for ‘poor respond-
child. N Engl J Med. 1999;341(26):2016–7. ers’ to controlled ovarian hyper stimulation
(COH) in in-vitro fertilisation (IVF). Cochrane is used for triggering final oocyte maturation
Database Syst Rev. 2010;1:CD004379. instead of HCG in patients undergoing IVF with
45. Xiao J, Chang S, Chen S. The effectiveness of GnRH antagonists. Hum Reprod.
gonadotropin-releasing hormone antagonist in 2005;20(10):2887–92.
poor ovarian responders undergoing in vitro fer- 59. Haahr T, et al. GnRH agonist trigger and LH
tilization: a systematic review and meta-analysis. activity luteal phase support versus hCG trigger
Fertil Steril. 2013;100(6):1594–601 e1–9. and conventional luteal phase support in fresh
46. Pu D, Wu J, Liu J. Comparisons of GnRH antag- embryo transfer IVF/ICSI cycles-a systematic
onist versus GnRH agonist protocol in poor PRISMA review and meta-analysis. Front
ovarian responders undergoing IVF. Hum Endocrinol (Lausanne). 2017;8:116.
Reprod. 2011;26(10):2742–9. 60. Yilmaz N, et al. GnRH agonist versus HCG trig-
47. Maggi R, et al. GnRH and GnRH receptors in gering in different IVF/ICSI cycles of same
the pathophysiology of the human female repro- patients: a retrospective study. J Obstet Gynaecol.
ductive system. Hum Reprod Update. 2020;40(6):837–42.
2016;22(3):358–81. 61. Haas J, et al. GnRH agonist and hCG (dual trig-
48. Olivennes F, et al. The use of GnRH antagonists ger) versus hCG trigger for final follicular matu-
in ovarian stimulation. Hum Reprod Update. ration: a double-blinded, randomized controlled
2002;8(3):279–90. study. Hum Reprod. 2020;35(7):1648–54.
49. Barmat LI, et al. A randomized prospective trial 62. Ehrenreich H, Goebel FD. The role of opioids in
comparing gonadotropin-releasing hormone the endocrine function of the pancreas. Diabetes
(GnRH) antagonist/recombinant follicle- Res. 1986;3(2):59–66.
stimulating hormone (rFSH) versus GnRH- 63. Li S, et al. Dual trigger of triptorelin and HCG
agonist/rFSH in women pretreated with oral optimizes clinical outcome for high ovarian
contraceptives before in vitro fertilization. Fertil responder in GnRH-antagonist protocols.
Steril. 2005;83(2):321–30. Oncotarget. 2018;9(4):5337–43.
50. Kolibianakis EM, et al. Fixed versus flexible gonad- 64. Practice Committee of American Society for
otropin-releasing hormone antagonist administra- Reproductive M. Intracytoplasmic sperm injection
tion in in vitro fertilization: a randomized controlled (ICSI). Fertil Steril. 2008;90(5 Suppl):S187.
trial. Fertil Steril. 2011;95(2):558–62. 65. Practice Committees of the American Society for
51. Escudero E, et al. Comparison of two different Reproductive M. and a.a.o. the Society for
starting multiple dose gonadotropin-releasing Assisted Reproductive Technology. Electronic
hormone antagonist protocols in a selected group address, Intracytoplasmic sperm injection (ICSI)
of in vitro fertilization-embryo transfer patients. for non-male factor indications: a committee
Fertil Steril. 2004;81(3):562–6. opinion. Fertil Steril. 2020;114(2):239–45.
52. Lambalk CB, et al. GnRH antagonist versus long 66. Johnson LN, et al. Does intracytoplasmic sperm
agonist protocols in IVF: a systematic review and injection improve the fertilization rate and
meta-analysis accounting for patient type. Hum decrease the total fertilization failure rate in cou-
Reprod Update. 2017;23(5):560–79. ples with well-defined unexplained infertility? A
53. Youssef MA, Abou-Setta AM, Lam WS. systematic review and meta-analysis. Fertil Steril.
Recombinant versus urinary human chorionic 2013;100(3):704–11.
gonadotrophin for final oocyte maturation trig- 67. Practice Committee of the American Society for
gering in IVF and ICSI cycles. Cochrane Database Reproductive M. Progesterone supplementation
Syst Rev. 2016;4:CD003719. during the luteal phase and in early pregnancy in
54. Casper RF. Basic understanding of gonadotropin- the treatment of infertility: an educational bulle-
releasing hormone-agonist triggering. Fertil tin. Fertil Steril. 2008;89(4):789–92.
Steril. 2015;103(4):867–9. 68. Devine K, et al. Vitrified blastocyst transfer
17 55. Turkgeldi E, et al. Gonadotropin-releasing hor-

mone agonist triggering of oocyte maturation in
cycles with the use of only vaginal progesterone
replacement with Endometrin have inferior ongo-
assisted reproductive technology cycles. Turk J ing pregnancy rates: results from the planned
Obstet Gynecol. 2015;12(2):96–101. interim analysis of a three-arm randomized con-
56. Wang TH, et al. Human chorionic gonadotropin- trolled noninferiority trial. Fertil Steril.
induced ovarian hyperstimulation syndrome is 2018;109(2):266–75.
associated with up-regulation of vascular endo- 69. Pan SP, et al. Early stop of progesterone supple-
thelial growth factor. J Clin Endocrinol Metab. mentation after confirmation of pregnancy in
2002;87(7):3300–8. IVF/ICSI fresh embryo transfer cycles of poor
57. Humaidan P, et al. GnRH agonist (buserelin) or responders does not affect pregnancy outcome.
hCG for ovulation induction in GnRH antagonist PLoS One. 2018;13(8):e0201824.
IVF/ICSI cycles: a prospective randomized study. 70. Shoham G, Leong M, Weissman A. A 10-year
Hum Reprod. 2005;20(5):1213–20. follow-up on the practice of luteal phase support
58. Kolibianakis EM, et al. A lower ongoing preg- using worldwide web-based surveys. Reprod Biol
nancy rate can be expected when GnRH agonist Endocrinol. 2021;19(1):15.
389 17
71. van der Linden M, et al. Luteal phase support for 85. Delvigne A, Rozenberg S. Epidemiology and pre-
assisted reproduction cycles. Cochrane Database vention of ovarian hyperstimulation syndrome
Syst Rev. 2015;7:CD009154. (OHSS): a review. Hum Reprod Update.
72. Jerome S, Robert B. Medical approaches to ovar- 2002;8(6):559–77.
ian stimulation for infertility. In: Yen & Jaffe’s 86. Tomas C, et al. Annual incidence of severe ovar-
reproductive endocrinology. Elsevier; 2018. ian hyperstimulation syndrome. Dan Med J.
73. Stillman RJ, et al. Elective single embryo transfer: 2021;68(2):A12190738.
a 6-year progressive implementation of 784 single 87. Gustofson RL, Segars JH, Larsen FW. Ganirelix
blastocyst transfers and the influence of payment acetate causes a rapid reduction in estradiol levels
method on patient choice. Fertil Steril. without adversely affecting oocyte maturation in
2009;92(6):1895–906. women pretreated with leuprolide acetate who are
74. Practice Committee of the American Society for at risk of ovarian hyperstimulation syndrome.
Reproductive Medicine. Electronic address, Hum Reprod. 2006;21(11):2830–7.
A.a.o. and T. Practice Committee of the Society 88. Aboulghar MA, et al. A prospective randomized
for Assisted Reproductive, Guidance on the limits study comparing coasting with GnRH antagonist
to the number of embryos to transfer: a commit- administration in patients at risk for severe
tee opinion. Fertil Steril. 2017;107(4):901–3. OHSS. Reprod Biomed Online. 2007;15(3):271–9.
75. Practice Committee of the American Society for 89. Hill MJ, et al. GnRH antagonist rescue in high
Reproductive Medicine. Electronic address, responders at risk for OHSS results in excellent
A.a.o. and M. Practice Committee of the assisted reproduction outcomes. Reprod Biomed
American Society for Reproductive, Performing Online. 2012;25(3):284–91.
the embryo transfer: a guideline. Fertil Steril. 90. Practice Committee of the American Society for
2017;107(4):882–96. Reproductive Medicine. Electronic address,
76. Practice Committee of the American Society for A.a.o. and M. Practice Committee of the
Reproductive Medicine. Electronic address, American Society for Reproductive, Prevention
A.a.o., et al. ASRM standard embryo transfer and treatment of moderate and severe ovarian
protocol template: a committee opinion. Fertil hyperstimulation syndrome: a guideline. Fertil
Steril. 2017;107(4):897–900. Steril. 2016;106(7):1634–47.
77. D’Angelo A, Amso N. Embryo freezing for pre- 91. Britt K, Short R. The plight of nuns: hazards of
venting ovarian hyperstimulation syndrome. nulliparity. Lancet. 2012;379(9834):2322–3.
Cochrane Database Syst Rev. 2007;3:CD002806. 92. van den Belt-Dusebout AW, et al. Ovarian stimu-
78. Kuwayama M. Highly efficient vitrification for lation for in vitro fertilization and long-term risk
cryopreservation of human oocytes and embryos: of breast cancer. JAMA. 2016;316(3):300–12.
the Cryotop method. Theriogenology. 93. Yli-Kuha AN, et al. Cancer morbidity in a cohort
2007;67(1):73–80. of 9175 Finnish women treated for infertility.
79. Rienzi L, et al. Oocyte, embryo and blastocyst Hum Reprod. 2012;27(4):1149–55.
cryopreservation in ART: systematic review and 94. Hayashi M, et al. Adverse obstetric and perinatal
meta-analysis comparing slow-freezing versus vit- outcomes of singleton pregnancies may be related
rification to produce evidence for the develop- to maternal factors associated with infertility
ment of global guidance. Hum Reprod Update. rather than the type of assisted reproductive tech-
2017;23(2):139–55. nology procedure used. Fertil Steril.
80. Ethics Committee of the American Society for 2012;98(4):922–8.
Reproductive M. Disposition of abandoned 95. Hwang SS, et al. Health of infants after ART-
embryos: a committee opinion. Fertil Steril. treated, subfertile, and fertile deliveries. Pediatrics.
2013;99(7):1848–9. 2018;142(2):e20174069.
81. Lutjen P, et al. The establishment and mainte- 96. Hattori H, et al. Association of four imprinting
nance of pregnancy using in vitro fertilization disorders and ART. Clin Epigenetics.
and embryo donation in a patient with primary 2019;11(1):21.
ovarian failure. Nature. 1984;307(5947):174–5. 97. Massaro PA, et al. Does intracytoplasmic sperm
82. Practice Committee of the American Society for injection pose an increased risk of genitourinary
Reproductive M. and T. the Practice Committee congenital malformations in offspring compared
of the Society for Assisted Reproductive, to in vitro fertilization? A systematic review and
Recommendations for gamete and embryo dona- meta-analysis. J Urol. 2015;193(5 Suppl):1837–42.
tion: a committee opinion. Fertil Steril. 98. Tararbit K, et al. The risk for four specific con-
2013;99(1):47–62 e1. genital heart defects associated with assisted
83. Myers ER. Outcomes of donor oocyte cycles in reproductive techniques: a population-based
assisted reproduction. JAMA. 2013;310(22):2403–4. evaluation. Hum Reprod. 2013;28(2):367–74.
84. Centers for Disease Control and Prevention. 2014 99. Busnelli A, et al. Risk factors for monozygotic
assisted reproductive technology national sum- twinning after in vitro fertilization: a systematic
mary report. US Dept of Health and Human review and meta-analysis. Fertil Steril.
Services. 2016. 2019;111(2):302–17.
100. Shapiro BS, et al. Clinical rationale for cryo- 112. Viotti M, et al. Using outcome data from one
preservation of entire embryo cohorts in lieu of thousand mosaic embryo transfers to formulate
fresh transfer. Fertil Steril. 2014;102(1):3–9. an embryo ranking system for clinical use. Fertil
101. Maheshwari A, et al. Is frozen embryo transfer Steril. 2021;115(5):1212–24.
better for mothers and babies? Can cumulative 113. Silverberg KM, et al. Elevated serum progester-
meta-analysis provide a definitive answer? Hum one levels on the day of human chorionic gonad-
Reprod Update. 2018;24(1):35–58. otropin administration in in vitro fertilization
102. Maheshwari A, Raja EA, Bhattacharya cycles do not adversely affect embryo quality.
S. Obstetric and perinatal outcomes after either Fertil Steril. 1994;61(3):508–13.
fresh or thawed frozen embryo transfer: an analy- 114. Bosch E, et al. Circulating progesterone levels
sis of 112,432 singleton pregnancies recorded in and ongoing pregnancy rates in controlled ovar-
the Human Fertilisation and Embryology ian stimulation cycles for in vitro fertilization:
Authority anonymized dataset. Fertil Steril. analysis of over 4000 cycles. Hum Reprod.
2016;106(7):1703–8. 2010;25(8):2092–100.
103. Ginstrom Ernstad E, et al. Neonatal and mater- 115. Edelstein MC, et al. Progesterone levels on the day
nal outcome after frozen embryo transfer: of human chorionic gonadotropin administration
increased risks in programmed cycles. Am J in cycles with gonadotropin-releasing hormone
Obstet Gynecol. 2019;221(2):126 e1–126 e18. agonist suppression are not predictive of preg-
104. Evans MB, et al. Adverse effect of prematurely nancy outcome. Fertil Steril. 1990;54(5):853–7.
elevated progesterone in in vitro fertilization 116. Van Vaerenbergh I, et al. Progesterone rise on
cycles: a literature review. Biol Reprod. HCG day in GnRH antagonist/rFSH stimulated
2018;99(1):45–51. cycles affects endometrial gene expression.
105. Giles J, et al. Medroxyprogesterone acetate is a Reprod Biomed Online. 2011;22(3):263–71.
useful alternative to a gonadotropin-releasing 117. Li R, et al. MicroRNA array and microarray
hormone antagonist in oocyte donation: a ran- evaluation of endometrial receptivity in patients
domized, controlled trial. Fertil Steril. with high serum progesterone levels on the day of
2021;116(2):404−12. hCG administration. Reprod Biol Endocrinol.
106. Bosdou JK, et al. Higher probability of live-birth 2011;9:29.
in high, but not normal, responders after first fro- 118. Labarta E, et al. Endometrial receptivity is
zen-embryo transfer in a freeze-only cycle strategy affected in women with high circulating proges-
compared to fresh-embryo transfer: a meta-analy- terone levels at the end of the follicular phase: a
sis. Hum Reprod. 2019;34(3):491–505. functional genomics analysis. Hum Reprod.
107. Le KD, et al. A cost-effectiveness analysis of 2011;26(7):1813–25.
freeze-only or fresh embryo transfer in IVF of 119. Shulman A, et al. The significance of an early
non-PCOS women. Hum Reprod. (premature) rise of plasma progesterone in
2018;33(10):1907–14. in vitro fertilization cycles induced by a “long
108. Rubio C, et al. In vitro fertilization with preim- protocol” of gonadotropin releasing hormone
plantation genetic diagnosis for aneuploidies in analogue and human menopausal gonadotropins.
advanced maternal age: a randomized, controlled J Assist Reprod Genet. 1996;13(3):207–11.
study. Fertil Steril. 2017;107(5):1122–9. 120. Feldberg D, et al. The impact of high progester-
109. Scott RT Jr, et al. Blastocyst biopsy with compre- one levels in the follicular phase of in vitro fertil-
hensive chromosome screening and fresh embryo ization (IVF) cycles: a comparative study. J In
transfer significantly increases in vitro fertiliza- Vitro Fert Embryo Transf. 1989;6(1):11–4.
tion implantation and delivery rates: a random- 121. Hamori M, et al. Premature luteinization of fol-
ized controlled trial. Fertil Steril. licles during ovarian stimulation for in-vitro fer-
2013;100(3):697–703. tilization. Hum Reprod. 1987;2(8):639–43.
17 110. Harton GL, et al. Diminished effect of maternal

age on implantation after preimplantation
122. Fanchin R, et al. Premature progesterone eleva-
tion spares blastulation but not pregnancy rates
genetic diagnosis with array comparative in in vitro fertilization with coculture. Fertil
genomic hybridization. Fertil Steril. 2013;100(6): Steril. 1997;68(4):648–52.
1695–703. 123. Schoolcraft W, et al. Lower pregnancy rate with
111. Munne S, et al. Preimplantation genetic testing premature luteinization during pituitary suppres-
for aneuploidy versus morphology as selection sion with leuprolide acetate. Fertil Steril.
criteria for single frozen-thawed embryo transfer 1991;55(3):563–6.
in good-prognosis patients: a multicenter ran- 124. Xu B, et al. Serum progesterone level effects on
domized clinical trial. Fertil Steril. the outcome of in vitro fertilization in patients
2019;112(6):1071–1079 e7. with different ovarian response: an analysis of
391 17
more than 10,000 cycles. Fertil Steril. abortion rates in fresh and subsequent frozen
2012;97(6):1321–7.e1–4. embryo transfers? Gynecol Endocrinol.
125. Venetis CA, et al. Progesterone elevation and 2017;33(6):472–5.
probability of pregnancy after IVF: a systematic 129. Hill MJ, et al. Does elevated progesterone on day
review and meta-analysis of over 60 000 cycles. of oocyte maturation play a role in the racial dis-
Hum Reprod Update. 2013;19(5):433–57. parities in IVF outcomes? Reprod Biomed Online.
126. Healy MW, et al. Does a frozen embryo transfer 2017;34(2):154–61.
ameliorate the effect of elevated progesterone 130. Connell MT, et al. Is the effect of premature ele-
seen in fresh transfer cycles? Fertil Steril. vated progesterone augmented by human chori-
2016;105(1):93–9.e1. onic gonadotropin versus gonadotropin-releasing
127. Hill MJ, et al. Are good patient and embryo char- hormone agonist trigger? Fertil Steril.
acteristics protective against the negative effect of 2016;106(3):584–589.e1.
elevated progesterone level on the day of oocyte 131. Hill MJ, et al. Defining thresholds for abnormal
maturation? Fertil Steril. 2015;103(6):1477–84. premature progesterone levels during ovarian
e1–5. stimulation for assisted reproduction technolo-
128. Healy M, et al. Does premature elevated progester- gies. Fertil Steril. 2018;110(4):671–679.e2.
one on the day of trigger increase spontaneous
393 18
ART: Laboratory Aspects

Charles L. Bormann
Contents
18.2 Oocyte Assessment – 395
18.3 In Vitro Maturation – 396
18.4 permatozoa Collection, Evaluation, and

S
Processing – 397
18.5 Sperm Isolation for IVF and ICSI – 397
18.6 In Vitro Fertilization (IVF) – 398

18.6.1 onventional Insemination – 398
C
18.6.2 Intracytoplasmic Sperm Injection (ICSI) – 398
18.6.3 Fertilization Assessment – 399
18.6.4 Embryo Assessment – 399
18.6.5 Time-Lapse Imaging – 401
18.6.6 Assisted Hatching – 401
18.6.7 Preimplantation Genetic Testing – 402
18.6.8 Embryo Biopsy – 402
18.6.9 Cryopreservation – 402
18.6.10 Slow-Rate Freezing – 403
18.6.11 Vitrification – 403
18.6.12 Artificial Intelligence in the IVF Laboratory – 403
18.6.13 Laboratory and Media Preparation – 404
18.6.14 Culture Conditions – 405
18.7 Monitoring Clinical Outcomes – 405

https://doi.org/10.1007/978-3-030-99596-6_18
18.8 Future Directions – 406
18.10 Answers – 407
References – 407
395 18
Robert G. Edwards combined John’s sperm
Key Points with the oocyte in the laboratory, and the
55 Proper assessment, processing, and resulting embryo was placed into Lesley’s
handling of gametes are essential to uterus a few days later. On July 25, 1978,
attain normal fertilization and high- Louise Joy Brown was delivered by cesarean
quality embryo development. section at approximately 37 weeks of gesta-
55 Many of the clinically relevant results tion and weighed 5 lb., 12 oz. In 2010, 32 years
reported from the IVF laboratory are later, Robert G. Edwards was awarded the
largely based on visual morphologic Nobel Prize for Physiology or Medicine “for
assessments which can be highly subjec- the development of IVF.” Today, most IVF is
tive. performed after ovarian stimulation so that
55 Technologies such as preimplantation multiple eggs can be retrieved transvaginally
genetic testing for aneuploidy, time- with a sonographically guided needle, fol-
lapse imaging, and artificial intelligence lowed by transcervical embryo transfer.
have been used as methods to select Currently, more than 300,000 cycles of
high-quality embryos for transfer. human IVF and similar techniques are per-
55 A well-established quality management formed each year in the United States, result-
plan is essential for monitoring the per- ing in the birth of over 80,000 babies.
formance of laboratory procedures and Far-reaching advances in laboratory tech-
maintaining optimal embryo culture niques and culture conditions have been made
conditions. since 1978, when the first IVF baby was born
in England. Today, ART procedures are
responsible for over 2% of all children born in
the United States annually [4].
18.1 Introduction
The concept of IVF as a treatment for infertil- Case Vignette

ity is straightforward: obtain eggs from the
ovaries, mix them with sperm in a dish con- ART Laboratory- A 30-year-old woman
taining culture medium, and transfer the eggs with polycystic ovary syndrome has under-
back to the woman after fertilization has gone IVF. She had 25 oocytes retrieved of
occurred. However, this technique took over which 5 fertilized normally and only 2
100 years to develop. The initial development embryos made it to the blastocyst stage for
of IVF in humans can be attributed directly to transfer.
a team of two investigators, Drs. Patrick
Steptoe and Robert Edwards. It was in 1969
that Dr. Edwards first stated, “Human oocytes 18.2 Oocyte Assessment
have been matured and fertilized by sperma-
tozoa in vitro. There may be certain clinical Mammalian oocytes are maintained in mei-
and scientific uses for human eggs fertilized by otic arrest throughout most of follicular
this procedure” [1]. This understated conclu- development; the resumption of meiosis I
sion marked the first successful attempt to fer- (MI) is induced by the preovulatory surge of
tilize human eggs in a laboratory. LH, which is emulated during an IVF cycle by
In 1959, successful IVF was reported using administration of hCG. Retrieval of oocytes
rabbits [2]. The first human birth to result is generally performed 34–36 h after adminis-
from IVF was achieved in England in 1978 [3]. tration of hCG in order to allow adequate
John and Lesley Brown had 9 years of infertil- time for oocyte maturation and to avoid pre-
ity secondary to bilateral fallopian tube mature ovulation. During the oocyte retrieval,
obstruction. Dr. Patrick Steptoe surgically each follicle is punctured with a biopsy needle
retrieved a single mature oocyte from one of under the guidance of a transvaginal ultra-
Lesley’s ovaries during a natural cycle. Dr. sound. The fluid from within the follicle is
396 C. L. Bormann
gently aspirated by the physician into a sterile and the male and female pronuclei form
test tube containing a processing medium. (. Fig. 18.4).
Heparin may be added to the processing
medium to help prevent blood from clotting
in the tube or search dishes. In the laboratory, 18.3 In Vitro Maturation
aspirates are examined quickly for the pres-
ence of cumulus-oocyte complexes. Oocytes In vitro maturation (IVM) of oocytes is a pro-
are rinsed thoroughly and placed in holding cedure in which eggs are collected from antral
medium until the time of conventional follicles at a stage prior to selection and domi-
insemination or cumulous cell removal. nance. These immature oocytes are cultured
Immature oocytes are defined as being at a under conditions that facilitate the cytoplas-
stage of meiosis prior to metaphase of meiosis mic and nuclear maturation of eggs to meta-
II (MII). This includes oocytes in prophase of phase II. This procedure is especially
meiosis I, which are identified by the presence important for cancer patients, where the time
of a germinal vesicle or nuclear envelope in and hormonal milieu associated with a tradi-
the cytoplasm, without any polar body pres- tional IVF cycle may adversely affect the
ent in the perivitelline space (. Fig. 18.1). If patient’s treatment and medical outcome.
present, cumulus and corona cells are com- Likewise, patients with contraindications for
monly very tightly condensed. As prophase I
resumes, the oocyte enters into metaphase of
meiosis I (MI). This intermediate stage of
maturation is recognized by the disappear-
ance of the germinal vesicle and the absence
of the first polar body (. Fig. 18.2). For MI
oocytes, cumulus cells may be expanded, but
the corona cell layer can still be compact. The
extrusion of the first polar body marks the
transition to a mature oocyte, which is now
considered to be at MII (. Fig. 18.3).
Metaphase II oocytes will usually have a fully
expanded cumulus cell complex. Under nor-
mal circumstances, the oocyte will remain at
.. Fig. 18.2 Metaphase I (MI) human oocyte without
MII until fertilization; when meiosis II
a polar body after cumulus cell removal. (Courtesy of
resumes, the second polar body is extruded, Dr. Nina Desai, Cleveland Clinic)
18
.. Fig. 18.1 Germinal vesicle intact representing an .. Fig. 18.3 Metaphase II (mature) oocyte. Denuded
immature oocyte after cumulus removal. (Courtesy of oocyte showing the presence of the first polar body.
Dr. Nina Desai, Cleveland Clinic) (Courtesy of Dr. Nina Desai, Cleveland Clinic)
397 18
ejaculation cannot be achieved via masturba-
tion, whether due to religious or psychologi-
cal reasons, non-toxic condoms can be used
to collect the ejaculation following sexual
intercourse. In cases where there is no pres-
ence of an ejaculate following orgasm,
patients are asked to immediately urinate in a
sterile cup, and the sample is analyzed for the
presence of sperm. The presence of semen in
the urine is a clear indicator of a retrograde
ejaculation. Men with this condition may be
prescribed stomach acid buffering medica-
tions in order to neutralize the pH of the
.. Fig. 18.4 Normal zygote showing the presence of
urine and thus provide a more hospitable
two polar bodies (only one seen in this view) and two environment for the sperm during collection
pronuclei. (Courtesy of Dr. Nina Desai, Cleveland and processing.
Clinic) In cases where men cannot achieve an
erection, or ejaculation due to neurologic or
ovarian stimulatory drugs such as those with psychogenic reasons, semen can still be col-
polycystic ovary syndrome (PCOS) and those lected via prostate massage, electrical stimula-
that are at higher risk of hyperstimulation tion of the prostate, or applied vibration to
with ovulation induction agents may be candi- the penis. Samples collected from men with
dates for IVM [5]. spinal cord injuries typically have high con-
Although the precise mechanisms that reg- centrations of sperm and poor motility, con-
ulate the control of oocyte maturation remain tain red blood cell contamination in the
obscure, it has been recognized for over ejaculate, and require rigorous washing steps
70 years that immature oocytes removed from to isolate highly motile sperm for ICSI.
antral follicles may undergo spontaneous In cases of non-obstructive and obstruc-
maturation in culture, termed “in vitro matu- tive azoospermia where sperm are not present
ration” (IVM), without the need for hormonal in the ejaculate, spermatozoa can be collected
stimulation. With IVM, immature oocytes are by way of testicular dissection or percutane-
typically obtained in the mid- to late follicular ous needle biopsy. This method of collection
phase of the menstrual cycle. To date, IVM is highly invasive and is generally the last
has been most successful in young women resort in obtaining sperm for ICSI. Samples
with multiple antral follicles that typically obtained by testicular dissection contain large
have a high chance of pregnancy with conven- amounts of red blood cells and testicular tis-
tional IVF. Despite this selection bias, IVM sues; thus requiring additional steps to isolate
pregnancy rates remain lower than in stimu- a clean sample of spermatozoa.
lated IVF cycles [6]. As culture conditions for
IVM are optimized and pregnancy rates
improve, this technology may offer a safer, less 18.5 perm Isolation for IVF
S
expensive, more convenient alternative to and ICSI
stimulated IVF.
One of the oldest and most used methods of
sperm isolation is the swim-up procedure. This
18.4 Spermatozoa Collection, sperm separation technique is mostly used on
Evaluation, and Processing normozoospermia males. The swim-up method
is based on the active movement of motile
The most common method of obtaining a sperm from a pre-washed pellet of sperm into
semen sample is through masturbation and an above layer of fresh medium. The first step
ejaculation into a sterile cup. In cases where in swim-up involves repeat dilution and cen-
398 C. L. Bormann
trifugation (two to three times) of the semen times to ensure complete removal of the den-
sample to separate spermatozoa from seminal sity gradient medium prior to insemination.
plasma. Following centrifugation, the pelleted There are many advantages in using a den-
spermatozoa can be both suspended and over- sity gradient to process spermatozoa for IVF
laid with media, or the pellet can be uninter- and ICSI. The entire ejaculate is used during
rupted and overlaid with media. If one chooses the centrifugation process, resulting in a sig-
to disrupt the pellet, extreme care must be nificantly higher yield of motile spermatozoa
taken when overlaying with media to prevent than can be obtained using other separation
mixing and contamination with immotile techniques. This makes this technique ideal
sperm, debris, and other cell types. for patients with suboptimal semen parame-
The swim-up method using either the ters (e.g., oligozoospermia and asthenozoo-
intact or disrupted sperm pellet is incubated spermia). Another advantage of this technique
at 37 °C for 30–60 min in a buffered media to is that it produces a relatively clean sample of
allow spermatozoa to swim from the pellet to spermatozoa, free of cellular debris and
the culture medium. Following incubation, leukocyte contamination. This property sig-
the upper layer of culture media is carefully nificantly reduces the ROS and problems
aspirated without disrupting the pellet and is associated with its contamination.
transferred to a clean test tube for further
analysis. One advantage of this technique is
that it isolates a population of sperm with 18.6 In Vitro Fertilization (IVF)
greater than 90% motility and without cellu-
lar debris. The disadvantages of this technique 18.6.1 Conventional Insemination
are in the low overall recovery of motile sper-
matozoa due to the limited surface area of the Oocytes are routinely inseminated 3–6 h after
pellet and culture media. Another disadvan- oocyte retrieval is performed, depending on
tage of this technique is that repeat centrifu- oocyte maturity. Individual or groups of
gation forces viable spermatozoa to be in close oocytes can be incubated and inseminated
contact with immotile spermatozoa, cellular either in organ culture dishes, four-well dishes,
debris, and leukocytes, which are known to or test tubes containing equilibrated medium,
produce very high levels of ROS and affect with or without oil overlay. Individual oocytes
subsequent fertilization ability. can also be inseminated in 30–50-μL drops of
Density gradient centrifugation is the sec- equilibrated medium in culture dishes with oil
ond most common method for isolating overlay, thus reducing the number of sperma-
motile sperm for ART purposes. Most of the tozoa necessary for the insemination. Generally,
density gradient systems used to isolate sper- concentrations range from 50,000 to 100,000
matozoa are discontinuous and consist of two motile spermatozoa/mL. Spermatozoa con-
to three layers. The most used materials for centrations that are too high can result in
density gradients are colloidal silica with increased incidence of polyspermic fertiliza-
covalently bound silane molecules, which have tions (more than one spermatozoon penetrat-
a low viscosity, are non-toxic, and are ing an oocyte). Concentrations that are too low
approved for human use. may compromise fertilization rates.
18 During centrifugation, highly motile
sperm migrate faster in the direction of the
sedimentation gradient and can penetrate this 18.6.2 Intracytoplasmic Sperm
interface faster than low-motile or non-motile Injection (ICSI)
spermatozoa. This unimpeded density gradi-
ent separation produces a clean fraction of ICSI consists of insertion of a single sper-
highly motile spermatozoa. The pellet is matozoon directly into the oocyte cyto-
washed with culture media and centrifuged at plasm. This technique was first successfully
300 g for 10 min. This process is repeated two applied to human oocytes in 1992 and has
399 18
since revolutionized the treatment of severe
male factor infertility [7]. By injecting a .. Table 18.1 Cleavage-stage embryo single-
spermatozoon into the oocyte cytoplasm, step grading system
many steps of spermatozoa processing and
developmental prerequisites are bypassed Parameter Score Description of embryo
without compromising fertilization rates. measured grade
There is currently a debate regarding the Cell number # Total number of
appropriate indications for ICSI. Current blastomeres
evidence supports the following indications
Blastomere 1 Regular, even
for the use of ICSI: symmetry blastomere division
55 Prior failed fertilization by conventional
insemination 2 <20% difference
between blastomeres
55 Prior IVF cycle with <50% fertilization of
MII oocytes 3 20–50% difference
55 Prior IVF cycle with a high rate of poly- between blastomeres
spermic fertilization 4 >50% difference
55 Total motile spermatozoa concentration between blastomeres
less than ten million/mL Fragmenta- 1 <10% fragmentation of
55 Poor forward progressing sperm score tion embryo
55 Spermatozoa morphology less than 4% 2 10–20% fragmentation
normal forms based on Kruger strict criteria of embryo
3 20–50% fragmentation
18.6.3 Fertilization Assessment of embryo
4 >50% fragmentation of
Fertilization assessments are performed embryo
15–18 h after insemination for both IVF and
ICSI procedures. It is necessary to examine
the oocytes/zygotes within this time period to
visualize the presence of pronuclei and 18.6.4 Embryo Assessment
extruded polar bodies. Normal fertilization is
characterized by the presence of two pronu- Embryos can be assessed and graded daily
clei, one male and one female, in the ooplasm while they are in culture. Standard morphologic
and two polar bodies in the perivitelline space methods of grading can be applied according
(. Fig. 18.4). If oocytes have undergone con- to observations made on embryo development
ventional IVF, the cumulus cells must be until their transfer to the uterus on day 3 (~68 h
removed to clearly see the oocyte. post fertilization) (. Tables 18.1 and 18.2) or
Abnormal fertilization may also be repre- on day 5 or 6 at the blastocyst stage
sented by oligopronuclear zygotes. The term (. Table 18.3) [8, 9]. There are numerous scor-
applies to zygotes that have single pronuclei. ing systems proposed for embryo development.
Only one pronuclei and the presence of two Criteria for grading include the rate of division
polar bodies may be observed in cases when as judged by the number of blastomeres, size,
the oocyte undergoes parthenogenic activa- shape, symmetry, appearance of the cytoplasm,
tion or failure of the spermatozoa head to and presence of cytoplasmic fragments.
decondense. It is possible that a second pro-
nucleus will be developed later than the first ►►Example
one; therefore, a repeat observation 2–4 h after The grade is recorded as (cell number) C (size
the first check is recommended. Failed fertil- fragmentation); therefore, an eight-cell embryo
ization is represented by the absence of pronu- with even cell division and approximately 15%
clei and presence of one or two polar bodies fragmentation by volume will be scored as an
that may be in the process of degeneration. “8C,1-2.” ◄
400 C. L. Bormann
.. Table 18.2 Cleavage-stage embryo two-step grading system
Embryo score Blastomere cell number

A Minimum of four cells by 40 h post-insemination
Minimum of eight cells by 64 h post-insemination
B Minimum of two cells by 40 h post-insemination
Minimum of four cells by 64 h post-insemination
C Minimum of two cells by 64 h post-insemination
D No minimums (lowest possible grade). Do not make
subtractions
Subtract from the grade for irregularities as follows:
Description of embryo Subtractions
Spherical blastomeres with no fragmentation No subtractions
Spherical blastomeres with ≤20% fragmentation Subtract one grade
Slightly irregular blastomeres with ≤50% fragmen- Subtract two grades

tation
Irregular blastomeres with >50% fragmentation Subtract three grades
.. Table 18.3 Blastocyst-stage embryo grading system
Parameter Score Description of embryo grade

measured
Expansion 1 Early blastocyst; blastocoel less than half the volume of the embryo, little or no
status expansion in overall size, zona pellucida (ZP) still thick
2 Blastocyst; blastocoel more than half the volume of the embryos, some expansion
in overall size, ZP beginning to thin
3 Full blastocyst; blastocoel completely fills the embryo
4 Expanded blastocyst; blastocoel volume now larger than that of the early embryo.
ZP very thin
5 Hatching blastocyst; trophectoderm has started to herniate through the ZP
6 Hatched blastocyst; the blastocyst has evacuated the ZP
Inner cell mass A ICM prominent, easily discernible, and consisting of many cells, cells compacted
and tightly adhered together
B Cells less compacted so larger in size, cells loosely adhered together, some
individual cells may be visible
18 C Very few cells visible, either compacted or loose, may be difficult to completely
distinguish from trophectoderm
D No viable ICM cells discernible in any focal plane
Trophectoderm A Many small identical cells forming a continuous trophectoderm layer
B Fewer, larger cells, may not form a completely continuous layer
C Sparse cells, may be very large, very flat or appear degenerate
D No viable trophectoderm cells discernible in any focal plane
401 18
►►Example Since the initial identification of developmental
The grade is recorded as (expansion stage) markers for blastocyst development, numerous
(ICM score, trophectoderm score); there- studies have identified a multitude of parame-
fore, an expanded blastocyst with a large ters that have been reportedly associated with
tightly compacted ICM and sparse elongated embryo implantation potential. Some of the
Trophectoderm cells will be scored as “5A,C.” positive predictors of implantation include
It is important to note that evaluation and timing of compaction, timing of early blastula-
scoring by morphology alone can be highly tion, and rate of blastocoel expansion. Addi-
subjective and may not necessarily reveal tionally, negative predictors of implantation
embryos with the best developmental potential. have been identified using TLI. This includes
Currently, there are numerous groups working the following early-stage abnormal cleavage
on translational research focused on noninva- (AC) events: AC1 (where the zygote divides to
sive means of assessing embryos for biomark- more than two daughter cells) and AC2 (where
ers that are indicative of embryonic one of the daughter cells divides to more than
developmental competence and implantation two daughter cells). In many cases, standard
potential. Such evaluation, in concert with morphology grading alone is unable to detect
morphology and genetic analysis, has an enor- AC embryos, and these embryos are selected
mous potential to reshape the practice of for freezing or transfer.
embryo selection in the future. ◄ Time-lapse embryo selection algorithms
(ESAs) have shown promising results in iden-
tifying embryos with low developmental
18.6.5 Time-Lapse Imaging potential when used by trained embryologists.
The addition of TLI systems to conventional
Time-lapse imaging (TLI) of embryos was manual embryo grading has not consistently
introduced in the field as an alternative demonstrated an improvement in clinical out-
method for assessing the competency of comes. These systems have led to lengthier
developing embryos. This technology allows embryo morphology assessment times [11–
embryologists to grade embryos at specific 15]. Despite the increasing use of TLI in this
time points without disturbing the culture field for selecting embryos for transfer, there
environment. This method of grading opened continues to be a large gap in high-quality evi-
the door to using a variety of quantifiable dence that supports its utility.
morphokinetic measurements to aid in
embryo selection. The first scientific evidence
for time-lapse selection markers was discov- 18.6.6 Assisted Hatching
ered by a group of researchers from Stanford
in 2008 [10]. They found that three cell divi- One of the most common unsolved problems
sion time intervals could predict successful in IVF is the fact that embryos with appar-
development to blastocyst by day 2, the four- ently good developmental potential do not
cell stage. The cell division timing parameters always implant. It has been proposed that this
were unique, because: may be due impart to defects of the zona pel-
1. They formed a distinct timing window lucida, uterine receptivity, extensive fragmen-
where blastocysts clustered very closely tation, modifications after freezing and
compared to arrested embryos. thawing, or even suboptimal culture condi-
2. They correlated with the underlying tions. An important observation leading to
molecular health of the embryo, as gene the clinical introduction of assisted hatching
expression analysis showed that embryos was the finding that there were higher implan-
with abnormal cell division timings had tation rates from embryos that were fertilized
defective RNA patterns. using microsurgical techniques such as
402 C. L. Bormann
ICSI. In addition, it was observed that cleaved formed on blastocysts). With the improvements
embryos with thinner zonae had higher in embryo culture, blastocyst conversion, and
implantation rates than those with thick zona high success rates with blastocyst vitrification,
pellucidas. It has also been reported that a an increasing number of labs are performing
naturally thick zona or hardening of the zona blastocyst-stage biopsy. The human blasto-
pellucida due to cryopreservation or subopti- cyst, depending upon the developmental stage,
mal in vitro culture conditions may interfere can contain more than 100 cells. As such, the
with (and prevent) the natural hatching pro- biopsy of five to ten cells from the outer layer
cess, leading to implantation failure. of the trophectoderm is less likely to have a
To overcome hatching failure, three differ- detrimental effect on the developing embryo.
ent micromanipulation procedures (mechani- Additional advantages of performing biopsies
cal, chemical, and laser-induced hatching) at the blastocyst stage include:
have been used to thin or produce holes in the 1. Improved development to the blastocyst
zona pellucida of cleavage-stage embryos. stage
Assisted hatching techniques, designed to 2. Pre-selection of top-quality embryos for
facilitate embryo escape from the zona, have biopsy
been used in IVF centers since 1992. The ini- 3. Improved DNA amplification with more
tial indications for assisted hatching were cells biopsied
patient age, zona thickness, high basal FSH 4. Lower rate of mosaicism
value, and repeated IVF failure. Several retro-
spective and prospective studies assessing To aid in the biopsy of trophectoderm cells,
assisted hatching in these cases have given dis- a small opening may be made in the zona
parate results. Therefore, the clinical relevance pellucida of the embryo during the cleavage
of assisted hatching in cleavage-stage embryos stage of development. As the embryo devel-
within an assisted reproduction program is ops and the blastocoel cavity expands, a por-
heavily debated [16]. tion of the blastocyst will herniate through
the zona breach making it easily accessible
for biopsy. Trophectoderm cells can be gen-
18.6.7 Preimplantation Genetic tly biopsied using a glass needle or a laser.
Testing Following biopsy, blastocysts will immedi-
ately collapse due to the opening in the zona
Preimplantation genetic testing (PGT) pellucida. Blastocysts should be cryopre-
includes preimplantation genetic diagnosis served while in the collapsed state as this
(PGD) performed for monogenic diseases and facilitates adequate exposure of cryoprotec-
translocations, as well as preimplantation tants to all cells.
genetic screening (PGS) for aneuploid screen-
ing. The PGT procedure is a very early form
of prenatal diagnosis for patients with a pre- 18.6.9 Cryopreservation
existing genetic risk. Technically, PGT con-
sists of micromanipulation (biopsy) and DNA Cryopreservation of gametes and embryos
analysis of gametes and/or embryos. maximizes success in any IVF program and
18 prevents wastage of specimens. It is important
to realize, however, that there are many ethi-
18.6.8 Embryo Biopsy cal, religious, legal, and social implications
involving embryo storage. Some countries,
Micromanipulation for the biopsy includes such as Germany, Austria, Switzerland,
the mechanical opening of the zona pellucida Denmark, and Sweden, have restricted or for-
and retrieval of one or two polar bodies (when bidden cryopreservation of embryos [8]. There
performed on oocytes or zygotes), one or two are currently two primary categories of gam-
blastomeres (when performed on cleavage- ete/embryo cryopreservation strategies: slow-
stage embryos), and five to ten cells (when per- rate freezing and vitrification.
403 18
18.6.10 Slow-Rate Freezing stage embryos, both approaches seem to be
equally successful. For freezing at the blasto-
Slow-rate freeze protocols vary in permeating cyst stage, vitrification may offer more consis-
cryoprotectants, non-permeating cryoprotec- tent results, although slow cooling is also
tants, and cooling and warming rates, thus quite efficacious [18]. With continued research,
making it difficult to generalize or compare protocols for both techniques will likely be
cryopreservation results. The following is one optimized.
general example of a cleavage-stage embryo
slow-rate cryopreservation protocol.
Prior to cryopreservation, embryos that 18.6.12 Artificial Intelligence
meet the program-specific freeze criteria are in the IVF Laboratory
selected and assigned to cryopreservation.
After washing embryos through processing Many of the clinically relevant results
media with 12–15 mg/mL of protein, they are reported from the IVF laboratory are largely
exposed to the same media containing based on visual morphology assessments.
1.5 mol/L of propylene glycol (propanediol) Similarly, some of the most complex labora-
and then 1.5 mol/L propylene glycol plus tory procedures performed in the IVF lab,
0.1 mol/L sucrose. Embryos are loaded into such as ICSI, assisted hatching and embryo
plastic straws or vials and placed in a pro- biopsy are guided by visual morphologic
grammable freezer, where they will be cooled cues. Manual gamete and embryo assess-
at −2 °C/min from room temperature down to ments are highly practice-dependent and sub-
−4 to −6 °C. After a period of 5 min of hold- jective. Deep learning artificial intelligence
ing the temperature, a supercooled object is technology has been demonstrated to help
pressed against the side of the container to overcome the labor constraints and subjective
induce “seeding.” The hold is continued for a nature of visually performing morphologic
period of time, followed by continued tem- assessments in the IVF laboratory [19].
perature drop at a rate of −0.3 °C/min until it Artificial intelligence algorithms have been
reaches −32 °C. At this point, the containers developed to aid embryologists with the fol-
can be plunged directly into liquid nitrogen lowing procedures:
for storage. 55 Kruger strict morphology assessments for
semen analyses [20].
55 Assessment of oocyte stage and quality
18.6.11 Vitrification [21, 22].
55 Properly align oocytes for safe intracyto-
Vitrification is a form of rapid cooling that plasmic sperm injection [23].
utilizes very high concentrations of cryopro- 55 Perform fertilization assessment on day 1
tectant that solidify without forming ice crys- of development [24, 25].
tals. Ice crystals are a major cause of 55 Assess and select embryos for transfer at
intracellular cryo-damage [17]. The vitrified the cleavage stage of development [26].
solids contain the normal molecular and ionic 55 Identify the proper location on the zona
distributions of the original liquid state and pellucida to perform laser-assisted hatch-
can be considered an extremely viscous, super- ing [27].
cooled liquid. In this technique, oocytes or 55 Assessment of blastocyst quality for PGT
embryos are dehydrated by brief exposure to a trophectoderm biopsy and vitrification
concentrated solution of cryoprotectant [19, 28].
before plunging the samples directly into liq- 55 Selection of embryos for transfer at the
uid nitrogen. blastocyst stage (. Fig. 18.5) [29–31].
Both slow-rate freezing and vitrification 55 Prediction of embryo karyotype based on
are being used extensively in the United States. morphology [32–34].
For oocyte cryopreservation, vitrification is 55 Cell tracking and witnessing of cleavage
superior to slow-rate freezing. For cleavage- and blastocyst stage embryos [35].
404 C. L. Bormann
.. Fig. 18.5 Day 0, 1, 3, and 5 images of the first baby born that was evaluated and selected for transfer using
artificial intelligence. (Courtesy of Dr. Charles L. Bormann, Massachusetts General Hospital)
55 Development of key performance indica- ment of embryos. Media should only be

tors (KPIs) to monitor laboratory perfor- opened in a laminar flow hood, with attention
mance [36]. to maintaining sterility during the addition of
protein.
There are two basic kinds of media used
18 for ART procedures: one used during the han-
18.6.13 Laboratory and Media dling of gametes and embryos out of the CO2
Preparation incubator, called “processing medium,” and
another used for culture while in CO2 incuba-
Advances in culture medium composition tors, called “culture medium.” Both consist of
have significantly influenced embryo quality a combination of nutrients necessary to main-
and pregnancy rates over the years. All media tain early embryo metabolism and proper pH
for ART can now be purchased commercially. and osmolarity. A source of protein, such as
Prior to use, they must be tested for toxins and albumin or synthetic serum, must be added in
their ability to support growth and develop- a percentage that can vary from 2 to 15 mg/L.
405 18
Media used for the culture of embryos are achieve early identification of factors that
usually bicarbonate buffered and kept in an could negatively impact laboratory function
incubation chamber. It is very important that which, in turn, allows timely insight into tar-
this medium is maintained at a stable pH and gets for corrective action. While KPIs may
temperature, because embryos are extremely vary among laboratories, some are routinely
sensitive to variations of these two factors. assessed and considered standard. These
Culture media, used for embryo development include the following:
inside incubation chambers, should always be
equilibrated inside the CO2 environment prior Fertilization Rates This is a useful indicator
to use. Overlaying of the medium with min- that provides real-time insight into variance in
eral oil is recommended to help avoid evapo- laboratory performance in addition, possibly,
ration and increase stability of pH while the to changes in stimulation protocols. Fertilization
dish is temporarily out of the CO2 environ- rates from both standard IVF and ICSI should
ment. Oil overlay provides an effective barrier be evaluated with data stratified by the embry-
to atmospheric volatile organic compounds ologists inseminating or injecting the oocytes.
(VOCs), which can be embryotoxic if exposed
directly to the culture medium. Day 2 Cleavage The rate of embryo develop-
ment is a predictive indicator of embryo qual-
ity. The number of four-cell embryos on day 2
18.6.14 Culture Conditions is a common indicator of quality of the culture
system.
Traditionally, laboratories have cultured
embryos at an atmospheric oxygen concentra- Day 3 Embryo Development The number of
tion of approximately 20%. In contrast, the cells on day 3 gives a considerable insight into
oxygen concentration in the fallopian tube performance of the lab’s culture system.
and uterus is approximately 5% [37]. In ani- Embryos developing along the normal timeline
mal models, high oxygen concentrations should have progressed to the seven- to eight-
increase the production of reactive oxygen cell stage. Therefore, the percentage of two pro-
species. This increased oxidative stress may nuclei (2PN) zygotes with more than seven-cell
have deleterious effects on embryo quality embryos provides a useful marker of overall
[38]. Several studies suggest that culturing embryo quality.
embryos at a lower oxygen concentration,
about 5%, may improve live birth rates with Blastocyst Formation and Embryo
IVF and ICSI [39]. Additionally, there is no Freezing Tracking total blastocyst formation,
evidence to date that culturing embryos under as well as quality of blastocysts as evidenced by
low oxygen concentrations is associated with those that meet a minimal freeze criterion,
an increased risk of any adverse outcomes, helps give insight into quality of the culture
such as multiple pregnancies, miscarriages, or system. These parameters can be measured on
congenital abnormalities [39]. day 5 and/or on day 6 of culture.
Cryo-survival: Tracking cell survival following

18.7 Monitoring Clinical Outcomes cryopreservation/thawing of oocytes and
embryos is an important marker of technical
Data analysis is a crucial part of maintaining efficiency of a cryopreservation program.
a successful ART laboratory and practice. Though success rates may vary based on the
Routine review of identified key performance stage of tissue frozen as well as method of cryo-
indicators (KPIs) is important to ensure preservation (slow-rate vs. vitrification).
proper laboratory functioning and, perhaps
more importantly, to identify potential prob- Pregnancy, Implantation, and Live Birth
lems to permit timely correction. In fact, this Outcomes The clinical outcome of an IVF
is the primary reason for data analysis: to cycle is perhaps the best indicator of system
406 C. L. Bormann
efficiency with implantation rates providing the B. Sperm motility score < 50%
most robust and timely marker of embryo C. Prior IVF cycle with <40% fertil-
quality. Assessment of pregnancy rates per ization of MII oocytes
physician and embryologist performing the D. Prior IVF cycle with a high rate of
transfer is critical. polyspermic fertilization
Advancements in artificial intelligence E. Total motile spermatozoa concen-
may be used to automate and improve the way tration less than five million/mL
we monitor laboratory performance. AI algo-
rithms developed to assess oocyte quality can ??2. Which of the following is not a benefit
predict with high accuracy which oocytes will for performing PGT biopsy at the blas-
fertilize successfully [22]. This type of moni- tocyst stage?
toring system will allow practices to monitor A. Improved development to the blas-
factors which may impact oocyte quality or tocyst stage
suboptimal fertilization rates. AI has also B. Higher survival rate of vitrified
been used to develop an accurate KPI to pre- blastocysts
dict the developmental fate of cleavage-stage C. Pre-selection of top-quality
embryos. This novel KPI has been shown to embryos for biopsy
have a direct correlation with ongoing preg- D. Improved DNA amplification with
nancy outcomes [36]. Utilization of early- more cells biopsied
stage KPIs that can predict treatment E. Lower rate of mosaicism
outcomes will allow us to identify and correct
factors which may be altering performance ??3. Which of the following IVF cycle results
are primarily determined based on
within the practice and laboratory.
highly subjective morphologic assess-
ments?
18.8 Future Directions A. Sperm morphology score
B. Oocyte maturation classification
Over the past three decades, few areas of med- C. Fertilization assessment
icine have experienced the rapid evolution that D. Cleavage-stage embryo selection
has occurred within the field of ART. Despite for transfer
this progress, success rates have plateaued in E. Blastocyst-stage embryo selection
recent years, and many new challenges and for transfer
opportunities for improvement lie ahead. With F. Blastocyst selection for trophecto-
growing pressure to decrease multiple gesta- derm biopsy
tions, methods to improve embryo selection G. Blastocyst selection for cryopreser-
(such as PGS, transcriptomic/metabolomic vation
profiling, time-lapse imaging, and artificial H. Embryo selection for disposition
intelligence) will become increasingly impor- I. All the above
tant. Finally, as a result of these innovations
??4. True or false: Artificial intelligence has
within our field, we will likely see a greater
been demonstrated to help overcome
shift toward eSET in all patient populations.
the labor constraints and subjective
18 nature of visually performing morpho-
18.9 Review Questions logic assessments in the IVF laboratory.
A. True
??1. Which of the following are not indica- B. False
tors for performing ICSI?
A. Prior failed fertilization by conven-
tional insemination
407 18
18.10 Answers 11. Conaghan J, Chen AA, Willman SP, Ivani K,
Chenette PE, Boostanfar R, et al. Improving
embryo selection using a computer-automated
vv1. B time-lapse image analysis test plus day 3 morphol-
ogy: results from a prospective multicenter trial.
vv2. B Fertil Steril. 2013;100(2):412–9.e5. https://doi.
org/10.1016/j.fertnstert.2013.04.021.
12. Kirkegaard K, Ahlström A, Ingerslev HJ,
vv3. I
Hardarson T. Choosing the best embryo by time
lapse versus standard morphology. Fertil Steril.
vv4. A 2015;103(2):323–32. https://doi.org/10.1016/j.
fertnstert.2014.11.003.
13. Kaser DJ, Bormann CL, Missmer SA, Farland LV,
Ginsburg ES, Racowsky C. Eeva™ pregnancy pilot
Acknowledgments The author would like to study: a randomized controlled trial of single
acknowledge the contributions of Drs. Beth embryo transfer (SET) on day 3 or day 5 with or
Plante, Gary D. Smith, and Sandra Ann without time-lapse imaging (TLI) selection. Fertil
Steril. 2016;106(3) https://doi.org/10.1016/j.fertn-
Carson who were the authors of this chapter
stert.2016.07.886.
in a previous edition. 14. Chen M, Wei S, Hu J, Yuan J, Liu F. Does time-
lapse imaging have favorable results for embryo
incubation and selection compared with conven-
References tional methods in clinical in vitro fertilization? A
meta-analysis and systematic review of random-
ized controlled trials. PLoS One.
1. Edwards RG, Bavister BD, Steptoe PC. Early
2017;12(6):e0178720. https://doi.org/10.1371/jour-
stages of fertilization in vitro of human oocytes
nal.pone.0178720.
matured in vitro. Nature. 1969;221(5181):632–5.
15. Goodman LR, Goldberg J, Falcone T, Austin C,
2. Chang MC. Fertilization of rabbit ova in vitro.
Desai N. Does the addition of time-lapse morpho-
Nature. 1959;184(Suppl 7):466–7.
kinetics in the selection of embryos for transfer
3. Johnson MH. Robert Edwards: the path to
improve pregnancy rates? A randomized con-
IVF. Reprod Biomed Online. 2011;23(2):245–62.
trolled trial. Fertil Steril. 2016;105(2):275–85.
4. Centers for Disease Control and Prevention. 2017
assisted reproductive technology fertility clinic
Reproductive Medicine and Practice Committee
success rates report. Accessed 1 Oct 2020. https://
of the Society for Assisted Reproductive
www.cdc.gov/art/reports/2017/fertility-clinic.html.
Technology. Role of assisted hatching in in vitro
5. Gremeau AS, Andreadis N, Fatum M, Craig J,
fertilization: a guidline. Fertil Steril.
Turner K, McVeigh E, et al. In vitro maturation or
2014;102(2):348–51.
in vitro fertilization for women with polycystic
17. Rall WF, Fahy GM. Ice-free cryopreservation of
ovaries? A case–control study of 194 treatment
mouse embryos at −196 degrees C by vitrification.
cycles. Fertil Steril. 2012;98(2):355–60.
Nature. 1985;313(6003):573–5.
6. Mikkelsen AL. Strategies in human in-vitro matu-
18. Edgar DH, Gook DA. A critical appraisal of cryo-
ration and their clinical outcome. Reprod Biomed
preservation (slow cooling versus vitrification) of
Online. 2005;10(5):593–9.
human oocytes and embryos. Hum Reprod
7. Palermo G, Joris H, Devroey P, Van Steirteghem
Update. 2012;18(5):536–54.
AC. Pregnancies after intracytoplasmic injection
19. Bormann CL, Thirumalaraju P, Kanakasabapathy
of single spermatozoon into an oocyte. Lancet.
MK, Kandula H, Souter I, Dimitriadis I, Gupta
1992;340(8810):17–8.
R, Pooniwala R, Shafiee H. Consistency and
8. Gardner DK, Weissman A, Howles CM, Shoham
objectivity of automated embryo assessments
Z. Textbook of assisted reproductive technologies:
using deep neural networks. Fertil Steril.
laboratory and clinical perspectives. 3rd ed.
2020;113(4):781–7.
London: Taylor & Francis; 2008.
20. Thirumalaraju P, Kanakasabapathy MK,
9. Balaban B, Yakin K, Urman B. Randomized com-
Bormann CL, Kandula H, Pavan SKS,
parison of two different blastocyst grading sys-
Yarravarapu D, Shafiee H. Human sperm mor-
tems. Fertil Steril. 2006;85(3):559–63.
phology analysis using smartphone microscopy
10. Wong CC, Loewke KE, Bossert NL, Behr B, De
and deep learning. Fertil Steril. 2019;112(3,
Jonge CJ, Baer TM, Reijo Pera RA. Non-invasive
Suppl):e41.
imaging of human embryos before embryonic
21. Targosz A, Przystałka P, Wiaderkiewicz R,
genome activation predicts development to the
Mrugacz G. Semantic segmentation of human
blastocyst stage. Nat Biotechnol. 2010;28:1115–21.
oocyte images using deep neural networks. Biomed
408 C. L. Bormann
Eng Online. 2021;20(1):40. https://doi.org/10.1186/ AJ, Garcia-Sandoval JP. Predicting pregnancy test
s12938-021-00864-w. PMID: 33892725; PMCID: results after embryo transfer by image feature
PMC8066497 extraction and analysis using machine learning. Sci
22. Kanakasabapathy M, Bormann C, Thirumalaraju Rep. 2020;10(1):4394. https://doi.org/10.1038/
P, Banerjee R, Shafiee H. Improving the perfor- s41598-020-61357-9. PMID: 32157183; PMCID:
mance of deep convolutional neural networks PMC7064494
(CNN) in embryology using synthetic machine- 31. Tran D, Cooke S, Illingworth PJ, Gardner
generated images. In: Human reproduction, vol. DK. Deep learning as a predictive tool for fetal
35. Oxford: Oxford Univ Press; 2020. heart pregnancy following time-lapse incubation
23. Dickinson J, Meyer A, Kelly N, Thirumalaraju P, and blastocyst transfer. Hum Reprod.
Kanakasabapathy M, Kartik D, Bormann C, 2019;34(6):1011–8. https://doi.org/10.1093/hum-
Shafiee H. Advancement in the future automation rep/dez064. PMID: 31111884; PMCID:
of ICSI: use of deep convolutional neural net- PMC6554189
works (CNN) to identify precise location to inject 32. Meyer A, Dickinson J, Kelly N, Kandula H,
sperm in mature human oocytes. In: Human Kanakasabapathy M, Thirumalaraju P, Bormann
reproduction, vol. 35. Oxford: Oxford Univ Press; C, Shafiee H. Can deep convolutional neural net-
2020. work (CNN) be used as a non-invasive method to
24. Dimitriadis I, Bormann CL, Kanakasabapathy replace Preimplantation Genetic Testing for
MK, Thirumalaraju P, Gupta R, Pooniwala R, Aneuploidy (PGT-A)? In: Human reproduction,
Souter I, Rice ST, Bhowmick P, Shafiee H. Deep vol. 35. Oxford: Oxford Univ Press; 2020.
convolutional neural networks (CNN) for assess- p. I238–8.
ment and selection of normally fertilized human 33. Chavez-Badiola A, Flores-Saiffe-Farías A,
embryos. Fertil Steril. 2019;112:e272. Mendizabal- Ruiz G, Drakeley AJ, Cohen
25. Bormann CL, Curchoe CL, Thirumalaraju P, J. Embryo Ranking Intelligent Classification
Kanakasabapathy MK, Gupta R, Pooniwala R, Algorithm (ERICA): artificial intelligence clinical
Kandula H, Souter I, Dimitriadis I, Shafiee assistant predicting embryo ploidy and implanta-
H. Deep learning early warning system for embryo tion. Reprod Biomed Online. 2020;41(4):585–93.
culture conditions and embryologist performance https://doi.org/10.1016/j.rbmo.2020.07.003. Epub
in the ART laboratory. J Assist Reprod Genet. 2020 Jul 5
2021; https://doi.org/10.1007/s10815-021-02198-x. 34. Chavez-Badiola A, Zhang J, Flores-Saiffe-Farías
Epub ahead of print. A, Mendizabal-Ruiz G, Drakeley AJ, Olcha
26. Kanakasabapathy MK, Thirumalaraju P, M. Non-invasive chromosome screening and its
Bormann CL, Gupta R, Pooniwala R, Kandula H, correlation against ranking prediction made by
Souter I, Dimitriadis I, Shafiee H. Deep learning erica, a deep-learning embryo ranking algorithm.
mediated single time-point image-based prediction Fertil Steril. 2020;114(3):e436–7.
of embryo developmental outcome at the cleavage 35. Kanakasabapathy MK, Hammer KC, Dickinson
stage. arXiv preprint arXiv. 2020;2006.08346:5–21. K, Veiga C, Kelly F, Thirumalaraju P, Bormann
27. Kelly N, Bormann CL, Dickinson J, Meyer AD, CL, Shafiee H. Using artificial intelligence to avoid
Kanakasabapathy MK, Thirumalaraju P, Shafiee human error in identifiying embryos. Fertil Steril.
H. Future of automation: use of deep convolu- 2020;113(4):e45.
tional neural networks (CNN) to identify precise 36. Bormann CL, Curchoe CL, Thirumalaraju P,
location to perform laser assisted hatching on Kanakasabapathy MK, Gupta R, Pooniwala R,
human cleavage stage embryos. Fertil Steril. Kandula H, Souter I, Dimitriadis I, Shafiee
2020;114(3, Suppl):e144. H. Deep learning early warning system for embryo
28. Thirumalaraju P, Kanakasabapathy MK, culture conditions and embryologist performance
Bormann CL, Gupta R, Pooniwala R, Kandula H, in the ART laboratory. J Assist Reprod Genet.
Souter I, Dimitriadis I, Shafiee H. Evaluation of 2021; https://doi.org/10.1007/s10815-021-02198-x.
deep convolutional neural networks in classifying 37. Fischer B, Bavister BD. Oxygen tension in the ovi-
human embryo images based on their morphologi- duct and uterus of rhesus monkeys, hamsters and
18 29.
cal quality. Heliyon. 2021;7(2):E06298.
Bormann CL, Kanakasabapathy MK, 38.
rabbits. J Reprod Fertil. 1993;99(2):673–9.
Karagenc L, Sertkaya Z, Ciray N, Ulug U, Bahceci
Thirumalaraju P, Gupta R, Pooniwala R, Kandula M. Impact of oxygen concentration on embryonic
H, Hariton E, Souter I, Dimitriadis I, Ramirez LB, development of mouse zygotes. Reprod Biomed
Curchoe CL, Swain J, Boehnlein LM, Shafiee Online. 2004;9(4):409–17.
H. Performance of a deep learning based neural 39. Bontekoe S, Mantikou E, van Wely M, Seshadri S,
network in the selection of human blastocysts for Repping S, Mastenbroek S. Low oxygen concen-
implantation. Elife. 2020;9:E55301. trations for embryo culture in assisted reproductive
30. Chavez-Badiola A, Flores-Saiffe Farias A, technologies. Cochrane Database Syst Rev.
Mendizabal-Ruiz G, Garcia-Sanchez R, Drakeley 2012;(7):CD008950.
409 19
Preimplantation Genetic
Testing
Jason M. Franasiak, Katherine L. Scott
and Richard T. Scott Jr.
Contents
19.2 pplications for Genetic Testing

A
of Embryos – 412
19.2.1 S ex-Linked Diseases – 412
19.2.2 Single Gene Diseases – 412
19.2.3 Translocations – 412
19.2.4 Genetic Predisposition Disorders – 413
19.2.5 HLA Matching – 413
19.2.6 Aneuploidy Screening – 413
19.2.7 Summary – 415
19.3 Obtaining Genetic Material – 415

19.3.1 olar Body Analysis – 416
P
19.3.2 Blastomere Biopsy – 416
19.3.3 Trophectoderm Biopsy – 418
19.4 Strategies for Single-Gene Defect PGT-M – 419

19.4.1 Alternative Strategies for PGT-M – 420
19.5 Strategies for PGT-A – 420

19.5.1 Clinical Impact – 422
19.6 Review Quesions – 424
19.7 Answers – 424
References – 424

https://doi.org/10.1007/978-3-030-99596-6_19
410 J. M. Franasiak et al.
In the short time since the first IVF birth

Key Points in 1978 [3], utilization of the technology has
55 The most frequent genetic disorders increased dramatically. The primary goal of
requiring preimplantation genetic test- technology applied to embryo selection in the
ing for monogenic conditions (PGT-M) IVF laboratory is to distinguishing those
are cystic fibrosis and hemoglobinopa- embryos which are reproductively competent
thies (beta thalassemia, sickle cell ane- and are able to become a healthy child from
mia), and spinal muscular atrophy. those which cannot. The drive to select healthy
55 While greatly reducing the prevalence embryos as a means to avoid the need for
of these abnormalities is an inevitable pregnancy termination led to the first applica-
consequence of preimplantation genetic tions of preimplantation genetic testing
testing for aneuploidy (PGT-A), the (PGT) in 1990 [4].
clinical goal was (and remains) to raise The first applications for PGT were for
sustained implantation rates and lower PGT-M and were testing monogenic disor-
clinical loss rates. ders and sex-linked disorders. Focusing on
55 Fluorescent in situ hybridization X-chromosome-linked diseases, amplification
(FISH) typically screened the seven and detection of Y-chromosome-specific
chromosomes most frequently seen in repeat sequences allowed for selection of
miscarriage specimens (chromosomes embryos that were female and thus not at risk
13, 16, 18, 21, 22, X, and Y) analyzing of carrying the disease. This technique has
only one or two blastomeres. The devel- evolved to detection of gene mutations on
opment of technologies for single-cell autosomes and sex chromosomes as well as
whole genome amplification (WGA) translocations in either partner and allowed
allowed for analysis of all 24 chromo- for selection of embryos which do not harbor
somes. the mutation for embryo transfer.
55 Polar body (PB) analysis tests only for The success of PGT-M to predict embryos
meiotic errors in the oocyte. which did not have genetic disease led to
55 Trophectoderm biopsy of four to five attempts to apply the technology more widely
cells from an expanded blastocyst rep- to all embryos and identify those embryos
resents the safest way to obtain cells with normal chromosome complements [5–
from a developing embryo that contains 13]. This practice became known as preim-
the full maternal and paternal comple- plantation genetic testing for aneuploidy
ment of DNA that will become the (PGT-A). This evolving effort was borne out
conceptus. of the historical practice of transferring mul-
55 Genetic counseling is an important tiple embryos to overcome the inability to
aspect of all preimplantation genetic accurately predict which embryos were com-
testing. petent. Even the relatively conservative
embryo transfer guidelines of the American
Society for Reproductive Medicine (ASRM)
had previously recommended five or more in
older patients. While increasing the number
19.1 Introduction of embryos transferred enhanced delivery
rates, the prevalence of multiple gestations,
The development and enhancement of the including higher order (>3) which are associ-
19 assisted reproductive technologies (ART) culated with a high morbidity as compared to
minating in in vitro fertilization (IVF) over the singleton deliveries, are also increased at
last 35 years have resulted in dramatic improve- unacceptable levels [9].
ments in treatment outcomes. At the current The contribution of embryonic aneu-
time, IVF provides both the most successful ploidy to the inefficiency of human reproduc-
and often the most cost-effective approach to tion is well established [14–16]. Indeed, it
the care of most infertile couples [1, 2]. seemed intuitive that assessment of the ploidy
Preimplantation Genetic Testing
411 19
status of each embryo within the developing newer and more powerful molecular technol-
cohort would allow selection of only euploid ogies has overcome some of the early limits
embryos and ought to improve IVF outcomes and, along with optimization of the entire
[17]. This premise was always valid, but early process, has produced meaningful improve-
attempts at embryonic aneuploidy screening ments in clinical outcomes.
were clinical failures [18, 19]. In reality, the This chapter focuses on the past, pres-
techniques employed for molecular analysis ent, and future of PGT applications, tech-
of a single or very small number of cells have niques used to obtain genetic material for
lacked sufficient precision to be clinically analysis, and molecular strategies utilized
meaningful. More recently, application of for analysis.
Case Vignette 1: Preimplantation Genetic Diagnosis
A 32-year-old G2P1001 presents to the clinic for The patient undergoes IVF and genetic
preimplantation counseling. She presented late material from the embryos is obtained from the
to care with her first pregnancy, and it was dis- trophectoderm on day 5 for testing, and then
covered after birth that the child was affected by vitrification of the embryos is performed.
cystic fibrosis. They desire to discuss options for Testing reveals that she has two embryos of her
preventing cystic fibrosis in their next pregnancy. six which are chromosomally normal and do
Her physician orders carrier testing and she not possess the two mutations which would
and her partner have mutations identified in result in cystic fibrosis.
their CFTR gene. She possesses the pN1202K After endometrial preparation with
mutation and he the p.F508del. The treatment estrogen and progesterone, a single embryo

plan utilizing linked markers and sequencing of transfer is performed utilizing a normal
the gene of interest is devised in collaboration blastocyst.
with a single-gene genetics laboratory.
Case Vignette 2: Preimplantation Genetic Screening
A 36-year-old G2P1011 with male factor infer- transfer but wants to limit the chance of having
tility presents in follow-up to the clinic. She had a chromosomally abnormal pregnancy once
a successful birth of a child from IVF 3 years again.
ago. The couple desires a second child but does The patient undergoes IVF with trophecto-
not want twins. They have five embryos remain- derm biopsy of the embryo on day 5 followed
ing which are cryopreserved. She undergoes a by embryo vitrification. The results show that
single embryo transfer, and the resulting preg- two of five blastocysts are chromosomally nor-
nancy is diagnosed with trisomy 21 with chori- mal and designated suitable for embryo trans-
onic villus sampling. She undergoes termination fer. After endometrial preparation with estrogen
of pregnancy and returns to the clinic to discuss and progesterone, a single embryo transfer is
further options. She desires a single embryo performed.
19.2 Applications for Genetic 19.2.1 Sex-Linked Diseases

Testing of Embryos
At the outset, a readily available application
Preimplantation genetic testing for human of PGT-M came in the form of X-linked con-
embryos was first instituted in 1990 by ditions. This approach was ideal for several
Handyside et al. The report entailed two cou- reasons. First, in keeping with the goal of
ples at risk for transmission of X-linked men- decreasing the need for pregnancy termina-
tal retardation and adrenoleukodystrophy [4]. tion in couples adverse to it, it allowed for
Analysis of a blastomere at the six- to eight-cell selection of couples with a 50% chance of
stage with polymerase chain reaction (PCR) requiring pregnancy termination. This was
analysis which amplified a Y- chromosome- most commonly done utilizing fluorescent in
specific repeat sequence allowed for transfer situ hybridization (FISH) at the outset since
of female embryos. The field’s impetus at the identification and transfer of female embryos
outset was to identify only unaffected children eliminated the possibility of transmission of
prior to implantation and thus eliminate the disease. This did, however, result in the dis-
need for pregnancy termination after a diag- carding normal male embryos as FISH could
nosis was made at a later time by either chori- only indicate that they were male and could
onic villus sampling (CVS) or amniocentesis. not identify if they carried the normal or the
While PGT-M was initially applied to effected X chromosome. As sequencing infor-
a small subset of disorders with a high like- mation became more readily available, it
lihood, on the order of 25–50%, of being became more commonplace to test for the
present, over subsequent years, it quickly specific gene and thus to transfer normal
expanded. Testing for genetic disorders with embryos regardless of gender. This process
low penetrance and late-onset became more allowed for testing of many X-linked diseases,
common, and the list of disorders tested con- chiefly fragile X syndrome, Duchenne muscu-
sisted of over 100 conditions, although the lar dystrophy, and hemophilia.
most frequent were cystic fibrosis and hemo-
globinopathies [20].
Since that time the applications of PGT-M 19.2.2 Single Gene Diseases
have grown further to include a vast list of
sex-linked and autosomal single-gene disor- As PGT-M became more widespread, autoso-
ders, HLA typing, translocations, and aneu- mal recessive gene mutations became the most
ploidy screening. Of note, there are differences commonly tested. The most common of these
in national regulations which are constantly included cystic fibrosis, beta thalassemia,
evolving [21]. sickle cell anemia, and spinal muscular atro-
Finally, circumstances under which PGT- phy. Autosomal-dominant disorders such as
M is applied are also changing. In the past, it myotonic dystrophy type 1, Huntington’s dis-
was necessary that the couple has had or poor ease, and neurofibromatosis were also widely
pregnancy outcome or had strong family his- tested for in embryos utilizing PGT-M.
tory of disease in order to uncover the genetic
disease that was to be tested. Now, expanded
carrier screening is becoming more widely uti- 19.2.3 Translocations
lized and in some circumstances allows for
19 detection of a transmissible genetic anomaly Patients with balanced translocations pre-
before it has been phenotypically shown in sented a rather unique advancement for
couples. PGT-SR. This was not a circumstance which
413 19
had previously fallen under the prenatal diag- 19.2.5 HLA Matching
nosis category as poor pregnancy outcomes
related to miscarriages prior to routine test- In the same vein as genetic predisposition dis-
ing with CVS or amniocentesis. The first case orders, prenatal diagnosis for human lym-
of PGT-SR for maternal translocations which phocyte antigen (HLA) matching has not
did not require the use of specific DNA probes been part of standard care as it would then
specific to each translocation was performed involve decisions of termination of a preg-
in 1998 with the use of FISH analysis of nancy that was not HLA matched but other-
the first polar body [22]. Subsequent report- wise healthy. However, with IVF where a
ing with both polar bodies and blastomeres subset of embryos is chosen for embryo trans-
was also reported [23, 24]. These disorders fer as part of routine care, the addition of
are now easily screened for using next-gen- PGT-M to determine HLA typing was more
eration sequencing-based analytics following acceptable. The first case in 2001 involved a
trophectoderm biopsy. couple who had a child with Fanconi anemia.
Testing was done for both HLA typing and
Fanconi anemia in hopes of producing
19.2.4 Genetic Predisposition healthy offspring that may also serve as a
Disorders transplantation donor [29].
There are inherent limitations to PGT-M
As testing became more robust and sophisti- for HLA matching. There is in theory a 25%
cated, the original goal of decreasing the need chance of finding an HLA match, but this
to decide whether to terminate a pregnancy must be taken in combination with being able
with a known genetic disease expanded to to find an embryo that is both an HLA match
include disease states that may not have been and does not carry the disease in question.
clear indications for pregnancy termination Adding aneuploidy screening on top of this
when found during prenatal testing with CVS results in only 12–15% of embryo being eligi-
and amniocentesis. This new group of disease ble for transfer [30, 31].
included those with genetic predisposition
toward disease. The use of PGT-M allowed
for selection of embryos which did not pos- 19.2.6 Aneuploidy Screening
sess the predisposition and thus eliminating
the need to discuss termination for a disease Utilization of PGT-A for aneuploidy screen-
with uncertain phenotypic consequences. ing was initially borne out of a desire to
One of the first such case series involved improve pregnancy rates in patients with
PGT-M for patients at risk for familial adeno- advanced reproductive age. Antenatal diagno-
matous polyposis coli (FAP), von Hippel- sis for aneuploidy was utilized to decrease
Lindau syndrome (VHL), retinoblastoma, and rates of live births of ongoing aneuploid ges-
Li-Fraumeni syndrome, determined by p53 tations. While greatly reducing the prevalence
tumor suppressor gene mutations [25]. This of these abnormalities is an inevitable conse-
was also applied in slightly more controversial quence of PGT-A, the clinical goal was (and
cases, for example, in the case of selecting for remains) to raise sustained implantation rates
an embryo that did not carry a gene known to and lowering clinical loss rates.
be associated with Alzheimer’s disease [26]. FISH was initially employed with various
Although this area of PGT-M is still dis- combinations of chromosomes. Investigators
cussed, both the American Society for employed FISH instead of traditional cytoge-
Reproductive Medicine (ASRM) ethics com- netics because there was no need for the cell to
mittee for adult-onset conditions and be in metaphase. This empowered rapid anal-
ESHRE ethics task force concluded the use ysis allowing transfers to be done 2 days after
of PGT-M for late-onset disorders was the biopsy at the blastocyst stage without
appropriate [27, 28]. the need for cryopreservation. Given that
cryopreservation was much less successful at Platforms which utilize various types of
that time, this was a major concern. WGA include metaphase comparative
While an interesting concept, FISH was genomic hybridization (mCGH) [42, 43],
applied clinically with wholly inadequate vali- array CGH (aCGH) [44, 45], single nucleotide
dations. Problems with fixation, overlapping polymorphism (SNP) arrays [5, 46, 47], oligo-
signals, inconsistent staining, and the low nucleotide CGH [48], and more recently next-
number of fluorophores which could be uti- generation sequencing (NGS) [49]. An
lized in a single analysis resulted in poor pre- additional method, which enables 24 chromo-
cision and accuracy. Initial efforts to elute the some evaluation without requiring whole
probes off after the first “five” were read, and genome amplification, is quantitative real
then probe for additional chromosomes only time polymerase chain reaction (qPCR) [50].
made the results less accurate. This method Each of these platforms varies in their
was always limited by the inability to simulta- reported accuracy, based upon cell line pre-
neously screen for all 24 chromosomes [19]. dictions; consistency between polar body and
FISH typically screened the seven chromo- oocyte; amount of time required to complete
somes most frequently seen in miscarriage the analysis; stage of biopsy which would
specimens (chromosomes 13, 16, 18, 21, 22, X, enable a timely, fresh embryo transfer; num-
and Y), analyzing only one or two blasto- ber of probes required; and minimum detect-
meres [32, 33]. Five trials examining the able imbalance [51].
impact of chromosomal screening in patients In the last several years, analytics have
with advanced maternal age [32–34], typically shifted toward the use of next-generation
classified as poorer prognosis, and four trials sequencing. These techniques still require
in relatively good prognosis patients failed to substantial amplification as a typical biopsy
show benefit when screening with FISH [35– would have approximately 30 pg and would
38]. This is due in part to the limited interro- require amplification to attain 250 ng or more
gation of chromosomes, and the error for a of DNA to allow analysis. Results have been
chromosome is extrapolated based on the mixed with WGA-based trials with an RCT
presence or absence of a single locus. showing benefit [52], but a large multi-lab and
The development of technologies for multi-clinical center study (the STAR trial)
single-cell whole genome amplification found little or no benefit (depending on the
(WGA) allowed for analysis of all 24 chromo- age of the patient) [53]. In reality, the STAR
somes [39–41]. A wide variety of techniques trial had many flaws which relate principally
have been used for WGA ranging from primer to a lack of validation. The predictive values
extension preamplification (PEP) PCR, dege of the analytical results were never deter-
nerate oligonucleotide primed (DOP) PCR, mined, and the overall prevalence of abnor-
multiple displacement amplification (MDA), mal was so high as to not be credible.
end-labeling, and more recently multiple Another approach to next-generation-
annealing and looping-based amplification based PGT-A is to use targeted amplification
cycles (MALBAC). Unfortunately, there are prior to sequencing. This approach provides a
no published studies comparing the vari- small number of sites which are amplified
ous methods used for WGA and no clinical (~4000), but the amplification is much more
data regarding the predictive value of the consistent which with appropriate analytics
techniques. High-quality randomized trails provides a more reliable result [54]. A recent
remain to be done which include different test- large prospective triple-blinded non-selection
19 ing platforms and actual clinical outcomes to study demonstrates that the delivery rate for
confirm the findings. Indeed, WGA remains embryos diagnosed as aneuploid was 0% [55].
a complex and unresolved issue. WGA is a While highly encouraging, no RCT has been
major weakness of many analytical platforms completed using this technology to date.
as no technique requiring WGA has ever been Utilization of PGT-A is increasing as clini-
demonstrated to have acceptably low false cians, embryologists, and patients seek higher
positive rates—an enormous clinical burden. sustained implantation rates. A recent study
415 19
serves to remind investigators and clinicians embryo with precision without removing cells
alike that diagnostics do not improve the at some stage of development. When consid-
reproductive potential of any given embryo ering the stage of development during which
[56]. If you simply transfer all the embryos, the biopsy is performed, safety of the proce-
then ultimately the cumulative delivery will be dure and to the predictive value of analytical
the same in the PGT-A and the non-PGT-A result for actual clinical outcomes are impor-
groups. Such a statement is mathematically tant factors.
correct but fails to consider the burden of care At the current time, biopsy for PGT may
to the patient and the personal suffering which be accomplished at one or more of four pos-
accompanies unnecessary clinical losses and sible developmental stages: (1) first polar
futile transfer cycles [57]. A detailed study body from the oocyte, (2) second polar body
showed that PGT-A is cost-effective in reduc- from the two-pronuclear embryo, (3) blasto-
ing the ultimate cost to deliver, and that was mere biopsy obtained at the cleavage stage, or
prior to recent cost reductions which have (4) trophectoderm biopsy at the blastocyst
occurred as sequencing-based technologies stage. A recent experience from the ESHRE
have become more widely available. data set suggests that ~12% of biopsies have
been done at the polar body stage, ~88% have
been done at the cleavage stage, and that less
19.2.7 Summary than 1% have been done at the blastocyst
stage [61]. Of course, this varies from pro-
Since PGT’s inception in 1990, the utilization gram to program and even country to coun-
worldwide has increased, and its indications try where regulatory restrictions may provide
for use have expanded. At its outset mono- limits on the timing of the biopsy.
genic disorders represented the most common Additionally, there are a number of technical
indication for PGT. While single-gene cases and clinical considerations which guide this
continue to rise, PGT is most commonly uti- decision [62–64].
lized in the United States and Europe for Defining the optimal time to obtain the
aneuploidy screening according to the Society critical specimen for analysis requires careful
for Assisted Reproductive Technology consideration of several factors: (1) Does the
(SART) and the European Society of Human timing of the biopsy allow accurate identifica-
Reproduction (ESHRE) [58, 59]. A major rea- tion of the genetic errors for which the
son for this trend is that single-gene cases embryos are being screened? Screening too
most commonly need to be referred by pri- early in development might miss critical errors
mary care physicians who can alert their which occur later that could impact the repro-
patients who have heritable diseases about this ductive potential of the embryo. (2) Do the
technology. However, according to available abnormalities identified in the specimen accu-
data, less than 10% of internists feel comfort- rately and consistently predict a correspond-
able discussing PGT-M with their patients, ing abnormality in the embryo? If the embryo
and less than 5% ultimately recommend it for has the potential to self-correct, then identifi-
their patients [60]. This data demonstrates cation of imbalances in the biopsy specimen
that the potential of PGT to impact the bur- might result in assignment of an incorrect
den of disease in the human population has karyotype which could cause some normal
only begun to be realized. embryos to be discarded. (3) Can the speci-
men be obtained quickly enough to allow
timely embryo selection? This parameter
19.3 Obtaining Genetic Material impacts the ability to perform an embryo
transfer in the same cycle as the screening. (4)
Although technologic advances may prove Finally, does the biopsy itself compromise the
otherwise, at present, there is no reliable way embryo? The safety of the biopsy itself is
to diagnose genetic disease in the human sentinel.
19.3.1 Polar Body Analysis cal sister-sister homologues. Clinically, when

the PB analysis returns abnormal results, the
Polar bodies (PB) represent an attractive tar- resulting embryo will be discarded. Given the
get as they have been extruded from the oocyte high prevalence of PSSC (90% of meiosis I
and they eventually undergo apoptosis. The errors) and the 50% self-correction rate in the
first PB is removed prior to conception, and second meiotic division [70], this provides an
the second PB is removed following insemina- exceedingly high clinical error rate and results
tion and fertilization. Initial data showed that in an unacceptably large number of euploid
PB biopsy did not impact embryonic develop- embryos being discarded (. Fig. 19.2).
ment, but more recent studies have called this
into question [65, 66].
More significant than these concerns are 19.3.2 Blastomere Biopsy
the issues related to the clinical meaningfulness
of the information attained from PB analysis. Biopsy of the embryo itself is essential to
First, PB analysis tests only for meiotic errors attain the greatest opportunity to capture
in the oocyte. This is effective if single-gene aneuploidy. This may be done at the cleavage
cases are being performed on a maternally stage prior to compaction or later in develop-
inherited disease process. However, when it ment after blastocyst formation. Removal of
comes to aneuploidy screening, the opportu- cells from two- and four-cell embryos is known
nity to identify male meiotic errors or mosaic to reduce the inner cell mass (ICM), the por-
errors, which account for approximately one tion of the embryo from which the fetus is
third of embryonic aneuploidy, is lost. derived [75]. Common practice in the past had
The molecular analytical challenge results been to biopsy embryos at the eight-cell stage
from the different types of meiotic errors. on the morning of day 3. Indeed, until recently
Maternal meiotic errors may arise from either 88% of biopsies for preimplantation genetic
nondisjunction (ND) or premature separation diagnosis (PGT) cases were performed on day
of sister chromatids (PSSC) (. Fig. 19.1). 3 of cleavage stage embryos, with less than 1%
Classically, it was assumed that the substan- being performed at the later blastocyst stage
tial majority of maternal meiotic errors came [61]. Greater concerns arise when more than
from nondisjunction in meiosis I [14, 68, 69]. one cell is required, as is the case with many
In fact almost 90% of meiosis I errors arise platforms capable of PGT.
from PSSC [70–74]. With ND, reciprocal The safety of biopsy at the eight-cell stage
errors in the polar bodies (meaning gain in was based upon the fact that all cells at this
the first PB and loss in the second PB or vice stage are thought to be totipotent [76] and
versa) indicate an imbalance and will result that removal of cells did not appear to com-
in an aneuploid embryo. In contrast, when promise ICM allocation [77]. However, both
PSSC has occurred, then the presence of the cells and cytoplasm have become polar-
reciprocal errors indicates that the abnormal- ized at this stage, and given that all cells are
ity in the first meiotic division was corrected morphologically the same, it is not possible to
in the second meiotic division and that the determine which cells are destined to become
embryo will be euploid for that chromosome. fetal and may be more likely to be detrimen-
The molecular analytical challenge comes in tal to development if biopsied. Finally, the
distinguishing the amount of material lost number of cells available at the cleavage stage
limits the number of cells that can be safely
19 or gained in a polar body. Techniques such
removed and thus limits the starting mate-
as quantitative SNP microarray can detect a
loss or gain for a particular chromosome, but rial available for amplification and analysis.
cannot reliably distinguish the extent of the Removal of one blastomere affects outcomes,
change. Traditional approaches such as het- and removal of two blastomeres has been
erozygosity analyses are less informative here shown to be detrimental to ultimate blasto-
as the polar bodies may contain nearly identi- cyst formation [78].
417 19
Outcomes
From Screening Results
Normal and
Abnormal Meiosis I Meiosis II Embryo
st nd
Meiosis I 1 PB 2 PB Status
Normal
Meiosis Normal Normal Normal
Non-
Dysjunction Loss Gain Trisomy
-Initial Gain
Loss Gain Normal

Premature
Separation
of Sister or
Chromatids
-Initial Gain
Loss Normal Trisomy
Non-
Dysjunction Gain Loss Monosomy
-Initial Loss
Gain Loss Normal

Premature
Separation
of Sister
Chromatids or
-Initial Loss
Gain Normal Monosomy
.. Fig. 19.1 Reciprocal errors and PSSC. Impact of cal errors prognosticate aneuploidy after nondisjunction
the type of meiotic error and the predictive value of but euploidy after premature separation of sister chro-
polar body (PB) screening results and the eventual chromatids (PSSC) making that result indeterminate.
mosomal composition of the embryo. Note that recipro- (Adapted from [67])
Normal GV oocyte
Meiosis I
1st polar body:-21

MII oocyte
4
3
CN
with abnormal 2
1st PB 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14151617 x
1819 21
chromosome 20 22
Insemination and
Completion of Meiosis II
2nd polar body:+21

Zygote with 4
3
CN
abnormal 2
1
2nd PB
1 2 3 4 5 6 7 8 9 10 11 12 13 14151617 x
1819 21
chromosome 20 22
Blastocyst Formation
Embryo:46,XX
Embryo with 4
normal 3
CN
2
trophectoderm 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14151617 x
1819 21
chromosome 20 22
Embryo Transfer and

Newborn Delivery
Newborn:46,XX
4
.
Chromosomally 3
CN
2
normal child 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14151617 x
1819 21
chromosome 20 22
.. Fig. 19.2 PSSC with correction. Data from an ter chromatids with correction of the meiosis I error in
oocyte that underwent first and second polar body anal- meiosis II. The reproductive competence of the embryo
yses and subsequent embryo biopsy. The polar bodies was demonstrated by the delivery of a healthy infant.
demonstrated reciprocal errors. Given that the embryo (Adapted from [67])
19 was normal, this represents premature separation of sis-
19.3.3 Trophectoderm Biopsy begun to develop, and the trophectoderm

cells, those destined to be amniotic mem-
The final stage of development prior to branes, and the ICM cells, those destined to
embryo transfer during IVF is the blastocyst become the embryo, can be easily distin-
stage. At this point the blastocoelic cavity has guished. It is possible to remove up to five or
419 19
six cells, which can be used to reliably reduce Thus, trophectoderm biopsy of four to five
no result rates due to failed amplification cells from an expanded blastocyst represents
when using platforms for CCS. Initially, the safest way to obtain cells from a develop-
trophectoderm biopsy was utilized as confir- ing embryo that contains the full maternal
matory diagnosis following a polar body or and paternal complement of DNA that will
blastomere biopsy [79]. become the conceptus. In light of the highly
Until only recently, no class I data existed predictive nature of the chromosome comple-
evaluating the safety of embryo biopsy at ment in the trophectoderm for the inner cell
these two developmental stages: cleavage stage mass (ICM), removing cells from the ICM
and blastocyst biopsy of trophectoderm. The represents an unnecessary risk [84].
major limitation of literature comparing the Embryonic mosaicism, the presence of
techniques was selection of controls. Given more than one chromosomally different cell
the large variety of reasons patients seek pre- line in the embryo, is important to note here.
implantation genetic diagnosis, it can be chal- It is known that FISH overestimates true-
lenging to compare two groups of patients. cleavage stage mosaicism [85] in some cases
Recently, a blinded, paired, randomized trial indicating it occurs as much as 100% of the
was undertaken to determine the impact of time. There is data utilizing SNP microarray
embryonic biopsy [80]. This experiment was which suggests it occurs 24–31% of the time
done for both cleavage stage biopsies and for [41, 85]. These mosaicism rates may account
trophectoderm biopsy at the blastocyst stage for the failures of euploid blastocyst transfers.
and showed a relative reduction of 30% in the Additionally, mosaicism likely accounts for
sustained implantation rate for blastomere the majority of misdiagnoses made when uti-
biopsy. The recent prospective blinded non- lizing a validated PGT-A platform [86]. It is
selection study also provided insight into the important to consult a genetic counselor in
risk of trophectoderm biopsy and showed cases where the only embryos that are avail-
equivalent outcomes in biopsied and non- able for transfer are mosaic.
biopsied embryos (with no genetics available
in either group at the time of transfer) [55].
This strongly supports the trophectoderm
biopsy may be done safely at least as relates to 19.4 Strategies for Single-Gene
implantation and delivery. Defect PGT-M
There are several possible reasons for these
results. First, the trophectoderm biopsy There were a number of limits which have
removes proportionally fewer cells than the faced PGT in its infancy. They primarily relate
cleavage stage biopsy [81]. One or two blasto- to the fidelity of amplification and analysis of
meres taken from an eight-cell cleavage stage samples with extremely limited amounts of
embryo represents 12.5–25% of the embryo, starting material. This was overcome by ana-
whereas four to five trophectoderm cells taken lyzing the DNA in multiple areas, primarily
from an expanded blastocyst containing 200– through linkage analysis. This was done by
220 cells represent only 2–3% of the total finding single nucleotide polymorphisms
cells. Another possibility is that, as noted (SNPs) on the impacted chromosome which
above, trophectoderm cells represent an extra- are different than those on the normal chro-
embryonic component of the blastocyst, mosome for each individual. Then, at the time
whereas the specific fate of the blastomere of analysis, multiplex PCR reactions are uti-
being removed cannot be determined by mor- lized to look not only for the mutation but
phology and thus could represent cells with also for the linked markers which should be
gene activation that have destined them to nearby. In doing this, the laboratory has sev-
become the embryo [82]. The final possibility eral chances to detect the presence or absence
is that blastocysts simply tolerate mechanical of the mutation.
manipulation better than cleavage stage Unfortunately, linkage analysis is not
embryos [83]. always straightforward. The following are
some of the factors that may impact the reli- 19.4.1 Alternative Strategies
ability of this approach: for PGT-M
1. It may not be possible to target the muta-
tion directly. In such cases, additional The widespread availability of cost-effective
linked markers are recommended. next-generation sequencing platforms may
2. The potential for recombination exists. impact PGT-M. A recent study has demon-
Recombination occurs during meiosis I, strated the ability to sequence through the
and at that time, the DNA is exchanged area of the defect providing both qualitative
between chromosomes. If the point of and quantitative information [49]. This would
recombination lies between the marker functionally provide more markers, and the
and the mutation, then the marker will be depth of the sequencing appears to meaning-
moved to the normal chromosome. In this fully enhance the precision of these assays.
setting, the assay might perform perfectly With the appropriate amplification strategies,
and still prognosticate the wrong clinical it may also allow simultaneous aneuploidy
result! There are ways to minimize the risk screening which would empower the transfer
that recombination will impact the validity of lower numbers of embryos while lowering
of the screening result [61]: loss rates and improving outcomes. There is
(a) Pick markers which are as close to the much work to be done as the validations are
mutation as possible. The closer the not yet published.
mutation, the less likely it is that a
recombination event will occur
between them. 19.5 Strategies for PGT-A
(b) Ideally the marker would be intragenic
and exhibit a high degree of heterozy- Amplification is a critical step in the molecu-
gosity and provide consistent high- lar analysis of these samples. There are
quality amplification. approximately 6 pg of DNA in a single cell.
(c) Extragenic markers which are utilized Thus, an average trophectoderm biopsy of
should ideally be within 1 MB of the five cells would provide approximately 30 pg
mutation. of DNA. Technologies capable of copy num-
(d) Use a total of four markers—two ber analyses require dramatically more DNA
upstream and two downstream of the to obtain a result: typically several hundred
mutation. Thus if ADO occurs but nanograms or more. This requires a 100,000-
there is concurrence with the other fold (or more) amplification of the DNA in a
three, a result may still be determined. relatively uniform fashion.
If only a single marker is used—spe- Many techniques employ whole genome
cifically in those cases where the muta- amplification. While it has the advantage of
tion is not being evaluated directly—an potentially amplifying the entire genome, uni-
indeterminate will result for any dis- formity is typically not attained and may vary
crepancy. as much as several thousand-fold across dif-
(e) Recombination will be reflected by a ferent portions of the genome. This disadvan-
discrepancy between the more proxi- tage may be overcome by evaluating the
mal and distal markers. This phe- chromosomes at a large number of different
nomenon should be rare (~1%). If sites and then performing statistical smooth-
you have several embryos in a cohort
19 with recombination in the interpreted
ing. Alternatively, a targeted approach focused
at specific loci on each chromosome may be
results, it may be prudent to reevaluate used. This is more uniform but still varies and
the screening strategy or the fidelity of requires some degree of statistical smoothing.
the amplification for those markers. Whole genome amplification is required for
421 19
SNP microarray and CGH-related technolo- the number of DNA base probes across the
gies. In contrast, qPCR is done with targeted 24 chromosomes. Although accuracy can-
amplification of specific loci, and next- not be precisely correlated with probe num-
generation sequencing (NGS) may be done ber, resolution, which in CCS is the ability to
with either. distinguish between euploid and aneuploid,
One metric by which to compare the avail- varies significantly. For example, BlueGnome
able technologies is the time required to per- (Illumina, USA), a widely used aCGH plat-
form the test. This is of great importance in form, uses bacterial artificial chromosome
the application to real-time IVF. Often, the (BAC) arrays and possesses between 2000 and
embryo is transferred in the same cycle as the 5000 DNA probes spread across the 24 chro-
oocyte was retrieved, the so-called fresh mosomes [92]. By comparison, the Agilent
embryo transfer. If this is not possible, the (Agilent, USA) utilizes 180,000 oligonucle-
embryo must be subjected to freezing and otide probes [48], and the Affymetrix (USA)
transferred at a later day, the so-called frozen SNP array contains 262,000–370,000 probes
transfer. As discussed, the biopsy is most opti- [41, 46, 47].
mally performed on the expanded blastocyst. In addition to resolution differences, the
This leaves less than 24 h within which to way that a copy number is assigned for each
make a diagnosis and transfer the embryo in chromosome differs between aCGH and
that fresh cycle. If diagnosis takes longer than SNP arrays. With aCGH a copy number is
this, embryos must be frozen, using either assigned by analyzing a ratio of red (sample)
slow freezing methods or vitrification, and and green (control) fluorescence after differ-
then thawed after the diagnosis is made and ential labeling and mixing of biopsy DNA
transferred in a separate cycle. In circum- with control DNA [93]. With the Affymetrix
stances where results cannot be obtained in SNP array, a single-color system is used where
time for a fresh embryo transfer, modern vitri- the fluorophore hybridizes only to the biop-
fication techniques yield equivalent pregnancy sied DNA sample, and then computational
outcomes in fresh or frozen cycles [10]. comparisons of signal intensities are made
Traditional metaphase CGH requires a to separate control DNA-hybridized arrays
minimum of 72 h to yield results. There are [94]. The former has the advantage of com-
shorter mCGH protocols, but even these take paring a control sample in the same time
up to 24 h for the entire process to be com- frame under the same laboratory conditions.
pleted, and results may not be available in The latter has the advantage of comparing
time for a fresh transfer [65, 66, 87–89]. Thus, the sample DNA to several control samples,
aCGH is an attractive alternative, requiring rather than just one, which allows for better
only 12 h for results [90], with the added ben- statistical smoothing of natural inconsisten-
efit of greater throughput. SNP arrays have cies in control samples. Furthermore, the dif-
also been used to perform CCS on blasto- ferences in the paradigm utilized to assign
meres in time for a fresh transfer and also have copy number impact the platform’s ability to
a result rate time of 12 h [46]. Finally, qPCR gather further information from the test. For
results are available in as little as 4 h which example, SNP arrays allow for a determina-
enables a fresh embryo transfer after analysis tion of parental origin of both monosomy
of trophectoderm cells from an expanded and trisomy of parental origin from the SNP
blastocyst [91]. Thus, only qPCR analysis array data alone [74]. Additionally, uniparen-
allows for safe biopsy of a day 5 blastocyst tal isodisomy, although a rare event, has been
with results in time for a fresh transfer early validated utilizing SNP array through loss
on day 6. of heterozygosity analysis [5]. Finally, DNA
Thus, given the ability to have results rela- fingerprinting from SNP array data provides
tively quickly, DNA array technology was clinicians with the o pportunity to prevent
widely applied to CCS in the form of aCGH misdiagnosis from contamination and can
and SNP array. There are two main contrast- also be used to track which embryos implant
ing attributes of these two platforms. First is in the event of a multiple embryo transfer for
research and clinical purposes screening [95]. for each amplicon. Analytics are then used to
The array CGH platform is unable to provide translate these depths to a copy number for
these additional points of information. that site and only ultimately for each chromo-
While multiple approaches continued to some. The predictive values for results in this
be used for PGT, contemporary analytical way are very high, but complete validation
platforms typically utilized some sort of awaits performance of an RCT.
amplification followed by next-generation
sequencing. These techniques are not all
equivalent and are best distinguished by the 19.5.1 Clinical Impact
nature of the amplification and at times, the
rigor of the analytics. Intuitively it seems logical that PGT-A would
WGA followed by next-generation improve outcome with older patients.
sequencing typically sequences approximately Aneuploidy rate is closely related to maternal
25–30 million base pairs (BPs). Given that the age (. Fig. 19.3a). Furthermore, the com-
genome has 3.3 billion base pairs, it is evident plexity of the aneuploidy increases with age
that less than 1% of base pairs will be (. Fig. 19.3b). The fact that a platform is
sequenced even a single time. Clearly tradi- accurate and reliable and has known positive
tional approaches which rely on depth will not predictive value does not indicate that clini-
apply in these assays. To deal with that uncer- cal outcomes can be improved by applying
tainty, all the sequences in a given region of the technology. This is the final step in valida-
DNA will be combined to assign a copy num- tion: a prospective, randomized selection
ber. These regions are termed “molecular study. This class I data was recently obtained
bin.” For example, if 5 sequences of 200 BPs and demonstrated that CCS for aneuploidy
each were to fall in a 50,000 BP molecular bin, utilizing qPCR, which had been cross-vali-
then the copy number assigned there would be dated with SNP array, meaningfully enhances
weighted at 1000 (5 × 200) and the normalized embryo selection and ultimately implanta-
for the size of the bin, the frequency of ampli- tion and delivery rates [91]. Indeed, in this
fication in those regions, and many other fac- study, sustained implantation rates in the
tors. By doing that over hundreds or thousands trophectoderm biopsy and CCS group were
of bins, it is possible to assign a copy number 66.4% versus 47.9% in the control group.
to each bin, which are then combined to Subsequent class 1 data proved the single-
assign copy number to each chromosome. embryo transfer of a CCS-screened blasto-
These techniques have not been validated with cyst had equivalent outcomes as
robust non-selection studies, and thus the pre- double-embryo transfer in an unscreened
dictive values of the results remain unknown arm with elimination of twin pregnancies
and should be considered cautiously. [10]. Unfortunately, not all the platforms in
Alternatively, if targeted amplification is use for CCS have undergone rigorous valida-
done, then the DNA in the sample is amplified tion. However, many of the shortcomings
only at specific targeted sights. These sites are have been addressed, and continued work
selected for their stability and reproducibility. will hopefully alleviate this concern. It is crit-
The number of amplicons in the sequence ical that this occurs lest their use results in a
product may then be used to assign a depth similar story to that of FISH.
19
423 19
a 100
90
Percent of Embryos Which are Aneuploid
80
70
60
50
40
30
20
10
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+
Maternal Age (yrs)
b 100%
90%
80%
Proportion of all embryos within that age
70%
60%
50%
40%
30%
20%
10%
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 46 47 48 49
Age (yrs)
Euploid Single Error Double Error Three or More Errors
.. Fig. 19.3 a Embryonic aneuploidy rate. Aneuploidy ploidy screening results among 15,169 embryos. The
rate relative to maternal age in 15,169 embryos undergo- data are expressed as the proportion of the embryo
ing aneuploidy screening for clinical IVF. (Adapted which were euploid or as aneuploid involved a single
from [96]). b Complexity of aneuploidy with age. Com- chromosome, two chromosomes, or three or more chro-
parison of maternal age and the nature of the aneu- mosomes. (Adapted from [47])
References
Conclusion
Preimplantation genetic diagnosis has 1. Reindollar RH, et al. A randomized clinical trial to
evolved over the past several decades evaluate optimal treatment for unexplained infertil-
ity: the fast track and standard treatment (FASTT)
and existed in many forms. Its use as a
trial. Fertil Steril. 2010;94:888–99.
mechanism for enhancing embryo selection 2. Goldman MB, et al. A randomized clinical trial to
in hopes of improving pregnancy outcomes determine optimal infertility treatment in older cou-
with IVF has grown substantially in the ples: the Forty and Over Treatment Trial (FORT-T).
past decade. There is also continued growth Fertil Steril. 2014;101:1574–1581.e2.
3. Steptoe PC, Edwards RG. Birth after the reimplan-
of utilization for single-gene cases; however,
tation of a human embryo. Lancet. 1978;2:366.
this remains an underutilized technology. 4. Handyside AH, et al. Pregnancies from biopsied
human preimplantation embryos sexed by Y-specific
DNA amplification. Nature. 1990;344:768–70.
19.6 Review Quesions 5. Treff NR, et al. Accurate single cell 24 chromosome
aneuploidy screening using whole genome amplifi-
cation and single nucleotide polymorphism micro-
??1. Polar body (PB) analysis tests arrays. Fertil Steril. 2010;94:2017–21.
A. Meiotic errors in the oocyte 6. Treff NR, et al. Single nucleotide polymorphism
B. Mitotic errors in the oocyte microarray-based concurrent screening of
C. Meiotic errors of the embryo 24-chromosome aneuploidy and unbalanced trans-
locations in preimplantation human embryos. Fertil
D. Mitotic errors of the embryo
Steril. 2011;95:1606–12e1–2.
7. Scott RT, et al. Microarray based 24 chromosome
??2. A mosaic embryo is defined as embryo preimplantation genetic diagnosis (mPGD) is highly
with predictive of the reproductive potential of human
A. More than one chromosomally dis- embryos: a prospective blinded non-selection trial.
tinct cell line Fertil Steril. 2008;90:22.
8. Scott RT, et al. Comprehensive chromosome screen-
B. Aneuploidy
ing is highly predictive of the reproductive potential
C. Monogenic chromosomal abnor- of human embryos: a prospective, blinded, nonse-
mality lection study. Fertil Steril. 2012;97:870–5.
D. Abnormal inner cell mass differen- 9. Forman EJ, et al. Obstetrical and neonatal out-
tiation comes from the BEST Trial: single embryo transfer
with aneuploidy screening improves outcomes after
in vitro fertilization without compromising delivery
??3. The safest way to obtain cells from a
rates. Am J Obstet Gynecol. 2014;210:157.e1–6.
developing embryo that contains the 10. Forman EJ, et al. In vitro fertilization with single
full maternal and paternal complement euploid blastocyst transfer: a randomized con-
of DNA that will become the conceptus trolled trial. Fertil Steril. 2013;100(1):100–7.e1.
is by 11. Forman EJ, et al. Comprehensive chromosome
screening and embryo selection: moving toward
A. Trophectoderm biopsy of four to
single euploid blastocyst transfer. Semin Reprod
five cells from an expanded blasto- Med. 2012;30:236–42.
cyst 12. Wells D, Delhanty JD. Comprehensive chromo-
B. Inner cell mass biopsy somal analysis of human preimplantation embryos
C. Biopsy of early cleavage stage using whole genome amplification and single cell
comparative genomic hybridization. Mol Hum
embryo
Reprod. 2000;6:1055–62.
D. Polar body 13. Fragouli E, et al. Comprehensive molecular cytoge-
netic analysis of the human blastocyst stage. Hum
19 Reprod. 2008;23:2596–608.
19.7 Answers 14. Hassold T, Hunt P. To ERR (meiotically) is human:
the genesis of human aneuploidy. Nat Rev Genet.
2001;2:280–91.
vv1. A
15. Fragouli E, Wells D. Aneuploidy in the human blas-
tocyst. Cytogenet Genome Res. 2011;133:149–59.
vv2. A 16. Hassold T, Hunt P. Maternal age and chromosom-
ally abnormal pregnancies: what we know and what
vv3. A we wish we knew. Curr Opin Pediatr. 2009;21:703–8.
425 19
17. Munne S, et al. Embryo morphology, developmen- 35. Meyer LR, et al. A prospective randomized con-
tal rates, and maternal age are correlated with chro- trolled trial of preimplantation genetic screening in
mosome abnormalities. Fertil Steril. 1995;64:382–91. the “good prognosis” patient. Fertil Steril.
18. Mastenbroek S, et al. In vitro fertilization with pre- 2009;91:1731–8.
implantation genetic screening. N Engl J Med. 36. Jansen RP, et al. What next for preimplantation
2007;357:9–17. genetic screening (PGS)? Experience with blastocyst
19. Fritz MA. Perspectives on the efficacy and indica- biopsy and testing for aneuploidy. Hum Reprod.
tions for preimplantation genetic screening: where 2008;23:1476–8.
are we now? Hum Reprod. 2008;23:2617–21. 37. Staessen C, et al. Preimplantation genetic screening
20. Kuliev A, Verlinsky Y. Preimplantation diagnosis: a does not improve delivery rate in women under the
realistic option for assisted reproduction and genetic age of 36 following single-embryo transfer. Hum
practice. Curr Opin Obstet Gynecol. 2005;17: Reprod. 2008;23:2818–25.
179–83. 38. Mersereau JE, et al. Preimplantation genetic screen-
21. Basille C, et al. Preimplantation genetic diagnosis: ing in older women: a cost-effectiveness analysis.
state of the art. Eur J Obstet Gynecol Reprod Biol. Fertil Steril. 2008;90:592–8.
2009;145:9–13. 39. Handyside AH, et al. Isothermal whole genome
22. Munné S, et al. First pregnancies after preconcep- amplification from single and small numbers of
tion diagnosis of translocations of maternal origin. cells: a new era for preimplantation genetic diagno-
Fertil Steril. 1998;69:675–81. sis of inherited disease. Mol Hum Reprod.
23. Munne S, et al. Outcome of preimplantation genetic 2004;10:767–72.
diagnosis of translocations. Fertil Steril. 40. Hu DG, et al. Aneuploidy detection in single cells
2000;73:1209–18. using DNA array-based comparative genomic
24. Scriven PN, et al. Chromosome translocations: seg- hybridization. Mol Hum Reprod. 2004;10:
regation modes and strategies for preimplantation 283–9.
genetic diagnosis. Prenat Diagn. 1998;18:1437–49. 41. Northrop LE, et al. SNP microarray-based 24 chro-
25. Rechitsky S, et al. Preimplantation genetic diagnosis mosome aneuploidy screening demonstrates that
for cancer predisposition. Reprod Biomed Online. cleavage-stage FISH poorly predicts aneuploidy in
2002;5:148–55. embryos that develop to morphologically normal
26. Verlinsky Y, et al. Preimplantation diagnosis for blastocysts. Mol Hum Reprod. 2010;16:590–600.
early-onset Alzheimer disease caused by V717 L 42. Wells D, et al. Detailed chromosomal and molecular
mutation. JAMA. 2002;287:1018–21. genetic analysis of single cells by whole genome
27. Ethics Committee of American Society for Repro- amplification and comparative genomic hybridisa-
ductive Medicine. Use of preimplantation genetic tion. Nucleic Acids Res. 1999;27:1214–8.
diagnosis for serious adult onset conditions: a com- 43. Sher G, et al. Oocyte karyotyping by comparative
mittee opinion. Fertil Steril. 2013;100:54–7. genomic hybridization provides a highly reliable
28. Shenfield F, et al. Taskforce 5: preimplantation method for selecting “competent” embryos, mark-
genetic diagnosis. Hum Reprod. 2003;18:649–51. edly improving in vitro fertilization outcome: a mul-
29. Verlinsky Y, et al. Preimplantation diagnosis for tiphase study. Fertil Steril. 2007;87:1033–40.
Fanconi anemia combined with HLA matching. 44. Gutierrez-Mateo C, et al. Preimplantation genetic
JAMA. 2001;285:3130–3. diagnosis of single-gene disorders: experience with
30. Kahraman S, et al. Seven years of experience of pre- more than 200 cycles conducted by a reference labo-
implantation HLA typing: a clinical overview of ratory in the United States. Fertil Steril.
327 cycles. Reprod Biomed Online. 2011;23:363–71. 2009;92:1544–56.
31. Van de Velde H, et al. The experience of two Euro- 45. Hellani A, et al. Multiple displacement amplifica-
pean preimplantation genetic diagnosis centres on tion on single cell and possible PGD applications.
human leukocyte antigen typing. Hum Reprod. Mol Hum Reprod. 2004;10(11):847–52.
2009;24:732–40. 46. Johnson DS, et al. Preclinical validation of a micro-
32. Staessen C, et al. Comparison of blastocyst transfer array method for full molecular karyotyping of
with or without preimplantation genetic diagnosis blastomeres in a 24-h protocol. Hum Reprod.
for aneuploidy screening in couples with advanced 2010;25:1066–75.
maternal age: a prospective randomised controlled 47. Handyside AH, et al. Karyomapping: a universal
trial. Hum Reprod. 2004;19:2849–58. method for genome wide analysis of genetic disease
33. Hardarson T, et al. Preimplantation genetic screen- based on mapping crossovers between parental hap-
ing in women of advanced maternal age caused a lotypes. J Med Genet. 2010;47:651–8.
decrease in clinical pregnancy rate: a randomized 48. Traversa MV, et al. The genetic screening of preim-
controlled trial. Hum Reprod. 2008;23:2806–12. plantation embryos by comparative genomic
34. Debrock S, et al. Preimplantation genetic screening hybridisation. Reprod Biol. 2011;11(Suppl 3):51–60.
(PGS) for aneuploidy in embryos after in vitro fertil- 49. Treff NR, et al. Evaluation of targeted next-
ization (IVF) does not improve reproductive out- generation sequencing-based preimplantation
come in women over 35: a prospective controlled genetic diagnosis of monogenic disease. Fertil Steril.
randomised study. Fertil Steril. 2007;88:S237. 2013;99:1377–1384.e6.
50. Forman EJ, et al. Comprehensive chromosome preimplantation genetic diagnosis/screening (PGD/
screening alters traditional morphology-based PGS). Hum Reprod. 2011;26:41–6.
embryo selection: a prospective study of 100 con- 62. Dokras A, et al. Trophectoderm biopsy in human
secutive cycles of planned fresh euploid blastocyst blastocysts. Hum Reprod. 1990;5:821–5.
transfer. Fertil Steril. 2013;100:718–24. 63. McArthur SJ, et al. Pregnancies and live births after
51. Treff NR, Scott RT Jr. Methods for comprehensive trophectoderm biopsy and preimplantation genetic
chromosome screening of oocytes and embryos: testing of human blastocysts. Fertil Steril.
capabilities, limitations, and evidence of validity. J 2005;84:1628–36.
Assist Reprod Genet. 2012;29:381–90. 64. Kokkali G, et al. Blastocyst biopsy versus cleavage
52. Yang Z, Lin J, Zhang J, et al. Randomized compari- stage biopsy and blastocyst transfer for preimplan-
son of next-generation sequencing and array com- tation genetic diagnosis of beta-thalassaemia: a
parative genomic hybridization for preimplantation pilot study. Hum Reprod. 2007;22:1443–9.
genetic screening: a pilot study. BMC Med Genet. 65. Verlinsky Y, Kuliev A. Micromanipulation of gam-
2015;8:30. etes and embryos in preimplantation genetic diag-
53. Munne S, Kaplan B, Frattarelli JL, Child T, nosis and assisted fertilization. Curr Opin Obstet
Nakhuda G, Shamma FN, Silverger K, Kalista T, Gynecol. 1992;4:720–5.
Handyside AH, Katz-Jaffe M, Wells D, Gordon T, 66. Verlinsky Y. Single gene mutations in early embry-
Stock-Myer S, Willman S, Star Study Group. Preim- onic loss. J Assist Reprod Genet. 1992;9:504–5.
plantation genetic testing for aneuploidy versus 67. Scott RT, et al. Blastocyst biopsy with comprehen-
morphology as selection criteria for single frozen- sive chromosome screening and fresh embryo trans-
thawed embryo transfer in good-prognosis patients: fer significantly increases in vitro fertilization
a multicenter randomized clinical trial. Fertil Steril. implantation and delivery rates: a randomized con-
2019;112:1071–9. trolled trial. Fertil Steril. 2013;100:697–703.
54. Zimmerman RS, Tao X, Marin D, et al. Preclinical 68. Scott KL, et al. Selecting the optimal time to per-
validation of a targeted next generation sequencing- form biopsy for preimplantation genetic testing.
based comprehensive chromosome screening meth- Fertil Steril. 2013;100:608–14.
odology in human blastocysts. Mol Hum Reprod. 69. Hassold T, et al. The origin of human aneuploidy:
2018;24(1):37–45. where we have been, where we are going. Hum Mol
55. Tiegs AW, Tao X, Zhan Y, et al. A multicenter, pro- Genet. 2007;16(2):R203–8.
spective, blinded, nonselection study evaluating the 70. Forman EJ, et al. Embryos whose polar bodies con-
predictive value of an aneuploid diagnosis using a tain isolated reciprocal chromosome aneuploidy are
targeted next-generation sequencing-based preim- almost always euploid. Hum Reprod. 2013;28:502–8.
plantation genetic testing for aneuploidy assay and 71. Scott RT, et al. Delivery of a chromosomally nor-
impact of biopsy. Fertil Steril. 2021;11:627–37. mal child from an oocyte with reciprocal aneuploid
56. Yan Y, Qin Y, Zhao H, Sun Y, Gong F, Li R, Sun X, polar bodies. J Assist Reprod Genet. 2012;29(6):
Ling X, Li H, Hao C, Tan J, Yang J, Zhu Y, Liu F, 533–7.
Chen D, Wei D, Lu J, Ni T, Zhou W, Wu K, Gao Y, 72. Fragouli E, et al. The cytogenetics of polar bodies:
Shi Y, Lu Y, Zhang T, Wu W, Ma X, Ma H, Fu J, insights into female meiosis and the diagnosis of
Zhang J, Meng Q, Zhang H, Legro RS, Chen aneuploidy. Mol Hum Reprod. 2011;17:286–95.
ZJ. Live birth with or without preimplantation 73. Gabriel AS, et al. Array comparative genomic
genetic testing for aneuploidy. N Engl J Med. hybridisation on first polar bodies suggests that
2021;385:2047–58. non-disjunction is not the predominant mechanism
57. Neal SA, Morin SJ, Franasiak JM, et al. Preimplan- leading to aneuploidy in humans. J Med Genet.
tation genetic testing for aneuploidy is cost-effective, 2011;48(7):433–7.
shortens treatment time, and reduces the risk of 74. Treff NR, et al. Characterization of the source of
failed embryo transfer and clinical miscarriage. Fer- human embryonic aneuploidy using microarray-
til Steril. 2018;110(5):896–904. based 24 chromosome preimplantation genetic diag-
58. Ginsburg ES, et al. Use of preimplantation genetic nosis (mPGD) and aneuploid chromosome
diagnosis and preimplantation genetic screening in fingerprinting. Fertil Steril. 2008;90:S37.
the United States: a Society for Assisted Reproduc- 75. Tarín JJ, et al. Human embryo biopsy on the 2nd
tive Technology Writing Group paper. Fertil Steril. day after insemination for preimplantation diagno-
2011;96:865–8. sis: removal of a quarter of embryo retards cleavage.
19 59. Goossens V, et al. ESHRE PGD Consortium data
collection XI: cycles from January to December 76.
Fertil Steril. 1992;58:970–6.
Mottla GL, et al. Lineage tracing demonstrates that
2008 with pregnancy follow-up to October 2009. blastomeres of early cleavage-stage human pre-
Hum Reprod. 2012;27:1887–911. embryos contribute to both trophectoderm and
60. Klitzman R, et al. Views of internists towards uses inner cell mass. Hum Reprod. 1995;10:384–91.
of PGD. Reprod Biomed Online. 2013;26:142–7. 77. Hardy K, Handyside AH. Cell allocation in twin
61. Harton GL, et al. ESHRE PGD consortium/embry- half mouse embryos bisected at the 8-cell stage:
ology special interest group—best practice guide- implications for preimplantation diagnosis. Mol
lines for polar body and embryo biopsy for Reprod Dev. 1993;36:16–22.
427 19
78. Goossens V, et al. Diagnostic efficiency, embryonic mosaicism by short comparative genomic hybridiza-
development and clinical outcome after the biopsy tion. Fertil Steril. 2011;95:413–6.
of one or two blastomeres for preimplantation 88. Rius M, et al. Reliability of short comparative
genetic diagnosis. Hum Reprod. 2008;23:481–92. genomic hybridization in fibroblasts and blasto-
79. De Boer KA, et al. Moving to blastocyst biopsy for meres for a comprehensive aneuploidy screening:
preimplantation genetic diagnosis and single first clinical application. Hum Reprod.
embryo transfer at Sydney IVF. Fertil Steril. 2010;25:1824–35.
2004;82:295–8. 89. Landwehr C, et al. Rapid comparative genomic
80. Scott RT, et al. Cleavage-stage biopsy significantly hybridization protocol for prenatal diagnosis and its
impairs human embryonic implantation potential application to aneuploidy screening of human polar
while blastocyst biopsy does not: a randomized and bodies. Fertil Steril. 2008;90:488–96.
paired clinical trial. Fertil Steril. 2013;100(3): 90. Geraedts J, et al. Polar body array CGH for predic-
624–30. tion of the status of the corresponding oocyte. Part
81. Hardy K, et al. The human blastocyst: cell number, I: clinical results. Hum Reprod. 2011;26(11):3173–
death and allocation during late preimplantation 80.
development in vitro. Development. 1989;107: 91. Treff NR, et al. Four hour 24 chromosome aneu-
597–604. ploidy screening using high throughput PCR SNP
82. Hansis C, Edwards RG. Cell differentiation in the allele ratio analyses. Fertil Steril. 2009;92:S49–50.
preimplantation human embryo. Reprod Biomed 92. Fishel S, et al. Live birth after polar body array
Online. 2003;6:215–20. comparative genomic hybridization prediction of
83. Braude P, et al. Human gene expression first occurs embryo ploidy-the future of IVF? Fertil Steril.
between the four- and eight-cell stages of preim- 2010;93:1006e7–1006e10.
plantation development. Nature. 1988;332:459–61. 93. Kallioniemi A, et al. Comparative genomic hybrid-
84. Johnson DS, et al. Comprehensive analysis of ization for molecular cytogenetic analysis of solid
karyotypic mosaicism between trophectoderm and tumors. Science. 1992;258:818–21.
inner cell mass. Mol Hum Reprod. 2010;16:944–9. 94. Arteaga-Salas JM, et al. An overview of image-
85. Treff NR, et al. SNP microarray-based 24 chromo- processing methods for Affymetrix GeneChips.
some aneuploidy screening is significantly more Brief Bioinform. 2008;9:25–33.
consistent than FISH. Mol Hum Reprod. 95. Treff NR, et al. A novel single-cell DNA finger-
2010;16:583–9. printing method successfully distinguishes sibling
86. Werner MD, et al. The clinically recognizable error human embryos. Fertil Steril. 2009;94:477–84.
rate following the transfer of comprehensive chro- 96. Franasiak JM, et al. The nature of aneuploidy with
mosomal screened euploid embryos is low. Fertil increasing age of the female partner: a review of 15,
Steril. 2014;102(6):1613–8. 169 consecutive trophectoderm biopsies evaluated
87. Rius M, et al. Comprehensive embryo analysis of with comprehensive chromosomal screening. Fertil
advanced maternal age–related aneuploidies and Steril. 2014;101:656–663.e1.
429 20
Hysteroscopic
Management
of Intrauterine Disorders:
Polypectomy,
Myomectomy,
Endometrial Ablation,
Adhesiolysis, and Removal
of Uterine Septum
Michelle G. Park and Keith B. Isaacson
Contents
20.2 Indications – 433
20.3 Basic Hysteroscopic Hardware – 433

20.3.1 T ypes of Hysteroscopes – 433
20.3.2 Distention Media – 433
20.3.3 Low-Viscosity Fluids – 434
20.3.4 Carbon Dioxide – 434
20.3.5 Dextran 70 – 434
20.3.6 Diagnostic Hysteroscopy – 434
20.3.7 Operative Hysteroscopy – 435
20.3.8 Complications – 435
20.3.9 Office Hysteroscopy – 435
20.3.10 Equipment – 436
20.3.11 Technique – 436

https://doi.org/10.1007/978-3-030-99596-6_20
20.3.12 ain Management – 436
P
20.3.13 NSAIDs and Anxiolytics – 437
20.3.14 Topical Analgesia – 437
20.3.15 Paracervical Block – 437
20.3.16 Conscious Sedation – 437
20.3.17 Patient Selection – 438
20.4 Complications – 438

20.4.1 F luid Intravasation – 438
20.4.2 Perforation – 439
20.4.3 Vasovagal Reaction – 439
20.4.4 Bleeding – 439
20.4.5 Hysteroscopic Polypectomy – 439
20.4.6 Technique – 440
20.4.7 Hysteroscopic Myomectomy – 440
20.4.8 Classification – 440
20.4.9 Surgical Approach According to Stage – 440
20.4.10 Technique – 442
20.4.11 Intraoperative Ultrasonography – 443
20.4.12 Fertility Preservation – 443
20.4.14 Endometrial Ablation – 444
20.4.15 Endometrial Ablation Techniques – 444
20.4.16 First-Generation Hysteroscopic
Endometrial Ablation – 444
20.4.17 Technique: First-Generation Hysteroscopic
Endometrial Ablation – 444
20.4.18 Vasopressin – 445
20.4.19 Technique: Rollerball and Endomyometrial
Resection – 445
20.4.20 Outcomes – 446
20.4.21 Second-Generation Endometrial Ablation Devices – 446
20.4.22 Complications of Endometrial Ablation – 446
20.4.23 Hysteroscopic Resection of Adhesions – 446
20.4.24 Pathophysiology – 447
20.5 Classification of Intrauterine Adhesions – 447

20.5.1 arch Classification – 447
M
20.5.2 American Society for Reproductive Medicine
Classification – 447
20.5.3 Clinical Manifestations – 447
20.6.1 S onohysterogram – 448
20.6.2 Hysteroscopy – 448
20.7 Surgical Treatment – 448

20.7.1 ysteroscopic Surgery – 448
H
20.7.2 Postoperative Adjunctive Therapy – 449
20.7.4 Outcome – 449
20.8 Uterine Septum – 450

20.8.1 E tiology – 450
20.8.2 Classification – 451
20.8.3 Incidence – 451
20.8.4 Pathophysiology of Pregnancy Complications – 451
20.8.5 Diagnosis – 452
20.8.6 Hysterosalpingogram – 452
20.8.7 Ultrasonography – 452
20.8.8 Magnetic Resonance Imaging – 452

20.9.1 I ndication – 453
20.9.2 Hysteroscopic Technique – 453
20.9.3 Abdominal Metroplasty – 454
20.9.4 Postoperative Care – 454
20.9.6 Outcome – 454
20.11 Answers – 455

References – 455
432 M. G. Park and K. B. Isaacson
gies. During hysteroscopy, a telescope is

Key Points inserted transvaginally through the cervix and
55 When hysteroscopically removing intra- into the uterine cavity. A distention media is
uterine pathology, the goal is to remove used to expand the uterine cavity in order to
the entire lesion and not perform a par- visualize the endometrium and tubal ostia.
tial resection. The appropriate hystero- Pathology can then be detected and treated
scopic tools should be used to with direct visualization.
accomplish this task. As the technology has advanced, hyster-
55 Minimize trauma to the normal endome- oscopy has become more accessible to gyne-
trium by using cold energy when possible. cologists both in the office and in the
Avoid resecting lesions such as fibroids or operating room. It has become an indispens-
polyps on opposing walls to minimize the able tool for treating fibroids, polyps, syn-
risk of intrauterine scar tissue. echiae, and congenital uterine anomalies and
55 Office hysteroscopy is a useful technique for performing endometrial ablation
for diagnostic and minor operative procedures.
procedures. The use of hysteroscopes Many hysteroscopic procedures that were
<5 mm in outer diameter and a vagino- historically only performed in the operating
scopic technique will offer the patients theater are now performed in an office-based
rapid treatment without the need for setting often without the need for local or
local or general anesthesia. systemic anesthesia and often without the
use of a vaginal speculum. These vagino-
scopic procedures are well tolerated by the
patients and allow for a rapid return to
20.1 Introduction normal activities.
Hysteroscopy is a minimally invasive and

highly accurate means of diagnosing and
treating a multitude of intrauterine patholo-
Case Vignette
Mrs. F is a 29-year-old with regular cycles that to insert the scope vaginoscopically (without
are very heavy in flow and presents two sponta- the need for a speculum or tenaculum). The hys-
neous miscarriages and persistent bleeding since teroscope was guided into the right horn, and
her third D&C following this last pregnancy 12 the retained POCs were removed in a piecemeal
weeks ago. She reported no problem conceiving fashion. The septum was then cut with 5Fr scis-
when trying. On her initial visit, a three-dimen- sors and the type III myoma was left in place.
sional ultrasound was obtained which showed a This case demonstrates the value of com-
uterine septum extending 2/3 down from the bined US and hysteroscopic approach in an
fundus to the cervix. The right horn demon- office setting. The patient likely had retained
strated a thickened endometrial echo consistent POCs by doing a D&C in the wrong uterine
with retained products of conception, and on horn. Her early miscarriages could be due to the
the left a type III 2 cm submucous myoma was uterine septum, the myoma, or other unknown
noted. causes. Since she is young, it is reasonable to
20 A 5.5 mm continuous flow hysteroscope was encourage her to conceive spontaneously after 8
the instrument of choice in the office on the ini- weeks post septum repair. Should another mis-
tial visit. Normal saline for distention was used carriage occur, she will consider a myomectomy.
Hysteroscopic Management of Intrauterine Disorders: ...
433 20
20.2 Indications need for a light source and allows the image to
be projected directly through a USB port for
The most common indications for evaluation visualization and image capture.
of the uterine cavity are abnormal uterine Resectoscopes are all continuous flow sys-
bleeding and infertility. Although hysterosal- tems that allow the attachment of operative
pingography (HSG ) and modern ultrasonog- instruments, including monopolar and bipo-
raphy are relatively sensitive in detecting lar electrodes in a variety of shapes. These are
intrauterine anomalies, diagnostic hysteros- 7–10 mm systems and are more typically uti-
copy remains the gold standard tool to visual- lized in the operating room setting. All resec-
ize the cervical canal and uterine cavity. Today, toscopes incorporate a rod lens system for
there remain two schools of thought regard- light delivery and image return.
ing initial evaluation of the uterine cavity. The newest additions to the hysterosco-
Many clinicians utilize HSG, transvaginal pist’s armamentarium are the hysteroscopic
ultrasonography, and sonohysterography for morcellators also known as tissue shavers.
initial evaluation. However, gynecologists can They use mechanical energy rather than elec-
proceed directly to diagnostic hysteroscopy in trical energy to cut the uterine tissue. A hys-
the office or outpatient setting with little or no teroscopic morcellator is comprised of a rigid
anesthesia for this purpose. Operative office metal tube with a cutting edge housed within
hysteroscopy allows for a visually directed an outer metal tube, creating a side opening
biopsy of focal lesions and treatment of intra- at the tip of the instrument. This device is
uterine lesions, including endometrial polyps, attached to suction so that when the device is
intracavitary leiomyomas, uterine septa, and placed against intrauterine pathology, the tis-
uterine synechiae. sue is sucked into the cavity of the opening.
The cutting device is then activated causing
the tissue to be morcellated, with the pieces
20.3 Basic Hysteroscopic Hardware of tissue being vacuumed through the device
and into an external collecting receptacle.
20.3.1 Types of Hysteroscopes Several versions of these morcellators are
available, some of which oscillate side to side
Hysteroscopes incorporate an optical system parallel to the morcellator tube and some of
that includes mechanisms to deliver light into which oscillate perpendicular. There are also
the uterine cavity and return the reflective disposable and reusable versions. These mor-
image to an eyepiece or a camera. The most cellators generally have a proprietary hystero-
commonly used system is the rigid hysteroscope that is required to fit the morcellation
scope with an objective lens at the tip offset by devices. All are continuous-flow hystero-
0°, 12°, 25°, or 30° from the horizontal plane. scopes which range in size from 4.6 to 9 mm.
Other systems include the fiber-optic diagnos- These devices are appropriate for office or
tic single-channel flexible hysteroscopes and operating room use.
digital flexible dual-channel hysteroscopes.
All hysteroscopes include at least one channel
for the inflow of distention media. Continuous 20.3.2 Distention Media
flow hysteroscopes incorporate a second chan-
nel for the return of distention media and the The uterine cavity is a potential space that
placement of operative instruments. Since must be distended with either gas or fluid
CCD and CMOS camera chips have been media in order to visualize the endometrium
miniaturized and less expensive, new hystero- and intrauterine pathology in three dimen-
scopes have incorporated the “chip on a stick” sions. Each distention media has its own
and LED light design. This eliminates the advantages and disadvantages.
20.3.3 Low-Viscosity Fluids 20.3.5 Dextran 70
Low-viscosity fluids are the most common One of the first fluid-distention media used
distention media used today because they are was high-viscosity hypertonic dextran 70. A
suitable for both diagnostic and operative hys- 32% solution of dextran 70 in 10% dextrose
teroscopies, are relatively inexpensive, and are in water is a nonelectrolytic, nonconductive
relatively low risk to use. The two groups of fluid with syrup-like consistency that can be
low-viscosity fluids are isotonic electrolyte- used for both diagnostic and operative hys-
containing fluids and nonelectrolyte media teroscopy. It is rarely used today as hystero-
that may be hypotonic or isotonic. scopic distention media because of higher
Isotonic electrolyte-containing fluids can be rates of allergic reactions and hypertonic-
used for all operative procedures except those associated problems, including pulmonary
that require monopolar electrosurgery. Two edema [3].
commonly used fluids are 0.9% sodium chlo-
ride and acetated lactated Ringer’s solution.
When electrolyte-containing solutions are 20.3.6 Diagnostic Hysteroscopy
used (e.g., saline), the procedure should be
discontinued when a fluid deficit of 2500 mL Diagnostic hysteroscopy is used to examine
is reached. The patient may require a diuretic the intrauterine cavity. Patients should be on
if this fluid deficit is higher. suppressive hormones or have the procedure
Hypotonic nonelectrolyte-containing fluids timed to occur during the proliferative phase
are required when the monopolar resecto- of their menstrual cycle in order to improve
scope is used, and several types are available. visualization. Diagnostic hysteroscopy can be
The most common fluids used are 5% manni- performed in the office setting or the operat-
tol, 3% sorbitol, and 1.5% glycine. The theo- ing room, depending on the level of discom-
retical advantage of 5% mannitol is that it is fort the patient experiences during the
isotonic, which, in theory, may reduce the risk procedure.Usually diagnostic hysteroscopy
of cerebral edema with excessive absorption can be performed in the office setting without
[1]. Excessive absorption of all electrolyte-free the need of any analgesia or anesthesia.
media can lead to hyponatremia and its poten- Narrow, rigid, and flexible hysteroscopes gen-
tially life-threatening complications. Sodium erally have diameters of <4 mm that can be
levels fall 10 mEq/mL for every 1 L of inserted with minimal discomfort to the
electrolyte-free media absorbed. When a fluid patient. If the patient experiences discomfort,
deficit of 1000 cm3 of nonelectrolyte solution oral analgesics may be required, and if cervi-
is identified, electrolytes should be drawn, and cal dilation is necessary, a paracervical block
the case should be terminated. Consideration may also be placed.
should be given to administer diuretics with It is important to insert the hysteroscope
close monitoring of electrolytes following sur- slowly and under direct visualization of the
gery. Injection of 3–4 mL of dilute vasopres- canal so that a false channel is not created
sin (10 units in 200 mL saline) into the cervix and uterine perforation can be avoided. In
prior to distention of the cavity can decrease order to allow for controlled insertion of the
both intraoperative bleeding and intravasa- hysteroscope, some patients may require cer-
tion for at least 20–30 min [2]. vical softening prior to hysteroscopy.
Misoprostol is most commonly used for cer-
vical softening. Vaginal misoprostol (200–400
20.3.4 Carbon Dioxide mcg) can be given 8–12 h before surgery, or
20 oral misoprostol (400 mcg) can be given 12
Carbon dioxide is less commonly used and 24 h before surgery. This should only be
today and is only appropriate for diagnostic used if cervical stenosis is documented since
procedures. routine use can lead to a cervix that is too soft
435 20
and cannot maintain distention. If a patient the uterine venous sinuses, as in hysteroscopic
is menopausal, the misoprostol is only myomectomy.
effective after vaginal estrogen has been

administered.
Once the uterine cavity is entered, visual- 20.3.9 Office Hysteroscopy
ization of landmarks is critical. A panoramic
inspection of the endocervix, lower uterine Office hysteroscopy is the gold standard tool
segment, endometrial cavity, and tubal ostia for evaluation of intrauterine pathology. While
should be performed as the hysteroscope is it has been available for over 20 years, it has
inserted. A careful, thorough survey is neces- recently become more commonplace due to
sary so that pathology is not missed. Myomas improved technology, improved reimburse-
of the endocervix and lower uterine segment ments, and patients’ desire to avoid general
can easily be missed with too rapid insertion anesthesia and the operating room setting.
of the hysteroscope. Patients are able to undergo the procedure
with minimal discomfort, most often with no
or minimal oral and local analgesia. When
20.3.7 Operative Hysteroscopy performing any procedure in the office setting,
the clinician must be especially cognizant of
For operative procedures, hysteroscopes and possible complications of hysteroscopy given
resectoscopes are used that usually require the limited resources available to manage any
cervical dilation prior to insertion. Operative complications that may be encountered. Office
hysteroscopes and hysteroscopic morcellators hysteroscopy is an effective and well-tolerated
are used commonly in the office setting as well alternative to day-surgery hysteroscopy. One
as the operating room. Resectoscopes are study randomized 40 women requiring pol-
used in an operating room setting under seda- ypectomy into either office hysteroscopy or
tion or with general or regional anesthesia. day-surgery hysteroscopy. The results demon-
strated that the office hysteroscopy subjects
experienced minimal pain during the proce-
20.3.8 Complications dure and had faster recovery times and lower
postoperative analgesia requirements than
The overall complication rate associated with the subjects who underwent day-surgery hys-
hysteroscopy is reported to be 2.7% [4]. The teroscopy. Ninety-five percent of women who
operative complications of hysteroscopy underwent office hysteroscopy stated they
include uterine perforation, excessive hemor- would repeat outpatient hysteroscopy if their
rhage, air embolus, pulmonary edema, pelvic polyps recurred. Eighty-two percent of women
organ injury secondary to thermal damage if who underwent day-surgery hysteroscopy
electrode surgical systems are used, excessive stated that they would like to try office hys-
fluid absorption, major vessel injury, intra- teroscopy if their polyps recurred [6]. Several
uterine scar formation, and infection [5]. The studies such as these have demonstrated the
different procedures described below carry all safety and significantly lower cost of office hys-
these risks to varying degrees, depending on teroscopy when compared to day surgery [6,
the pathology being treated and the equip- 7]. Additionally, it seems that patients are well
ment being used. These complications are able to tolerate these hysteroscopic procedures
more or less likely depending on the proce- in the office and they have the added benefit of
dure being performed. For example, perfora- avoiding general anesthesia. Given all of these
tion is more likely during adhesiolysis of benefits, clinicians should give serious thought
severe Asherman’s syndrome, and fluid over- to developing facilities for office hysteroscopy
load is more likely in procedures that require if they are lacking and promoting office hys-
incisions deep into the myometrium, exposing teroscopy to their patients when appropriate.
20.3.10 Equipment 20.3.11 Technique
The two categories of hysteroscopes used in The traditional approach to office hysteros-
the office setting are rigid and flexible. The copy involves the use of a speculum to visual-
hysteroscopes used for office hysteroscopy ize the cervix and a tenaculum to grasp the
range from 3 to 9 mm in diameter. When diag- cervix and provide traction to straighten the
nostic hysteroscopy is performed, the hystero- cervical canal. Although this approach may
scopes are introduced without the operative be necessary for some patients when a difficult
sheaths so as to decrease the diameter of the entry is encountered, in a vast majority of
hysteroscope and minimize trauma to the patients, the clinician may dispense with the
cervical canal. Rigid hysteroscopes may be
speculum and tenaculum by traversing the
used, which are 2.7–5.7 mm in outer diameter. vagina via vaginoscopy. Bettocchi et al. have
Zero°, 15°, or 30° hysteroscopic lenses are shown that hysteroscopy can be performed
appropriate for diagnostic hysteroscopy. If the very successfully with this technique, while
cervical canal is tortuous or the uterus is espe- decreasing the amount of pain experienced by
cially anteflexed or retroflexed, flexible hys- the patient [8].
teroscopes are generally superior to rigid With this technique, the hysteroscope is
hysteroscopes. They have the added advan- placed just inside the vaginal canal, and the
tage of having a tip that can deflect from 0° to distention media is instilled. The vaginal walls
110° and curve with the natural course of the distend, allowing the clinician to advance the
endometrial canal. hysteroscope through the vaginal canal under
If operative procedures are planned in the direct visualization and without causing
office, operative hysteroscopes are used. trauma to the walls. The hysteroscope is
Sheaths can be placed over rigid diagnostic directed along the posterior wall of the vagina
hysteroscopes in order to add an operative until the posterior fornix is reached. It is then
channel and outflow. This will increase the pulled back slightly and angled upward until
diameter of the hysteroscope to 6.25–9 mm. the cervical os is visualized. The hysteroscope
The inflow channel is essential for appropriate can then be introduced into the cervical os,
distention of the uterine cavity, and the out- which then distends the endocervical canal.
flow channel is used to flush out any blood With the inflow distention media on low flow,
and debris that may accumulate, thereby the hysteroscope is guided through the canal
improving visibility. Handheld scissors, grasp- under direct visualization so that the clinician
ers, or biopsy forceps can then be placed into may follow the natural course of the canal
the operative port to address intrauterine with minimal trauma to the surrounding tis-
pathology. These are the standard operative sue. Unless cervical stenosis is encountered,
tools available in the office setting, and they this procedure can be performed with mini-
continue to be the most cost-effective method mal discomfort to the patient. In many cases,
for addressing intrauterine pathology. no analgesia or anesthesia is required.
For larger pathology, hysteroscopic mor-
cellators are available for use in the office.
Operative scopes for these morcellators are 20.3.12 Pain Management
generally 4.6–7.25 mm in diameter and have
0° or 30° lenses available. These morcellators With appropriate pain management, office
are remarkable for their ease of use. However, hysteroscopy is successful in 90–95% of cases
the high costs of these devices, especially the [9, 10]. Many patients are able to tolerate hys-
disposable versions, can be prohibitive. In teroscopy without any analgesics or anesthet-
20 addition, 5 mm bipolar hysteroscopes have ics, especially when the vaginoscopic technique
recently been approved and are excellent tools is used. However, if the patient experiences
to remove large polyps or small type 0 myo- significant discomfort, the clinician should be
mas using the vaginoscopic approach. armed with tools to manage the patient’s pain
437 20
so that the hysteroscopy can be completed Studies are conflicted regarding the effi-
successfully. cacy of the paracervical block. Some studies
showed no significant difference in pain scores
between groups, while an equal number of
20.3.13 NSAIDs and Anxiolytics other studies showed a statistically significant
decrease in pain overall [12]. There was
Patients can be pretreated with nonsteroidal improvement in pain at insertion of the hys-
anti-inflammatory drugs (NSAIDs) so that teroscope in the group with lidocaine, but
prophylactic pain management can be initi- patients commented that the injections were
ated before the procedure has even begun. as painful as the hysteroscopic procedure [12].
Patients should be told to take NSAIDs 1–2 h A Cochrane review, which included 19 studies
prior to their procedure. The patient may take evaluating pain relief for hysteroscopy as an
this orally before arriving at the office, or it outpatient, concluded that there was no con-
may be administered at the office in the form sistent good-quality evidence showing a dif-
of IM ketorolac once they arrive. Anxiolytics ference in safety or effectiveness between
may also be administered to calm the patient; different types of pain relief compared with
lorazepam is usually the drug of choice. each other or with placebo [68].
20.3.14 Topical Analgesia 20.3.16 Conscious Sedation
Lignocaine spray of 30, 50, or 100 mg to the Conscious sedation is characterized by

cervix and cervical canal was shown to decreasing the patient’s consciousness while
decrease pain at the time of insertion of the allowing them to maintain their own airway.
hysteroscopy, and it was also shown to They are usually still able to respond to physi-
decrease vasovagal reactions [11]; 25 mg of cal and verbal stimuli. Because the effects of
lignocaine cream with 25 mg of prilocaine, the narcotics may be unpredictable, the
administered to the cervix, was shown to have patient’s vital signs must be continuously
the same benefits. There have not been many monitored. Typical agents used for conscious
studies in support of this method of analge- sedation are fentanyl, propofol, and mid-
sia. However, given the current data, topical azolam. Antiemetics may also be infused to
analgesia is a reasonable option to reduce counteract the gastrointestinal upset caused
patient discomfort. by the narcotics.
There are several requirements, outlined
by the American Congress of Obstetricians
20.3.15 Paracervical Block and Gynecologists, which an office must fulfill
in order to safely perform conscious sedation
If cervical dilation is required, a paracervical in the office setting [13]. The patient’s oxygen-
block may be performed to minimize patient ation must be monitored continuously; this is
discomfort. In most studies, paracervical most commonly done using pulse oximetry. If
block was performed by placing 10 mL of deeper sedation is administered, the patient’s
mepivacaine or lidocaine via a 22-gauge spi- ventilatory function should also be moni-
nal needle at 3, 5, 7, and 9 o’clock positions tored by direct observation, auscultation, or
paracervically. It is imperative that the sur- capnography. The patient’s circulatory func-
geon placing the paracervical block be aware tion should be monitored with a continuously
of the maximum dose of the local anesthetic displayed electrocardiogram, blood pressure
based on the patient’s weight as well as signs and heart rate measurements every 5 min, and
of allergy. Protocols should be in place to pre- pulse plethysmography. Anesthesiologists or
vent, recognize, and treat these events should nurse anesthetists must be present to moni-
they occur. tor the patient during conscious sedation.
Gynecologists may administer conscious appropriate in order for the patient to remain
sedation after undergoing certification. comfortable. For example, large myomas or
However, they must keep in mind that an polyps (>3 cm) and large septum resections
additional healthcare professional must be are more appropriately and safely done in the
present whose sole responsibility is monitor- operating room.
ing and attending to the patient. The clinician
must also be certified in ACLS, PALS, or BLS
and must be sufficiently free after the proce-
dure is performed to monitor the patient until 20.4 Complications
stable for discharge.
Respiratory suppression is a significant 20.4.1 Fluid Intravasation
concern when administering conscious
sedation. The office must have all the equip- Complications may be encountered regardless
ment necessary to manage complications from of the type of distention media used. A com-
respiratory suppression. An oxygen source plication that may be seen, regardless of the
must be present, as well as suction, resuscita- type of distention media, is fluid overload,
tion equipment including a defibrillator, and which occurs in approximately 0.2% of cases
emergency medications. This equipment must [15]. This is seen when there is significant
be maintained and tested according to manu- intravasation of the distention media. To pre-
facturer’s specifications. If any of these vent this from occurring, intrauterine pressure
requirements are lacking, conscious sedation should be maintained at the lowest possible
is not recommended. pressure while still maintaining adequate
intracavitary visibility. Ancillary staff should
be available to aid the clinician with the proce-
20.3.17 Patient Selection dure and monitor the fluid deficit closely. If
there is evidence of rapid intravasation of dis-
Several factors must be considered when tention media, the procedure should be termi-
determining if a patient is a reasonable candi- nated. Clinicians should be especially cautious
date for office hysteroscopy. First and fore- when performing lysis of adhesions, myomec-
most, a thorough history must be taken of the tomies, resection of septums or any other pro-
patient. The patient should be screened for cedures that may open the vascular channels
significant comorbid conditions compromis- and potentiate intravasation.
ing her ability to tolerate the stresses of hys- For isotonic electrolyte-containing solu-
teroscopy. If a patient has a history of severe tions, the maximum deficit in an office setting
anxiety, for example, the patient should be should not exceed 1000–1500 mL. If these
considered for day-surgery hysteroscopy [14]. deficits are surpassed, the patient should be
In terms of the pathology that can safely monitored and the procedure terminated.
be treated in the office setting, clinicians There is no place to use electrolyte-free media
should consider what the patient will be able in an office-based setting.
to tolerate and be wary of what complications However, in most cases, procedures done
can potentially be encountered. Appropriate in the office should be relatively quick, and
procedures include diagnostic hysteroscopy, fluid deficits should not be approaching maxi-
endometrial biopsies, lysis of adhesions, small mum levels. Hysteroscopic procedures should
polyps, small fibroids, and global endometrial be discontinued at lower fluid deficits than the
ablation. These procedures are appropriate thresholds described above, given that there is
because they are relatively short, so that the limited acute care available in the outpatient
20 patients will be able to tolerate them, and they setting [14]. Therefore, if a long operative time
have a very low risk of complications. is anticipated for a procedure, it may be better
Any procedure requiring lengthy operative to schedule it for the operating room where
time (>15 min) is not suggested for an office- the patient can be monitored closely as the
based procedure. The operating room is more fluid deficit increase.
439 20
20.4.2 Perforation patient has known history of vagal reactions,
one can pretreat with 0.4 mg of atropine IM
The most frequent reported complication of prior to the procedure.
hysteroscopy is uterine perforation, which
occurs at a rate of 0.76% procedures [15].
These perforations commonly occur during 20.4.4 Bleeding
dilation of the cervix, as well as during the
hysteroscopic portion of the procedure. Most bleeding encountered during hysteros-
Perforations of the lower uterine segment copy is self-limiting. However rare, persistent
and fundus of the uterus may be seen. In bleeding may be encountered. This can be
most cases, no treatment is required. seen when the cervical canal is lacerated dur-
However, if there are signs of intra-abdomi- ing dilation, after uterine perforation, or when
nal bleeding, such as when there is a lateral vessels in the myometrium are transected,
perforation through major vessels, the patient such as when clinicians are performing myo-
should be transferred immediately for lapa- mectomies or septum resections. If persistent
roscopic exploration with possible repair of bleeding is seen, electrocautery is most often
the defect. Management of perforation with ineffective. The primary treatment should be a
an activated electrosurgical device or a tissue Foley catheter placed into the cavity to tam-
shaver also warrants emergent surgical evalu- ponade the bleeding [20]. The Foley catheter
ation. These injuries usually occur when cli- is placed into the cavity and inflated with
nicians are activating the mechanical or 15–30 mL of water until the bleeding stops
electrical energy while moving them away [21]. If persistent bleeding is encountered
rather than toward themselves. Perforations despite these measures, more aggressive explo-
with 1.5 mm semirigid instruments can be ration in the operating room may be
monitored for 10–15 minutes. Certain proce- warranted.
dures such as lysis of adhesions and resection
of septums have higher rates of perforation
than other hysteroscopic procedures but if 20.4.5 Hysteroscopic Polypectomy
cold small instruments are used, these proce-
dures are still safe to perform in the office set- Symptomatic polyps are generally character-
ting [16, 17]. ized by abnormal bleeding, postcoital staining,
chronic vaginal discharge, or dysmenorrhea.
Abnormal bleeding symptoms include inter-
20.4.3 Vasovagal Reaction menstrual spotting or heavier menstrual
flow. There is good evidence that polyps can
A vasovagal reaction is not uncommon in decrease fertility and that their removal will
office hysteroscopy. One study reported a rate improve the chances of pregnancy [22].
of 0.72% in patients undergoing hysteroscopy It is obvious that symptomatic endome-
without analgesia [18]. Smaller hysteroscopes trial polyps should be removed. However,
and improved pain control were shown to it is also important to remove asymptom-
decrease the rates of vasovagal reaction [19]. atic polyps, particularly in postmenopausal
A vasovagal episode is generally preceded by a women [23]. Although the vast majority of
feeling of light-headedness, nausea, diaphore- polyps are benign, endometrial cancer and
sis, bradycardia, and/or pallor. If these symp- hyperplasia will be found in approximately
toms are encountered, the procedure should 2% of endometrial polyps and are associated
be immediately terminated. Patient should be with coexisting malignancies elsewhere in the
placed in Trendelenburg position or with her endometrium. In 1 study of over 1400 pol-
legs raised. Her vital signs should be moni- yps, endometrial cancer was found in 27 pol-
tored closely, and an intravenous fluid bolus yps (1.8%) [23]. All but one of these women
may be necessary. In most cases, patients recu- were postmenopausal, and only 26% were
perate quickly with these interventions. If a asymptomatic.
20.4.6 Technique nificant limitations. During hysteroscopy,

myomas can be compressed and recede into
Polyps can generally be removed with hystero- the myometrium as a result of the pressure of
scopic scissors and pulled through the cervical the distention media, thereby preventing full
canal intact. Larger polyps, with thick stalks, visualization of the myoma. For this reason,
require resection with morcellation, with a preoperative evaluation with ultrasonography
resectoscope or hysteroscopic morcellator so is required to accurately determine how many
that the tissue can be removed piecemeal. myomas are present and how deeply the myo-
Of the various methods described above mas penetrate the myometrium. Magnetic
for removing polyps, none have been shown to resonance imaging (MRI) can also be used for
be more safe or effective than another, though this purpose.
there is a significant increase in the cost of the
procedure if disposable devices are used. The
choice of equipment should be based on the 20.4.9 Surgical Approach
surgeon’s preference when cost, safety, and According to Stage
efficacy are taken into account.
For a successful surgical outcome, it is impor-
tant to preoperatively identify the size, number,
20.4.7 Hysteroscopic Myomectomy location, and intramural extension of uterine
myomas. These characteristics predict the sur-
Patients with symptomatic myomas generally geon’s ability to completely resect the fibroids
present with abnormal uterine bleeding (i.e., during one surgical procedure. Most often,
menorrhagia), infertility, pelvic pain, or pres- when there is a large type II myoma, the proce-
sure. When determining the optimal surgical dure has to be terminated prior to completion
approach for their removal, it is important to due to excessive fluid absorption [26]. Most
determine the fibroid location in relation to importantly, the goal of a myomectomy is to
the endometrial cavity. Fibroids can be remove the entire fibroid and not partially resect
described using the FIGO classification sys- or shave. Partial myomectomy has been shown
tem, which groups fibroids into types based to have a high risk of symptom recurrence.
on the degree to which the myomas intrude The degree of surgical difficulty and, thus,
into the endometrium and myometrium the risk to the patient are related to the depth
(. Fig. 20.1). of penetration and size of the myomas.
Pedunculated hysteroscopic type 0 (class 1)
myomas up to 3 cm in diameter can usually be
20.4.8 Classification easily removed hysteroscopically. Larger hys-
teroscopic type 0 myomas (>3 cm) and hys-
Type 0 myomas are pedunculated, with the teroscopic type I (class 2) myomas can also be
myoma lying completely within the endome- approached hysteroscopically. However, the
trial cavity (. Fig. 20.2). Type I myomas are risk of fluid intravasation increases as a result
described as “sessile” with <50% intramural of increased surgical time and the opening of
extension (. Fig. 20.3). Type II myomas are myometrial venous channels during resection.
submucosal in location, with >50% intramu- Additionally, there is poorer visibility with
ral extension. These include transmural myo- larger myomas given the more limited space
mas, which extend from the submucosal to within the uterus and inability to distend the
serosal edge. When viewed hysteroscopically, cavity well. Often, incomplete removal of
type II myomas form a bulge that can be seen larger myomas requires two or more separate
20 in the endometrial cavity. operative procedures. Only the most experi-
This system was originally designed to enced hysteroscopist would attempt a hystero-
classify myomas exclusively on hysteroscopic scopic resection of an intracavitary myoma
appearance. However, this approach has sig- 5 cm or larger.
441 20
Hysteroscopic Sonohysterographic class

type [24] Description
[25]
Type 0 Class 1 Pedunculated myomas, where 100% of the myoma lieswithin the endometrial
cavity with no intramural extension
Type I Class 2 Sessile myomas, with <50% intramural extension
Type II Class 3 Submucous myomas, with >50% intramural extension
.. Fig. 20.1 Hysteroscopic and sonohysterographic nongravid women of reproductive age (7 pharllc.com).
classification system for myomas encroaching upon the Malcolm G. Munro a,b, ⁎, Hilary O.D. Critchley c,
endometrial cavity. (FIGO classification system (PALM- Michael S. Broder d, Ian S. Fraser e; for the FIGO
COEIN) for causes of abnormal uterine bleeding in Working Group on Menstrual Disorder)
.. Fig. 20.2 Hysteroscopic view of a type 0 myoma. It

is pedunculated and the total myoma lies within 100% .. Fig. 20.3 Hysteroscopic view of a type I myoma that
of the endometrial cavity. (Reproduced with permission involves less than 50% of the myometrium. (Reproduced
from Bradley [73]) with permission from Bradley [73])
Likewise, hysteroscopic resection of type the myoma. As the wire loop is drawn toward
II (class 3) myomas should only be approached the surgeon, small, crescent-shaped “chips” or
by high volume hysteroscopists. They are fragments of myoma are created. The whorled
more commonly approached abdominally by fibrous appearance of the myoma is clearly
laparoscopy or laparotomy. Hysteroscopic different from the fascicles of soft underlying
removal of type II myomas is also associated myometrium. The fibrous tissue should be
with a greater risk of fluid intravasation and methodically resected until the border of the
uterine perforation and commonly requires underlying myometrium is reached. However,
two or more procedures for complete removal. increased bleeding from the myometrial bed
Fibroids that are completely intramural (type and fluid intravasation may be encountered if
III or greater) and fibroids that abut the uter- the myometrium is breached. The bipolar
ine serosa should not be attempted hystero- loop can be used to dessicate each individual
scopically due to increased risk for perforation. bleeding vessel which greatly helps visualiza-
When patients have multiple intracavitary tion within the cavity. The resecting loop
fibroids throughout the endometrial cavity, should stay within the pseudocapsule of the
they would benefit from a “two-staged” oper- myoma and not cut this myometrium. If the
ative hysteroscopic myomectomy, in which hysteroscopist stays within the pseudocapsule,
myomas are removed from only one uterine the likelihood of a uterine perforation will
wall at a time. This is to decrease the risk of nearly be zero.
apposition of the uterine walls and the Myoma chips can remain free-floating
development of postoperative intrauterine
until they interfere with visualization and are
synechiae. then removed with polyp forceps, Corson
graspers, suction curette, or with the loop
itself under direct visualization. All free-
20.4.10 Technique floating tissue fragments should be removed
and sent for histologic examination. Removing
There are various techniques for removing all free-floating tissue also prevents delayed
pedunculated and submucosal myomas, vaginal extrusion of this tissue material, mal-
including avulsion, scissors, wire-loop resec- odorous discharge, adhesions, and infection.
tion with bipolar or monopolar equipment,
morcellation, and laser vaporization. Wire- 20.4.10.2 Morcellator
loop resection and hysteroscopic morcellation The hysteroscopic morcellators come in a
are the most popular methods of removing variety of shapes and sizes. The rotating
myomas and will be the techniques discussed blades are best for polyps, and the reciprocat-
in this section. ing blades are designed to remove fibroids.
This is not an appropriate tool for lysis of
20.4.10.1 Resectoscope adhesions or septum resection since the tissue
The preferred resectoscope uses bipolar radio- should be cut and not removed in these condi-
frequency energy due to the ability to use tions. The appropriate size of morcellator
electrolyte-
containing distention media. should be chosen based on the size of the
When monopolar energy is used for wire-loop fibroids being removed. The size of the open-
resection, the current setting should be ing at the tip of the morcellator is determined
60–80 W cutting current and requires an by the length of the opening parallel to the
appropriately sized grounding pad. Higher shaft and the width of the shaft. Most brands
settings may be necessary with very fibrous, will have at least 2 sizes for the morcellators,
dense, or calcified myomas. When the bipolar which differ by roughly 1 mm in diameter.
20 generator is used, it automatically adjusts the Smaller morcellators can be used for polyps
power to default settings. and fibroids 1–3 cm in size. Larger morcella-
Once the submucosal myoma is identified, tors are used for fibroids 4–5 cm in diameter
the wire-loop electrode is advanced in clear and for fibroids that are more dense or calci-
view and retracted toward the surgeon behind fied. Most morcellators have a single speed
443 20
once the device is activated. However, others in size. In fact, more myoma protrudes into
have varied rates of oscillation that can be the endometrial cavity allowing a more com-
adjusted depending on the density of the tis- plete resection without having to resect myo-
sue encountered. For example, smaller and metrium. False-negative views can occur
softer pathology, faster oscillations are used, during hysteroscopy because of the high
as tissue can be rapidly suctioned into the cyl- intrauterine pressures. The “disappearing
inder. Whereas for larger and more dense phenomena” refers to the flattening of endo-
pathology, slower oscillations are used in metrial polyps or fibroids, resulting in a
order to allow for more deliberate cutting. falsely negative hysteroscopic study. This dis-
After thorough survey of the cavity, the appearing phenomenon can be avoided by
morcellator can be introduced gently through decreasing the intrauterine pressure at the
the operative port. It is easy to lose track of end of the procedure and reinspecting the
the opening of the morcellators, so they have endometrial cavity. As a general rule, the dis-
markings on the tip that help maintain your tention pressure within the uterine cavity
bearings with the orientation of the working should be the lowest pressure that gives the
side of the device. The device opening is then surgeon adequate flow and visualization.
pressed firmly against the fibroid and acti- This will allow the myoma to protrude within
vated. With adequate pressure, this will result the cavity and minimize unwanted fluid
in a furrow as the device is drawn back toward absorption.
the surgeon. After a few of these furrows are
made along the surface of the fibroid, peaks
and valleys are created. The most efficient 20.4.11 Intraoperative
morcellation is performed by applying the Ultrasonography
opening of the device to the peaks, so that a
maximum amount of tissue is inserted into Intraoperative ultrasonography guidance dur-
the opening when the device is activated. For ing operative hysteroscopy is useful for resec-
type 2 fibroids, the portion of fibroid embed- tion of myomas that are hard to define.
ded in the wall of the uterus will extrude into Ultrasound guidance allows constant visual-
the intrauterine cavity in many cases and can ization of the uterine walls, as well as the hys-
be morcellated as described. In other instances, teroscopic instruments. Therefore, the
if the fibroid is still embedded, the pseudocap- hysteroscopist may know when they are in
sule can be identified, and the morcellator can danger of perforating the uterine wall. This
be gently introduced between the pseudocap- added imaging allows for resection beyond
sule and overlying fibroid. The fibroid can the limit conventionally defined by hysteros-
then be lifted and separated from the pseudo- copy [27].
capsule to allow further morcellation. This
should only be attempted if there is good vis-
ibility of the fibroid bed and pseudocapsule so 20.4.12 Fertility Preservation
as not to cause a uterine perforation. The hys-
teroscopes with a 30° angle of view would be If the patient desires fertility, overzealous
most ideal for these situations. resection of the myometrium must be
Intermittently throughout the procedure, avoided. Asherman’s syndrome may occur
the intrauterine pressure should be lowered when large portions of overlying endometrial
to 30 mmHg or the least amount of pressure tissue are resected with a sessile myoma.
that is possible while still maintaining visual- Patients who desire fertility and have multi-
ization. This rapid reduction in intrauterine ple intracavitary myomas, especially those
pressure will aid in enucleation of the myoma with myomas on opposite walls, may require
via a decompression mechanism that releases resection in two separate occasions to mini-
the encapsulated myoma from its myome- mize chances of intrauterine synechiae devel-
trial bed. The myoma may appear to increase oping postoperatively.
20.4.13 Complications “global” methods, differ in that they do not

require the use of the resectoscope to perform
Complications of hysteroscopic myomecto- the ablation. Hysteroscopy is an integral part
mies include uterine perforation, bleeding, of only one of these systems.
infection, and fluid intravasation. Uterine per-
foration most often occurs with cervical dila-
tion with a blunt dilator. These patients can be 20.4.16 First-Generation
observed in the recovery room and sent home Hysteroscopic Endometrial
when stable. Ablation
Major bleeding after a hysteroscopic myo-
mectomy is rare. When excessive bleeding is Mimicking the physiologic effect of
encountered, it is generally secondary to myo- Asherman’s syndrome, the ultimate goals of
metrial bleeding. When the bleeding is exces- endometrial ablation were to create severe
sive, it can be controlled with a 25-cm3 catheter endometrial scarification and secondary
balloon left in place for 4–12 h. amenorrhea.
Endomyometrial resection utilizing a resec-
toscope was first reported by DeCherney and
20.4.14 Endometrial Ablation Polan in 1983 [28]. This technique utilizes uni-
polar electrocautery and is performed with
Endometrial ablation was developed as a hypotonic nonelectrolyte-containing disten-
minor surgical procedure to treat women tion media. This technique was the forerunner
with intractable heavy menses unresponsive of hysteroscopic rollerball endometrial abla-
to medical management, who no longer tion, which has become the “gold standard” to
desire fertility. Each year approximately which all emerging endometrial ablation tech-
200,000 women undergo an endometrial nology is compared. Each of these devices
ablation. Compared to hysterectomy, endo- destroys the basalis layer of the endometrium
metrial ablation offers the advantages of and is designed to result in hypomenorrhea or
avoiding the morbidity and prolonged recov- amenorrhea.
ery associated with major surgery when
patients fail medical management. However,
the disadvantages include recurrence of 20.4.17 echnique: First-Generation
T
bleeding over time. Up to 35% of women who
receive an endometrial ablation will receive a
Hysteroscopic Endometrial
hysterectomy within 5 years of the procedure. Ablation
Endometrial ablation should only be offered
to women who are willing to accept eumenor- The general concept of hysteroscopic endo-
rhea, hypomenorrhea, or cyclical bleeding metrial ablation involves thorough destruc-
rather than amenorrhea as a final clinical tion of the basalis layer of the cornua and
result. Only 40% of women having an abla- lower uterine segment. For this reason, the
tion will be amenorrheic. patient should ideally be scheduled during the
early proliferative phase. Otherwise, hor-
monal suppression of the endometrium is
20.4.15 Endometrial Ablation required to thin the endometrium and increase
Techniques the chances of success of the ablation.
Hormonal suppression also increases visual-
There are several methods for endometrial ization by ridding the cavity of excess blood
20 ablation. The three “first-generation” hys- and tissue. Hormonal options for endometrial
teroscopic techniques include electrosurgical suppression include the use of depot leupro-
laser ablation, endomyometrial resection, and lide acetate, danacrine, oral contraceptive
electrosurgical rollerball ablation. Second- pills, or progesterone-only pills 4–8 weeks
generation techniques, also referred to as prior to surgery. Surgical preparation with
445 20
suction or sharp curettage immediately prior Once the surgeon visualizes all of the land-
to ablation has also been used with reported marks, the lower uterine segment is cauterized
success. circumferentially to mark the endpoint and
lowest level of endometrial ablation therapy.
Ablation of the endocervix is avoided to mini-
mize the risk of cervical stenosis. Cervical ste-
20.4.18 Vasopressin
nosis can result in cyclic pain, dysmenorrhea,
and, in severe cases, hematometra.
Vasopressin is used to decrease the risk of
After the lower uterine segment is identi-
fluid absorption, fluid overload, and intraop-
fied and coagulated circumferentially, the cor-
erative bleeding [29]. A dilute solution of
nua and fundal region are treated initially.
vasopressin (10 units in 50 mL saline) is
With the rollerball, the electrode is advanced
injected as 5 mL aliquots into the stroma of
to the fundus and then directed at the cornua
the cervix at 12, 3, 6, and 9 o’clock positions.
utilizing a “touch technique” to desiccate the
This causes intense arterial and myometrial
cornua. It must be remembered that the thin-
wall contractions for 20–45 min. Vasopressin
nest region of the uterus is at the cornua.
is not approved by the FDA for this purpose
Extra care must be taken to avoid forward
and should not be used in patients who are
pressure, which could cause perforation. The
hypertensive.
most challenging part is the fundus, since the
rollerball cannot truly be rolled against the
fundus. The fundus should be addressed as
20.4.19 Technique: Rollerball the first step. The posterior wall should be
and Endomyometrial resected next, followed by the lateral walls and
Resection anterior walls. Traditional technique utilizes
direct tissue contact, such that one-half of the
Several varieties and shapes of electrodes are rollerball is buried in the endomyometrial
available to perform hysteroscopic endome- juncture. The rollerball should only be acti-
trial ablation, including ball, barrel, ellip- vated when the electrode is moving toward the
soid, and large-caliber loops. Most surgeons surgeon to avoid perforation. Perforation with
perform rollerball endometrial desiccation the rollerball has the added risk of inflicting
with a 3-mm rollerball probe, with the goal burns to the pelvic viscera beyond the uterine
of systematically destroying the entire endo- wall. Intermittently, the rollerball may need to
metrium to the lower uterine segment and be cleaned and debris evacuated to provide
cornual region. The technique of endomyo- optimal visualization.
metrial resection is also a popular method The endomyometrial resection with a wire
for endometrial ablation and is performed loop follows the same principles. This loop is
with a 90° wire-loop electrode.Following a generally 3–4 mm deep. The loop should be
systematic surgical plan ensures optimal buried into the endometrium just below the
clinical outcomes. Excellent visualization of superficial level of the myometrium. The cut
the entire uterine cavity and endocervix is is performed using 60–80 W of cutting cur-
imperative. All intrauterine landmarks are rent. The loop is then advanced under direct
clearly delineated hysteroscopically before view from the fundus to the lower uterine seg-
initiating the procedure. Once a panoramic ment. Thus, the endomyometrial junction is
view of the endometrium is accomplished, shaved off, creating “crescent-shaped” tissue
the surgeon should determine if there is any fragments.
previously unrecognized pathology. If a sub- At the conclusion of the endometrial
tle lesion is discovered, then a directed ablation procedure, the intrauterine pressure
biopsy with a wire- loop electrode is per- is reduced in order to identify bleeding areas
formed and the specimen labeled and sub- which may be treated with coagulation
mitted separately. current.
20.4.20 Outcomes 20.4.22 Complications

of Endometrial Ablation
The majority of patients who undergo endo-
metrial ablation are satisfied with their clinical When energy using heat is used, the most con-
outcome, and at least 90% will notice symp- cerning complication is perforation of the
tomatic improvement. However, 5–10% of uterus with concurrent thermal damage to the
patients may ultimately be required to undergo surrounding viscera. Perforations of this kind
additional interventions, such as repeat abla- require immediate laparoscopy to determine
tion or hysterectomy [30]. whether or not thermal injury to the pelvic
Hysteroscopic endometrial ablation is an organs has occurred. Thermal injury to the
outpatient procedure associated with a rapid bowel that is not repaired may result in break-
return to work, minimal complications, and down of the intestinal wall with spillage of
high patient satisfaction. Approximately bowel contents into the abdomen. When this
20–60% of patients undergoing endometrial occurs, it generally results in massive pelvic
ablation with rollerball techniques will achieve infections that may progress to disseminated
amenorrhea, 65–70% will become hypomen- intravascular coagulopathy. Other complica-
orrhic, and 5–10% will fail. Approximately tions include skin burns with circulating hot
35% of patients treated by endometrial abla- saline, direct coupling vaginal burns from
tion will require a subsequent operation [30]. monopolar energy, and unwanted bladder or
Women receiving appropriate preoperative bowel thermal injuries from cryotherapy.
counseling may find this attractive in treating
menstrual disorders.
20.4.23 Hysteroscopic Resection
of Adhesions
20.4.21 Second-Generation
Endometrial Ablation Most commonly, intrauterine adhesions form
Devices in the postpartum or postabortion period.
Unfortunately, there is usually no way to avoid
Second-generation or “global” endometrial this complication during these critical peri-
ablation refers to destruction of the entire ods, such as when a patient presents with
endometrium with devices that require little postpartum hemorrhage and requires intra-
or no hysteroscopic skills. Currently, FDA- uterine procedures (i.e., D + C) for hemosta-
approved second-generation devices available sis. Early detection of intrauterine synechiae
in the USA utilize intrauterine balloons, hot is a key preventative feature following intra-
saline irrigation, cryosurgery, bipolar radio uterine surgery, curettage, or spontaneous
frequency, and microwave energy. abortion. This is because early detection
Second-generation technology offers the allows for identification of adhesions while
advantage of shorter procedure times while they are still filmy, thin, and easily resected
retaining the acceptable outcome rates similar with prompt adhesiolysis [24, 31–34].
to traditional rollerball ablation. However, The incidence of Asherman’s syndrome in
these second-generation devices have limited a select group of women, especially after
or no ability to treat intracavitary pathology. curettage for missed or incomplete abortion,
For this reason, it is important for clinicians is reported in the range of 17%, but rates as
who routinely use these ablation devices to be high as 30% are reported in the literature, the
skilled in operative hysteroscopy so that they majority of which are mild in severity [35–38].
20 will be equipped to treat any intracavitary Furthermore, in at-risk women, such as those
pathology that they may encounter prior to who undergo curettage postpartum, the rate is
performing the ablation procedures. speculated to be even higher [5, 39].
447 20
20.4.24 Pathophysiology .. Table 20.1 Classification system for
intrauterine adhesionsa
Any intervention that destroys the endome-
trium may generate adhesions of the myome- Grade Finding
trium in the opposing uterine walls. The key
predictive factor to intrauterine adhesions is Minimal Less than one-fourth of the uterine
cavity is involved
the gravid uterus. The gestational changes
noted with a gravid uterus soften the uterine Thin, filmy adhesions
wall, resulting in greater denudation of the Fundus and ostia are clear of
basalis layer during surgical interventions. adhesions
The basalis layer is crucial because it is the Moderate 1/4–3/4 of the uterine cavity is
regenerative layer of the endometrium [40]. involved
No agglutination of uterine walls;
only adhesions are present
20.5 Classification of Intrauterine
Upper uterine cavity and ostial areas
Adhesions are only partially occluded
Severe More than three-fourth of the
20.5.1 March Classification uterine cavity is involved
Agglutination of uterine walls or
Intrauterine adhesions can be characterized thick adhesion bands
based on the extent of uterine involvement [25].
Minimal adhesions are defined as adhesions Upper uterine cavity and ostial areas
are totally o ccluded
that involve less than one-fourth of the uterine
cavity and are thin and filmy. The fundal and aAdapted from [25]
ostia areas are minimally involved or devoid of
any adhesions. Moderate adhesions involve
one-fourth to three-fourths of the uterine cav-
ity, but no agglutination of the uterine wall is The location of the adhesions is presumed to be
seen. The tubal ostia and fundus are only par- prognostic for reproductive outcome given that
tially occluded. Severe adhesions involve most implantation occurs in the top fundal por-
greater than three-fourths of the uterine cavity tion of the uterine cavity and cornual adhesions
with agglutination of the uterine walls or thick may cause tubal obstruction. In addition, unlike
bands with occlusion of the tubal ostia and the March classification system, the significance
upper uterine cavity. The March classification of endometrial sclerosis or atrophy is included
system is simple and easy to apply, but it is not in the ASRM system by ascertaining the men-
prognostic (. Table 20.1) [25]. strual pattern (. Table 20.2).
20.5.2 merican Society for

A 20.5.3 Clinical Manifestations
Reproductive Medicine
Classification The most common presentation of intrauter-
ine adhesions is menstrual disturbance and/or
According to the 1988 ASRM (formerly the reproductive disturbance (infertility and
American Fertility Society) classification sys- recurrent pregnancy loss). If conception
tem, synechiae are classified in three stages, with occurs, it may be complicated by preterm
stage III being complete obliteration of the labor or abnormal placentation such as pla-
uterine cavity (see . Table 20.1) [41]. The centa previa or placenta accreta. Menstrual
ASRM classification system provides both an disturbances are most often categorized by
indirect and direct grading of intrauterine adhe- amenorrhea or hypo- or oligomenorrhea but
sions with HSG and hysteroscopy, respectively. can also be seen in eumenorrheic women.
racy of sonohysterogram compared to lapa-

.. Table 20.2 American Fertility Society
intrauterine adhesions classification systema
roscopy and hysteroscopy, which are the gold
standards for diagnosis. The prospective study
Extent of cavity <1/3 1/3–2/3 >2/3 reviewed 86 women with infertility. In this
involved study, sonohysterogram had a high diagnos-
124
tic accuracy for the detection of Asherman’s
Type of adhesions Filmy and dense syndrome. Sonohysterogram accuracy in
124 diagnosis was greater than that for hystero-
salpingogram, with a sensitivity of 76.8%, a
Menstrual pattern Normal hypomenorrhea
amenorrhea
specificity of 100%, a PPV of 100%, and a
NPV of 97.7%.
024 Transvaginal ultrasound should be per-
Prognostic HSGb score hysteroscopy formed in the late follicular or early luteal
classification score phase of the cycle, as the endometrium is
Stage I (mild) 1–4 – – thick enough to appear more echogenic than
the myometrium and not too thick to obscure
Stage II (moderate) 5–8 – –
the midline echo. The classic appearance of
Stage III (severe) 9–12 – – the three-layer endometrium enables better
aReproduced
imaging of uterine defects than the postmen-
from American Fertility Society.
strual endometrium, which is thin, <3 mm.
The American Fertility Society classifications of
adnexal adhesions, distal tubal occlusion, tubal The typical appearance of uterine synechiae is
occlusion secondary to tubal ligation, tubal preg- focal, hyperechoic, irregular, cordlike struc-
nancies, Mullerian anomalies, and intrauterine tures seen within the echo-free space between
adhesions (Fertil Steril 1988; 49:944–55, with per- the basalis layers, which interrupt the continu-
mission from Elsevier the American Society for
ity of the endometrial cavity. These structures
Reproductive Medicine)
bAll adhesions should be considered dense can vary in size (2–6 mm) and/or in location
within the cavity [44].
The most common single presentation is 20.6.2 Hysteroscopy

infertility, representing 43% of reported cases.
The second most common is amenorrhea, Diagnostic hysteroscopy is the gold standard
which is seen in 37% of cases [42]. The rate of for the diagnosis of intrauterine adhesions,
abnormal placentation, although elevated in with demonstrated superiority to sonohys-
women with intrauterine adhesions, is the terogram and hysterosalpingogram, specifi-
least common presentation reported in women cally in false-positive rates. Both radiologic
with intrauterine adhesions. techniques have high false-positive rates.
Hysteroscopy has the added advantage of
being able to assess intrauterine adhesions
20.6 Diagnosis and classify them by location, shape, size, and
nature.
20.6.1 Sonohysterogram
A sonohysterogram is performed with trans- 20.7 Surgical Treatment

vaginal sonography (TVS) and can enhance
the detection of intrauterine adhesions. Saline 20.7.1 Hysteroscopic Surgery
20 serves as a homogenous, echo-free contrast
medium enabling better visualization of the Hysteroscopy has become not only an accu-
uterine cavity than transvaginal ultrasonog- rate tool for the diagnosis of adhesions but
raphy alone. Alborzi et al. [43] published the also the main method for their treatment.
largest series to evaluate the diagnostic accu- Hysteroscopic lysis of adhesions is indicated
449 20
when the extent of adhesions is moderate to Another approach is to place a postopera-
severe or access to tubal ostia is blocked. The tive intrauterine stent. Either a pediatric cath-
significance of mild adhesions is still contro- eter inflated with 15–20 cm3 or a balloon
versial, yet surgical treatment may be consid- uterine stent specifically designed for this pur-
ered if all other causes of infertility or recurrent pose (Cook OB/GYN, Spencer, Indiana) may
pregnancy loss have been excluded and/or suc- be inserted for 7–10 days to prevent the juxta-
cessfully corrected and the patient still experi- position of the uterine walls. Unfortunately,
ences persistent reproductive failure. the Cook balloon was recently taken off the
The basic technique involves resection of market and is unavailable at the time of this
the intrauterine adhesions either by sharp writing.
and/or blunt dissection. Successful hystero- A final approach is to perform office hys-
scopic resection can be accomplished by the teroscopy within the first 7–14 days following
use of sharp dissection using semirigid scis- extensive myomectomy to evaluate the endo-
sors, electrosurgery, and/or fiber-optic laser. metrium for synechiae. If detected early, the
Electrocautery is used by some clinicians. adhesions are filmy and easily lysed with the
However, the disadvantage of its use in this distal tip of the hysteroscope. In some circum-
context is possible thermal damage to the stances, hysteroscopic visualization every
endometrium. 7–10 days may be required until regeneration
Adhesiolysis begins inferiorly and is car- of the endometrium is confirmed and filmy
ried out cephalad until a panoramic view of adhesions treated. When performed too late,
the endometrial cavity can be obtained and dense fibrous adhesions may be encountered,
the tubal ostia are seen. The initiation of the requiring repeat operative hysteroscopic adhe-
adhesiolysis is from the internal os. The main- siolysis.
tenance of adequate distention is key to the
successful resection of intrauterine adhesions;
distention provides traction to the scar tissue 20.7.3 Complications
so that they may be more effectively resected
with hysteroscopic scissors. In cases of severe Complications after hysteroscopic adhesioly-
disease, transabdominal ultrasound guidance sis include all the standard risks seen with any
with a full bladder is very helpful in prevent- operative hysteroscopy. The perforation risk is
ing the creation of a false passage or uterine highest during hysteroscopic adhesiolysis [45].
perforation. The risk of postoperative infection after hys-
teroscopy in general is 1.42%, but the risk of
early-onset endometritis is highest after lysis
20.7.2 Postoperative Adjunctive of synechiae compared to other hysteroscopic
Therapy procedures including uterine septa [45].
Despite advances in the development of tech-

niques for adhesiolysis, the two basic prob- 20.7.4 Outcome
lems associated with poor outcome with these
procedures still exist: the inability to treat The success of surgery can be assessed by
extensive or severe adhesions and the lack of repeat hysteroscopy or imaging or simply by
methods to prevent recurrence of the adhe- the presence of withdrawal bleeding, sugges-
sions postoperatively. The use of Foley cathe- tive of adequate regeneration of the endome-
ters, antibiotics, and high-dose estrogen trium. Successful pregnancy outcome is also a
postoperatively to prevent recurrence of adhe- parameter or measure of success in women
sions is still widely debated, and no consensus trying to conceive and seems to be correlated
exists [40]. A typical regimen is conjugated with the severity of the intrauterine adhesions.
estrogen, 0.625–1.25 mg twice daily, or estra- A number of series have been published
diol, 2 mg twice daily for 25 days, followed by reporting the outcome of hysteroscopic treat-
5 days of progesterone (10 mg is prescribed). ment of intrauterine adhesions. However,
r andomized clinical trials are lacking. A report was used. The mean time to conception in
of 40 consecutive women with recurrent preg- these women was 12.2 months, and all preg-
nancy loss (24 women) or infertility (16 nancies were achieved within 2 years post-
women) resulting from intrauterine adhesions adhesiolysis.
showed excellent surgical results with mild or Increase in pregnancy complication rate
moderate disease [46]. Of the 40 women, 10 was noted. Preterm rate was 50%, and hyster-
had mild adhesions, 20 had moderate adhe- ectomy for abnormal placentation (placenta
sions, and 10 had severe adhesions, according accreta) was seen in 2 of the 20 patients (10%).
to March classification system. Hysteroscopic In addition, Zikopoulos et al. [47] reviewed
adhesiolysis was performed with hysteroscopic the literature of existing studies examining
scissors or monopolar electrosurgery. delivery rates in women undergoing hystero-
Prophylactic antibiotics were used, and, post- scopic adhesiolysis. A large array of tech-
operatively, a pediatric Foley was placed, and niques were used in these studies. He identified
estrogen was administered. All women with seven published studies in the last decade. A
recurrent pregnancy loss conceived after adhe- total of 126 women were reported with an
siolysis; 71% were term or preterm with a via- overall delivery rate of 38.1% (48/126) among
ble pregnancy. Among the women with all the studies analyzed.
infertility, 62% conceived, resulting in a 37.5% Pabuccu et al. [46] reported the highest
live birth rate. Adhesion reformation was success rate among women with recurrent
absent or rare in women with mild or moder- abortion, with a delivery rate of 70.8% vs.
ate adhesions, reported as 0–10%. However, women with infertility with a 37.5% delivery
adhesion reformation was seen in 60% of rate. The overall delivery rate was similar to
women with severe intrauterine adhesions, that reported by Siegler and Valle [48] in 1988.
and none of the patients with severe adhesions They reviewed a series of studies that encom-
conceived. Only one perforation was reported passed 775 subjects, of which 302 (38.9%)
in a patient with severe adhesions. achieved a term delivery.
Valle and Sciarra [16] reviewed 81 infertile The mainstay of diagnosis and treatment
women and reported a term pregnancy rate of of intrauterine adhesions remains hysteros-
81%, 66%, and 15%, respectively, in women copy. However, one cannot stress enough the
with mild, moderate, and severe disease. need to exert due diligence and avoid forced or
Among these women with recurrent pregnancy extensive interventions on the post-gravid
loss, the term pregnancy rate was 94%, 89%, uterus to minimize the development of intra-
and 65% in women who had mild, moderate, uterine adhesions. Mild and moderate adhe-
and severe adhesions, respectively. The litera- sions are associated with improved
ture is unified and quite clear that for women reproductive outcome post adhesiolysis, but
with severe intrauterine adhesions, the repro- severe intrauterine adhesions carry a very
ductive outcome remains poor even after hys- poor prognosis.
teroscopic adhesiolysis [16, 46]. The recurrence
rate of severe adhesions was 48.9% and
decreased to 35% after repeat adhesiolysis [16]. 20.8 Uterine Septum
The overall live delivery rate following
adhesiolysis in women was 43.5% during a 20.8.1 Etiology
mean follow-up period of 39.2 month (± 4.5
months). The live delivery rate based on the Uterine septa are created when there is a fail-
stage of adhesions was 33.3%, 44.4%, and ure of resorption of the midline septum
46.7% for stages I, II, and III, respectively. between the Müllerian ducts. The etiology of
20 The live birth rate among women who tried a septate uterus remains to be elucidated.
naturally was 61.9% vs. 28% after in vitro fer- Sporadic case reports on family pedigrees sug-
tilization. Similar pregnancy rates were noted gest familial aggregation exists, but no clear
in women who conceived naturally whether genetic cause has been linked to the develop-
the resectoscope or the coaxial bipolar system ment of a septate uterus [28, 49]. In general,
451 20
92% of women with congenital uterine anom- among women with first trimester recurrent
alies have a normal karyotype, 46 XX, and miscarriage and greater than 25% in women
approximately 8% of women have an abnor- with late first or early second trimester loss or
mal karyotype [50]. In rare cases, early in preterm delivery. The most frequent to least
utero exposure to radiation, infection such as frequent anomalies are bicornuate uterus,
rubella, and teratogens (diethylstilbestrol, arcuate uterus, incomplete uterine septum,
thalidomide) have been implicated as the uterus didelphys, complete uterine septum,
causal factor of the uterine anomaly. and a unicornuate uterus [51]. In this com-
bined series of women, bicornuate uteri and
complete or partial septums represented 74%
20.8.2 Classification of the uterine anomalies.
In women with recurrent pregnancy loss,
A number of classification systems have been the relative frequency of a septate vs. bicornu-
reported for Müllerian anomalies. However, ate uterus is less clear. This is often attributed
the classification system proposed by the to old surgical data that often did not defi-
ASRM in 2021 is most commonly used to nitely differentiate a septate from a bicornuate
describe or define Müllerian defects. The clas- uterus. In one of the largest studies of patients
sification system organizes uterine anomalies with recurrent pregnancy loss that were evalu-
into nine major uterine anatomic types or cat- ated with either laparoscopy or sonohystero-
egories. In this classification system, a septate gram, the septate uterus was more prevalent
uterus is among the vertical fusion defects in women with recurrent pregnancy loss than
described by the ASRM classification system. the controls [52]. A septate uterus is the most
A septate uterus is characterized by a likely anomaly in patients with recurrent preg-
smooth external fundal contour with two nancy loss.
uterine cavities. The extent of the septum or
the degree of septation can vary from a small
midline septum to total failure of resorption, 20.8.4 Pathophysiology
resulting in a complete septate uterus with a of Pregnancy Complications
longitudinal vaginal septum. A septate uterus
can be differentiated from an arcuate uterus The key presentation in women with a septate
by measuring the depth of internal indenta- uterus is difficulty in maintaining a pregnancy
tion and angle of indentation. and not a decreased ability to conceive (infer-
An arcuate uterus has an internal indenta- tility). Additionally, a septate uterus is thought
tion of <1 cm and angle of internal indenta- to impair normal reproductive performance
tion less than 90 degrees. A septate uterus has by increasing the risk or incidence of early
an internal indentation of >1 cm and an and late abortion, preterm delivery, and the
angle of internal indentation of greater than rate of obstetrical complications [53].
90 degrees. ASRM Mullerian Anomaly The pathogenesis of pregnancy complica-
Classification 2021 tions in women with a septate uterus has not
been completely elucidated. The most widely
accepted causal theory includes the inade-
20.8.3 Incidence quate vascularization of the fibroelastic sep-
tum and altered relations between the
The reported incidence of Müllerian or uter- myometrial and endometrial vessels, thus
ine anomalies is between 0.5% and 6% of exerting negative effects on fetal placentation.
reproductive-age women and highest among The septum is primarily composed of avas-
women with poor reproductive outcome. The cular, fibromuscular tissue. Hence, it has been
overall incidence of Müllerian defects proposed that the endometrium lining the sep-
reported in a series by Acien [51] was 5% tum responds poorly to estrogen, resulting in
among women with normal reproductive his- irregular differentiation and estrogenic matu-
tory, 3% among infertile women, and 5–10% ration [54]. Implantation on this poorly vascu-
larized, fibrous septum leads to abnormal best diagnosed with a three-dimensional ultra-
implantation, defective embryonic develop- sound scan. One study examined 61 patients
ment, and subsequent abortion [55–57]. with a history of recurrent miscarriage or
infertility. Subjects underwent a hysterosalpin-
gogram, two-dimensional TVS, and three-
20.8.5 Diagnosis dimensional TVS. The study demonstrated
that three-dimensional ultrasonography was
Uterine imaging techniques used as a method superior in the detection of arcuate uteri and
of detection of uterine anomalies include major congenital anomalies. It facilitated visu-
HSG; TVS, with or without three- and four- alization of the uterine cavity and myome-
dimensional technology; saline infusion sono- trium, allowing easier diagnosis of septate
hysterosonography (SHG); and MRI. uteri [59].
20.8.6 Hysterosalpingogram 20.8.8 Magnetic Resonance

Imaging
HSG is a useful screening test and should be
the first step in the evaluation of the uterine MRI can accurately predict the presence of
cavity. HSG is a simple, safe, relatively nonin- uterine anomalies and has become the imag-
vasive radiological procedure performed ing method of choice to confirm inconclusive
under fluoroscopic guidance that enables results from other methods. The clear advan-
visualization of the uterine cavity, but it is lim- tages of an MRI include the ability to distin-
ited in differentiating between a septate and guish between myometrial and endometrium
bicornuate uterus. Consequently, the limita- tissue, image the uterus in several planes, and
tions of HSG require additional evaluation. define uterine contour [47, 60–62]. Because
MRI can delineate the uterine contour, a sep-
tate uterus can be distinguished from a bicor-
20.8.7 Ultrasonography nuate uterus, unlike with other radiographic
imaging modalities. Furthermore, the uterine
Two-dimensional ultrasound and SHG can septum can be further characterized by the
also be used to diagnose women suspected of absence of myometrial tissue and vasculariza-
Müllerian anomalies. The diagnostic accuracy tion in the septum. Instead, a uterine septum
of two-dimensional TVS and SHG compared is seen to have a fibrous consistency through-
to HSG is shown in . Table 20.3 [58]. out its entire length. In a review of 23 cases of
However, the presence of a uterine septum is Müllerian anomalies, the correct diagnosis
.. Table 20.3 Diagnostic accuracy of HSG, TVS, and SHG for uterine malformationsa, b
Examination Sensitivity (%) Specificity (%) PPV (%) NPV (%)
HSG 75.0 (21.9–98.7) 95.1 (85.4–98.7) 50.0 (13.9–86.1) 98.3 (89.7–99.9)

TVS 0.0 (0.0–69.0) 95.2 (85.6–98.7) 0.0 (0.0–69.0) 95.2 (85.6–98.7)
SHG 75.0 (21.9–98.7) 93.4 (83.3–97.9) 42.9 (11.8–79.8) 98.3 (89.5–99.9)
HSG hysterosalpingogram, SHG sonohysterography, TVS transvaginal sonography, PPV positive predictive
20 value, NPV negative predictive value
aReprinted from Fertility and Sterility, 73/2, Soares SR, dos Reis MMBB, Camargos AF, Diagnostic accuracy
of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine diseases,

406–11, Copyright 2000, with permission from Elsevier
bThe numbers in parentheses are the limits of the 95% confidence interval
453 20
was made in 96% of cases with MRI, com- bidity, faster recovery, and lower risk of infec-
pared to 85% for TVS [63]. tion, hemorrhage, and adhesions than with
Another advantage of MRI is its ability to metroplasty via laparotomy or laparoscopy.
detect the associated anomalies in other organ There is no indication for metroplasty by lapa-
systems typically seen with Müllerian anoma- rotomy or laparoscopy. Additionally, by avoid-
lies such as renal or the urinary tract anoma- ing large incisions into the myometrium,
lies. The major disadvantage includes the lack hysteroscopic metroplasty does not result in a
of portability and higher costs compared with recommendation for cesarean delivery in future
other imaging modalities. pregnancies.
After initial imaging has been performed
with either HSG, TVS, or SHG, an MRI may
be used to determine the contour of the uter- 20.9.2 Hysteroscopic Technique
ine fundus to distinguish between a septate
uterus and bicornuate uterus. There must be a Hysteroscopic metroplasty is usually per-
less than 1 cm indentation at the fundus to formed under general anesthesia using either
qualify as a septate uterus. If there is any an operative hysteroscope or resectoscope.
ambiguity in terms of the diagnosis, the gold The basic technique usually involves simple
standard for the accurate and proper classifi- incision of the septum rather than removal or
cation for the diagnosis of a uterine anomaly resection. However some large, broad-based
is laparoscopy and hysteroscopy. septums are sometimes excised partially.
Microscissors are the method of choice for
surgical resection of the septum. However,
20.9 Surgical Treatment one limitation of the scissors is increased dif-
ficulty in dissecting and cutting broad-based
20.9.1 Indication septums. In these instances, electrocautery
with the wire loop can be used. Generally,
The most common and accepted indication for electrocautery is avoided secondary to theo-
surgical resection of a uterine septum is recur- retical concern that the use of electrocautery
rent pregnancy loss in either the first or early will cause thermal damage on the endome-
second trimester. The goal of surgical repair of trium and myometrium, with potential risk of
a uterine septum is restoration of a normal uterine rupture with a subsequent pregnancy.
uterine cavity. However, normal surgical resto- Hysteroscopic metroplasty is performed
ration of the uterine cavity does not necessar- ideally in the early follicular phase of the men-
ily imply good reproductive prognosis, as strual cycle when the endometrium is thin,
uterine vascularization may also be impaired. hence, not requiring any preparation of the
Most studies would support the observa- endometrium. Classical teaching has
tion that primary infertility in the presence of a described the use of a laparoscope to visualize
septate uterus is not an indication for hystero- the uterine fundus while it is transilluminated
scopic metroplasty. This procedure should only with the hysteroscope. This allows for assess-
be considered after a comprehensive infertility ment of myometrial thickness, which is impor-
evaluation. If no other etiologies are discov- tant to optimally resect the septum while
ered, and the patient’s infertility persists, this avoiding uterine perforation. However, this is
procedure may be undertaken. On the other not necessary in most cases. More recent data
hand, the simplicity and low morbidity of the suggest that a transabdominal intraoperative
hysteroscopic metroplasty has led many experts ultrasound can be used both safely and ade-
to recommend immediate removal prior to quately to prevent perforation.
more comprehensive evaluation, especially in The surgical technique for the manage-
women with advanced age, given that uterine ment of a complete uterine septum begins by
septums increase the rate of miscarriage. resecting the cervical septum. This can be
Hysteroscopic metroplasty is the method of achieved with Metzenbaum or Mayo scissors,
choice, with benefits that include lower mor- inserting each blade evenly into either side of
the septum. A single tooth tenaculum should 20.9.4 Postoperative Care

be used to grasp the anterior lip to provide
traction and stabilization of the cervix. Once Postoperative estrogens or intrauterine con-
the cervical portion is resected, the hystero- traceptive devices have been used. However,
scope can be introduced. At times, the single randomized studies in women undergoing
tooth tenaculum may need to be gently twisted hysteroscopic resection of their uterine sep-
or reapplied closer to the cervical os to help tums have noted no difference in the postop-
occlude the cervical opening and allow suffi- erative intrauterine adhesion rates, when
cient uterine distension. followed up with HSG or hysteroscopy,
Resection or horizontal incision of the sep- despite the use of either agent [64, 65]. Studies
tum is carried out from the lower margin of the have also not shown any added value with the
septum and continued cephalad toward the use of prophylactic antibiotics.
tubal ostia, always staying in the midline and
horizontal plane of the septum. It is important
to keep bilateral tubal ostia in view to ensure 20.9.5 Complications
there is no deviation from the midline, which
could cause a false passage into the myometrium The complications associated with the hys-
and subsequent uterine perforation. Incision teroscopic metroplasty can be viewed in two
into the myometrium should be minimized. major categories: those intrinsic to operative
The endpoint of resection can be charac- hysteroscopy and those related to the tech-
terized by a number of parameters. nique and instruments used for septum
Visualization of pink, vascular myometrium, resection.
distinct from the white, avascular tissue of the The major concern with the use of the
septum, is important. It is also important to electrosurgical systems is uterine rupture at
examine the relationship of the resection to the actual site of the septum with a later preg-
the tubal ostia and the proximity of the resec- nancy secondary to weakening of the uterine
tion to the uterine serosa, which can be wall from thermal damage. However, vaginal
assessed via the laparoscope or ultrasound. A delivery is still recommended unless extensive
successful resection of the septum is defined damage has occurred through thermal injury
when the tubal ostia are seen together with no or a fundal perforation has occurred. The rate
separation in between, an enlargement of the of uterine perforation is lower with resection
uterine cavity is demonstrated, and an of a uterine septum than it is for intrauterine
improvement in the uterine shape is accom- adhesiolysis. It is reported to be less than 1%.
plished.
20.9.6 Outcome
20.9.3 Abdominal Metroplasty
Many studies exist that report both presurgi-
Abdominal metroplasty was performed prior cal and postsurgical outcomes in women with
to the development of hysteroscopic septum hysteroscopic metroplasty. The existing stud-
resection techniques. These techniques ies do not demonstrate any impairment on
entailed either a wedge resection at the fundus ovarian response to stimulation nor implanta-
that removes the septum, as in the Jones pro- tion rates in the presence of Müllerian anom-
cedures, or opening the uterus in the midline alies, including a septate uterus. One
and removing the septum, as in the Tompkins randomized controlled trial by Rikken et al.
metroplasty technique. However, little out- enrolled women with a septate uterus and a
20 come data has been published for these proce- history of subfertility, pregnancy loss, or pre-
dures, and abdominal metroplasty is rarely term birth. They were randomly assigned to
performed today. septum resection or expectant management.
455 20
The primary outcome that was evaluated was ??2. A 2 cm type II uterine myoma should be
the rate of live birth within 12 months after removed
randomization. Results demonstrated live A. Laparoscopically
births in 31% of women with septum resec- B. Hysteroscopically with a tissue
tion and 35% of women unallocated to expect- shaver
ant management [69]. C. Hysteroscopically with a bipolar
However, the studies do report a higher loop electrode
rate of spontaneous abortion and preterm D. Hysteroscopically with a monopo-
delivery if the septum is uncorrected [66, 67, lar loop electrode
70–72]. Carrera et al. performed a systematic
review with a meta-analysis which demon- ??3. There is good evidence that posttreat-
strated a decrease in miscarriage rate in ment of Asherman’s syndrome with the
patients with complete or partial septum following will reduce post procedure
resections. There was a decrease in frequency adhesions
of preterm birth in patients who underwent A. High-dose oral estrogen
partial septum resection, but this was not B. High-dose vaginal estrogen
detected in patients who underwent complete C. Intrauterine balloon
septum resection [71]. Another retrospective D. All of the above
cohort study written by Fox et al. examined E. None of the above
109 women with uterine septums. Of these, 63
underwent septum resection which demon-
strated a decrease in preterm delivery: 4.5% in 20.11 Answers
the hysteroscopic resection group versus
31.6% in the expectant management group vv1. B
[72]. Despite these and several other studies
demonstrating an improvement in spontane- vv2. C
ous abortion and preterm delivery with hys-
teroscopic metroplasty, there is currently a vv3. E
paucity of well-designed randomized trials to
confirm these findings.
In conclusion, although the hysteroscopic References
metroplasty is not intended to enhance fertil-
ity, it may be indicated for the improvement of 1. Marlow JL. Media and delivery systems. Obstet
pregnancy outcome, especially after multiple Gynecol Clin North Am. 1995;22:409–22.
2. Corson SL, Brooks PG, Serden SP, Batzer FR,
treatment failed assisted reproductive cycles.
Gocial B. Effects of vasopressin administra-
The possible adverse effect of the presence of tion during hysteroscopic surgery. J Reprod Med.
a septate uterus on the outcome of assisted 1994;39:419–23.
reproductive technology is still debated. 3. Cooper JM, Brady RM. Intraoperative and early
postoperative complications of operative hysteros-
copy. Obstet Gynecol Clin North Am. 2000;27:
347–66.
20.10 Review Questions 4. Romer T, Lober R. Hysteroscopic correction of a
complete septate uterus using a balloon technique.
??1. When performing diagnostic or opera- Hum Reprod. 1997;12:478–9.
tive hysteroscopy, it is appropriate to 5. Lurie S, Appelman Z, Katz Z. Curettage after
midtrimester termination of pregnancy-is it neces-
use electrolyte free media for uterine sary? J Reprod Med. 1991;36:786–8.
distention when 6. Marsh FA, Rogerson LJ, Duffy SR. A randomised
A. Bipolar energy is used controlled trial comparing outpatient versus day-
B. Monopolar energy is used case endometrial polypectomy. BJOG.
C. When using tissue shavers 2006;113:896–901.
7. Kremer C, Duffy S, Moroney M. Patient satisfac-
D. Never tion with outpatient hysteroscopy versus day case
hysteroscopy: randomised controlled trial. BMJ. patients undergoing intrauterine insemination: a

2000;320:279–82. prospective, randomized study. Hum Reprod.
8. Bettocchi S, Selvaggi I. A vaginoscopic approach to 2005;20(6):1632–5.
reduce the pain of office hysteroscopy. J Am Assoc 23. Martin-Ondarza C, Gil-Moreno A, Torres-Cuesta
Gynecol Laparosc. 1997;4(2):255–8. L, Garcia A, Eyzaguirre F, Diaz-Feijoo B, et al.
9. Nagele F, O’Connor H, Davies A, Badawy A, Endometrial cancer in polyps: a clinical study of 27
Mohamed H, Magos A. 2500 Outpatient diagnostic cases. Eur J Gynaecol Oncol. 2005;26(1):55–8.
hysteroscopies. Obstet Gynecol. 1996;88:87–92. 24. Al-Inany H. Intrauterine adhesions. An update.
10. De Iaco P, Marabini A, Stefanetti M, Del Vecchio Acta Obstet Gynecol Scand. 2001;80:986–93.
C, Bovicelli L. Acceptability and pain of outpatient 25. March CM, Israel R, March AD. Hysteroscopic
hysteroscopy. J Am Assoc Gynecol Laparosc. management of intrauterine adhesions. Am J Obstet
2000;7:71–5. Gynecol. 1978;130:653–7.
11. Davies A, Richardson RE, O’Conner H, Baskett 26. Emanuel MH, Verdel MJ, Wamsteker K. A prospec-
TF, Nagele F, Magos AL. Lignocaine aerosol spray tive comparison of transvaginal ultrasonography
in outpatient hysteroscopy: a randomized double- and diagnostic hysteroscopy in the evaluation of
blind placebo-controlled trial. Fertil Steril. patients with abnormal uterine bleeding: clinical
1997;67:1019–23. implications. Am J Obstet Gynecol. 1995;172:
12. Readman E, Maher PJ. Pain relief and outpatient 547–52.
hysteroscopy: a literature review. J Am Assoc Gyne- 27. Wortman M, Dagget A. Hysteroscopic myomec-
col Laparosc. 2004;11:315–9. tomy. J Am Assoc Gynecol Laparosc. 1995;3(1):
13. American College of Obstetricians and Gyne- 39–46.
cologists. Office based surgery procedures under 28. Ergun A, Pabuccu R, Atay V, Kucuk T, Duru NK,
sedation. http://www.acog.org/About_ACOG/ Gungor S. Three sisters with septate uteri: another
ACOG_Sections/Arizona_Section/Office_Based_ reference to bi-directional theory. Hum Reprod.
Surgery___Procedures_under_sedation. Accessed 2 1997;12:140–2.
Jan 2013. 29. Phillips DR, Nathanson HG, Milim SJ, Haselkorn
14. American College of Obstetricians and Gynecolo- JS, Khapra A, Ross PL. The effect of dilute vaso-
gists. Technology assessment no. 7: hysteroscopy. pressin solution on blood loss during operative hys-
Obstet Gynecol. 2011;117:1486–91. teroscopy: a randomized controlled trial. Obstet
15. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans Gynecol. 1996;88(5):761–6.
J, Trimbos JB, Trimbos-Kemper TC. Complications 30. Stabinsky S, Einstein M, Breen J. Modern treat-
of hysteroscopy: a prospective, multicenter study. ments of menorrhagia attributable to dysfunctional
Obstet Gynecol. 2000;96(2):266–70. https://doi. uterine bleeding. Obstet Gynecol Surv.
org/10.1016/s0029-7844(00)00865-6. PMID: 1999;54(11):251–62.
10908775. 31. Asherman JG. Traumatic intrauterine adhesions. Br
16. Valle R, Sciarra J. Intrauterine adhesions: hystero- J Obstet Gynaecol. 1950;57:892–6.
scopic diagnosis, classification, treatment and repro- 32. Netter AP, Musset R, Lambert A, Salomon Y. Trau-
ductive outcome. Am J Obstet Gynecol. matic uterine synechiae: a common cause of men-
1988;158:1459–70. strual insufficiency, sterility and abortion. Am J
17. Hassiakos DK, Zourlas PA. Transcervical division Obstet Gynecol. 1956;71:368–75.
of uterine septa. Obstet Gynecol Surv. 1990;45: 33. Dicker D, Ashkenazi J, Dekel A, Orvieto R, Feld-
165–73. berg D, Yeshaya A, et al. The value of hysteroscopic
18. Agostini A, Bretelle F, Ronda I, Roger V, Cravello evaluation in patients with preclinical in-vitro fertil-
L, Blanc B. Risk of vasovagal syndrome during out- ization abortions. Hum Reprod. 1996;11:730–1.
patient hysteroscopy. J Am Assoc Gynecol Lapa- 34. Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan
rosc. 2004;11:245–7. E, Burak F, et al. Role of endometrial suppression
19. Cicinelli E, Schonauer LM, Barba B, Tartagni on the frequency of intrauterine adhesions after
M, Luisi D, Di Naro E. Tolerability and cardio- resectoscopic surgery. J Am Assoc Gynecol Lapa-
vascular complications of outpatient diagnostic rosc. 2000;7:351–4.
minihysteroscopy compared with conventional 35. Adoni A, Palti Z, Milwidsky A. The incidence of
hysteroscopy. J Am Assoc Gynecol Laparosc. intrauterine adhesions following spontaneous abor-
2003;10:399–402. tions. Int J Fertil. 1982;27:117–78.
20. Goldrath MH. Uterine tamponade for the control 36. Friedler S, Margalioth EJ, Kafka I, Yaffe H. Inci-
of acute uterine bleeding. Am J Obstet Gynecol. dence of post-abortion intra-uterine adhesions eval-
1983;147:869–72. uated by hysteroscopy-a prospective study. Hum
20 21. Serden SP, Brooks PG. Treatment of abnormal uter- Reprod. 1993;8:442–4.
ine bleeding with the gynecologic resectoscope. J 37. Golan A, Schneider D, Avrech O. Hysteroscopic
Reprod Med. 1991;36:697. findings after missed abortion. Fertil Steril.
22. Perez-Medina T, Bajo-Arenas J, Salazar F, Redondo 1992;58:508–10.
T, Sanfrutos L, Alvarez P, et al. Endometrial polyps 38. Romer T. Postabortion-hysteroscopy—a method for
and their implication in the pregnancy rates of early diagnosis of congenital and acquired intra-
457 20
uterine causes of abortions. Eur J Obstet Gynecol 54. Sparac V, Kupesic S, Ilijas M, Zodan T, Kurjak
Reprod Biol. 1994;57:171–3. A. Histologic architecture and vascularization of
39. Westendorp ICD, Ankum WM, Mol BWJ, Vonk hysteroscopically excised intrauterine septa. J Am
J. Prevalence of Asherman’s syndrome after second- Assoc Gynecol Laparosc. 2001;8:111–6.
ary removal of placental remnants or a repeat curet- 55. Fedele L, Dorta M, Brioschi D, Giudici MN, Candi-
tage for incomplete abortion. Hum Reprod. ani GB. Pregnancies in septate uteri: outcome in
1998;13:3347–50. relation site of uterine implantation as determined
40. Schenker JG. Etiology and therapeutic approach to by sonography. AJR Am J Roentgenol.
synechia uteri. Eur J Obstet Gynecol Reprod Biol. 1989;152:781–4.
1996;65:109–13. 56. Fedele L, Bianchi S, Marchini M, Franchi D, Tozzi
41. The American Fertility Society. The American fer- L, Dorta M. Ultrastructural aspects of endome-
tility society classifications of adnexal adhesions, trium in infertile women with septate uterus. Fertil
distal tubal occlusion, tubal occlusion secondary to Steril. 1996;65:750–2.
tubal ligation, tubal pregnancies, Mullerian anoma- 57. Propst AM, Hill JA. Anatomic factors associated
lies, and intrauterine adhesions. Fertil Steril. with recurrent pregnancy loss. Semin Reprod Med.
1988;49:944–55. 2000;18:341–50.
42. Schenker JG, Margalioth EJ. Intrauterine adhe- 58. Soares SR, dos Reis MMBB, Camargos AF. Diag-
sions. An updated appraisal. Fertil Steril. nostic accuracy of sonohysterography, transvaginal
1982;37:593–610. sonography, and hysterosalpingography in patients
43. Alborzi S, Dehbashi S, Khodaee R. Sonohysterosal- with uterine diseases. Fertil Steril. 2000;73:406–11.
pingographic screening for infertile patients. Int J 59. Jurkovic D, Geipel A, Gruboeck K, Jauniaux E,
Gynecol Obstet. 2003;82:57–62. Natucci M, Campbell S. Three-dimensional ultra-
44. Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach sound for the assessment of uterine anatomy and
R, Ben-Rafael Z. Predictive value of transvaginal detection of congenital anomalies: a comparison
sonography performed before routine diagnostic with hysterosalpingography and two-dimensional
hysteroscopy for evaluation of infertility. Fertil sonography. Ultrasound Obstet Gynecol.
Steril. 2000;73:412–7. 1995;5(4):233–7.
45. Agostini A, Cravello L, Shojai R, Ronda I, Roger V, 60. Mintz M, Thickman D, Gussman D, Kressel H. MR
Blane B. Postoperative infection and surgical hyster- evaluation of uterine anomalies. Am J Roentgenol.
oscopy. Fertil Steril. 2002;77:766–8. 1987;148:287–90.
46. Pabuccu R, Atay V, Orhon E, Urman B, Ergun 61. Pellerito JS, McCarthy SM, Doyle MB, Glickman
A. Hysteroscopic treatment of intrauterine adhe- MG, DeCherney AH. Relative accuracy of MRI
sions is safe and effective in the restoration of nor- imaging, endovaginal sonography, and hysterosal-
mal menstruation and fertility. Fertil Steril. pingography. Radiology. 1992;183:795–800.
1997;68:1141–3. 62. Takagi H, Matsunami K, Noda K, Furui T, Imai
47. Zikopoulos KA, Kolibianakis AM, Plateau P, de A. Magnetic resonance imaging in the evaluation of
Munck L, Tournaye H, Devroey P, et al. Live deliv- double uterus and associated urinary tract anoma-
ery rates in sub fertile women with Asherman’s syn- lies: a report of five cases. J Obstet Gynaecol.
drome after hysteroscopic adhesiolysis using 2003;23:525–7.
resectoscope or the versapoint system. RBM Online. 63. Doyle MB. Magnetic resonance imaging in Mulle-
2004;8:720–5. rian fusion defects. J Reprod Med. 1992;37:33–8.
48. Siegler AM, Valle RF. Therapeutic hysteroscopic 64. Assaf A, Serour G, Elkady A, El Agizy H. Endo-
procedures. Fertil Steril. 1988;50:685–701. scopic management of the intrauterine septum. Int
49. Verp MS, Simpson JL, Elias S, Carson SA, Sarto J Gynaecol Obstet. 1990;32:43–51.
GE, Feingold M. Heritable aspects of uterine 65. Dabirashrafi H, Mohammad-Tabrizi M. Is estrogen
anomalies. I. Three familial aggregates with Mulle- necessary after hysteroscopic incision of the uterine
rian fusion anomalies. Fertil Steril. 1983;40: septum? J Am Assoc Gynecol Laparosc. 1996;3:
80–6. 623–5.
50. Harger JH, Archer DF, Marchese SG, Muracca- 66. Kupesic S. Clinical implications of sonographic
Clemens M, Garver KL. Etiology of recurrent preg- detection of uterine anomalies for reproductive out-
nancy loss and outcome of subsequent pregnancies. come. Ultrasound Obstet Gynecol. 2001;18:
Obstet Gynecol. 1983;62:574–81. 387–400.
51. Acien P. Incidence of Mullerian defects in fertile 67. Homer HA, Li TC, Cooke ID. The septate uterus: a
and infertile women. Hum Reprod. 1997;12:1372–6. review of management and reproductive outcome.
52. Stephenson MD. Frequency of factors associated Fertil Steril. 2000;73(1):1.
with habitual abortion in 197 couples. Fertil Steril. 68. Ahmad G, Saluja S, O’Flynn H, Sorrentino A, Leach
1996;66:24–9. D, Watson A. Pain relief for outpatient hysteros-
53. Ludmir J, Samuels P, Brooks S, Mennuti MT. Preg- copy. Cochrane Database Syst Rev. 2017;(10). Art.
nancy outcome of patients with uncorrected uterine No.: CD007710. https://doi.org/10.1002/14651858.
anomalies managed in a high risk-obstetric setting. CD007710.pub3.
Obstet Gynecol. 1990;75:906–10.
69. Rikken JFW, Kowalik CR, Emanuel MH, Bongers E. Effect of hysteroscopic metroplasty on reproduc-
MY, Spinder T, Jansen FW, Mulders AGMGJ, Pad- tive outcomes in women with septate uterus. Sys-
mehr R, Clark TJ, van Vliet HA, Stephenson MD, tematic review and meta-analysis. J Minim Invasive
van der Veen F, BWJ M, van Wely M, Goddijn Gynecol. 202:S1553-4650(21)01210-3. https://doi.
M. Septum resection versus expectant management org/10.1016/j.jmig.2021.10.001. Epub ahead of
in women with a septate uterus: an international print. PMID: 34648934.
multicentre open-label randomized controlled trial. 72. Fox NS, Connolly CT, Hill MB, Klahr RA, Zaf-
Hum Reprod. 2021;36(5):1260–7. https://doi. man KB, Rebarber A. Pregnancy outcomes in
org/10.1093/humrep/deab037. PMID: 33793794; viable pregnancies with a septate uterus com-
PMCID: PMC8058590. pared with viable pregnancies after hysteroscopic
70. Venetis CA, Papadopoulos SP, Campo R, Gordts uterine septum resection. Am J Obstet Gynecol
S, Tarlatzis BC, Grimbizis GF. Clinical implications MFM. 2019;1(2):136–43. https://doi.org/10.1016/j.
of congenital uterine anomalies: a meta- analysis ajogmf.2019.05.003. Epub 2019 May 15. PMID:
of comparative studies. Reprod Biomed Online. 33345819.
2014;29(6):665–83. https://doi.org/10.1016/j. 73. Bradley LD. In: Falcone T, Hurd WW, editors. Clin-
rbmo.2014.09.006. Epub 2014 Sep 21. PMID: ical reproductive medicine and surgery. St. Louis:
25444500. Mosby/Elsevier; 2007.
71. Carrera M, Pérez Millan F, Alcázar JL, Alonso L,
Caballero M, Carugno J, Dominguez JA, Moratalla
20
459 21
Gynecologic Laparoscopy
Mohamed A. Bedaiwy, Howard T. Sharp, Tommaso Falcone
and William W. Hurd
Contents

21.1.1 istory – 462
H
21.1.2 General Techniques for Laparoscopy – 462
21.1.3 Direct Trocar Insertion – 463
21.1.4 Open Laparoscopy – 464
21.1.5 Left Upper Quadrant Technique – 464
21.1.6 Placement of Secondary Ports – 465
21.1.7 Removal of Ports and Port Site Closure – 466
21.1.8 Multifunctional Laparoscopic Instruments – 466
21.1.9 Laparoscopic Procedures – 467
21.1.10 Tubal Sterilization – 468
21.1.11 Lysis of Adhesion and Tubal
Reconstructive Surgery – 468
21.1.12 Excision and Fulguration of Endometriosis – 469
21.1.13 Ectopic Pregnancy Treatment – 469
21.1.14 Ovarian Cystectomy and Oophorectomy – 469
21.1.15 Myomectomy – 470
21.1.16 Laparoscopic Management of Pelvic Pain – 470
21.1.17 Hysterectomy – 471
21.1.18 Laparoscopic-Assisted Vaginal Hysterectomy – 471
21.1.19 Laparoscopic Hysterectomy – 471
21.1.20 Supracervical Hysterectomy – 471
21.1.21 Power Morcellation Following
Laparoscopic Surgery – 472
21.1.22 Oncologic Procedures – 473
21.1.23 Robotically Assisted Laparoscopic Surgery – 473
21.1.24 Robotic Gynecologic Surgery – 474
21.1.25 Robotically Assisted Tubal Reanastomosis – 475

https://doi.org/10.1007/978-3-030-99596-6_21
21.1.26 obotically Assisted Myomectomy – 475
R
21.1.27 Robotically Assisted Resection of Endometriosis – 476
21.1.28 Clinical Applications in Gynecologic Oncology – 476
21.1.29 Clinical Applications in Female Pelvic Medicine
and Reconstructive Surgery – 477
21.1.30 Single-Port Laparoscopy – 477
21.1.31 Laparoscopic Complications – 478
21.1.32 Retroperitoneal Vessel Injury – 478
21.1.33 Prevention – 478
21.1.34 Awareness of the Patient’s Position – 478
21.1.35 High-Pressure Entry – 478
21.1.36 Verify Veress Needle Location – 479
21.1.37 Other Laparoscopic Entry Methods – 479
21.1.38 Open Laparoscopy – 479
21.1.39 Direct Trocar Insertion – 479
21.1.40 Left Upper Quadrant – 479
21.1.41 Alternative Primary Trocar Design – 480
21.1.42 Treatment – 480
21.1.43 Abdominal Wall Vessel Injury – 480
21.1.44 Prevention – 481
21.1.45 Treatment – 481
21.1.46 Gastrointestinal Injury – 481
21.1.47 Preventive Measures – 482
21.1.48 Recognition and Treatment – 482
21.3 Answers – 486
References – 486
461 21
was revolutionized by the continuous fine-
Key Points tuning of the traditional instruments and the
55 The only reliable method of confirming addition of new ones. The last decade has
intraperitoneal placement of a Veress witnessed the introduction of robotic assis-
needle or primary trocar is by observing tance and the laparoendoscopic single-site
the intra-abdominal pressure which (LESS) surgery as new enhancements to the
should be less than 15 mm Hg. field. In addition, laparoscopy has become
55 The left upper quadrant technique is one of the most common surgical procedures
ideal for patients with previous abdomi- performed in the United States and world-
nal surgery with suspected or known wide. It became the gold standard for many
periumbilical bowel adhesions, laparos- gynecologic procedures, such as removal of
copy during pregnancy, and with large ectopic pregnancies and the treatment of
pelvic masses. endometriosis.
55 The inferior (deep) epigastric vessels are A recent study looked at a Cohort of
not visualized by transillumination. 264,758 women who underwent hysterectomy
They are visualized directly intra- for benign gynecologic disorders at 441 hospi-
abdominally. tals across the United States from 2007 to
55 Insertion of the Veress needle and pri- 2010. Use of robotically assisted hysterectomy
mary trocar for initial entry by trocar increased from 0.5% in 2007 to 9.5% of all
insertion remains the most hazardous hysterectomies in 2010. During the same time
part of laparoscopy, accounting for period, laparoscopic hysterectomy rates
40% of all laparoscopic complications increased from 24.3% to 30.5% [1, 2].
and the majority of the fatalities. For other procedures, including laparo-
scopically assisted hysterectomy and treat-
ment of gynecologic cancers, the relative risks
and benefits of the laparoscopic approach are
21.1 Introduction still being determined.
This chapter will give an overview of the
During the last four decades, the discipline of history and modern use of laparoscopy.
gynecologic surgery has seen significant Laparoscopic complications and specific lapa-
advancement in the use of minimally invasive roscopic techniques are considered in subse-
surgery. The laparoscopic technique itself quent chapters.
Case Vignette
A 42-year-old G3 P3 presents to her gynecolo- being intramural, measuring 7 cm in the maxi-

gist’s office with long-standing history of vaginal mum diameter with a 12 mm endometrial stripe.
bleeding, frequency of micturition, and consti- Laboratory evaluation includes a negative blood
pation over the past 3 years. Her gynecologic his- hCG, white blood cell count, hemoglobin of
tory is significant for a diagnosis of multifibroid 9.8 g/dL, and platelet count of 350,000 per
uterus. She has had bilateral tubal ligation. Her mcL. After reviewing different treatment
Pap smears have been normal. Her vital signs are options, she elected to go for total laparoscopic
stable and her review of systems is noncontribu- hysterectomy. On the day of surgery, peritoneal
tory. Her pelvic exam reveals normal-appearing access was obtained via Palmer’s point. Upon
vagina and cervix. Her bimanual examination is inserting the right lower quadrant trocar, the tro-
difficult because of her obesity, but does reveal a car tip went in the right common iliac vein.
16-week-size uterus. Pelvic ultrasound shows a Immediate laparotomy was performed, and vas-
multifibroid uterus with the dominant fibroid cular surgery were called for help.
462 M. A. Bedaiwy et al.
21.1.1 History principles of laparoscopic surgery apply to

robotic surgery. The first reported gynecologic
Hippocrates described the first example of surgical procedure performed with the addi-
an endoscope, an early rectal speculum, in tion of the robot was in 1999 at the Cleveland
Greece between 460 bc and 375 bc. The ruins Clinic [5].
of Pompeii, Italy (70 ad), provided the next
example, a three-bladed vaginal speculum,
similar to a modern-day speculum. Next, 21.1.2 General Techniques
Philipp Bozzini in Germany (1773–1809) for Laparoscopy
developed a light conductor that he called
“Lichtleiter,” which directed light into the 21.1.2.1 Primary Trocar Placement
patient’s body and then reflected the image
back to the eye of the surgeon. John D. Fisher For many years, the standard techniques used
(1798–1850) described an endoscope to for creating a pneumoperitoneum and placing
inspect the vagina, and he later modified it a laparoscopic port into the abdomen were
to examine the bladder and urethra. In 1853, either a closed technique or an open approach.
Antoine Jean Desormeaux pioneered the first In the last decades, multiple alternative
functional endoscope, which was mainly used approaches and locations have been reported.
for urologic cases. This instrument had mir- The five most common approaches are as
rors and a lens with a lamp flame as the light follows:
source, which burned a mixture of alcohol 55 Standard closed technique (Veress needle
and turpentine. insufflation followed by primary trocar
The first experimental laparoscopy (“celi- insertion)
oscopy”) was performed in Berlin in 1901, by 55 Direct trocar insertion (no insufflation
Dr. Georg Kelling, who placed a cystoscope prior to trocar insertion)
into the abdomen of dogs to evaluate the abil- 55 Open laparoscopy
ity of insufflated air to stop gastrointestinal 55 Left upper quadrant (LUQ) insertion
hemorrhage [3]. Dr. Hans Christian Jacobaeus technique
of Sweden published the first description of
“laparothoracoscopy” in 1910 as a technique Both reusable and disposable instruments are
to evaluate patients with peritoneal tuberculo- commonly used. The ultimate safety of many
sis. However, laparoscopy made little headway of the newer techniques and instruments has
into clinical practice until after World War yet to be determined.
I. It took until the 1960s for laparoscopy to be
accepted in the United States and Europe as a 21.1.2.2 Standard Closed Technique:
safe and valuable surgical procedure. Veress Needle and Primary
For many years, gynecologic laparoscopy Trocar Insertion
was performed almost exclusively for diagnos- The standard closed technique was used
tic purposes and for sterilizations. By the almost exclusively for decades and continues
1970s, the role of laparoscopy had expanded to be one of the most widely used techniques
to include lysis of adhesions and treatment of among gynecologists today [6]. Both the
endometriosis [4]. The technology and equip- Veress needle and primary trocar are blindly
ment advanced over the next four decades placed through a periumbilical incision into
such that laparoscopy is now used for a wide the peritoneal cavity. Using this approach
variety of procedures ranging from treatment with reusable instruments, the combined risk
of ectopic pregnancies and ovarian cysts to of injuring retroperitoneal vessels, bladder, or
hysterectomy, incontinence procedures, and bowel has been found to be less than 1 in 1000
management of gynecological malignancies. cases [7]. This approach has become the “gold
21 The addition of a robot extended the standard” against which all other techniques
potential of laparoscopic surgery. The general are judged.
463 21
a b c
.. Fig. 21.1 Changes in the anterior abdominal wall Overweight (BMI 25–30 kg/m2). c Obese
2
(BMI >30 kg/m ). An 11.5 cm Veress needle is superim-
anatomy with weight. Diagram of representative sagit-
tal views derived from magnetic resonance and composed on each view for comparison. (Reproduced with
puted tomographic imaging for patients in three groups. permission from Falcone and Hurd [133])
a Ideal weight (body mass index [BMI] <25 kg/m2). b
For the standard technique, the patient is Verification that the Veress needle tip is in
placed in a horizontal position, and the the peritoneal cavity is done by a number of
abdominal wall is elevated by manually grasp- methods, including the “hanging drop test,”
ing the skin and subcutaneous tissue. This is injection and aspiration of fluid through the
done to maximize the distance between the Veress needle, and close observation of intra-
umbilicus and the retroperitoneal vessels. An abdominal pressure during carbon dioxide
alternative method used to elevate the abdom- insufflation. The only reliable method of con-
inal wall is to place penetrating towel clips at firming intraperitoneal placement is by
the base of the umbilicus. observing the intra-abdominal pressure which
In a woman of ideal weight (body mass should be less than 15 mm Hg. After a pneu-
index (BMI) <25 kg/m2) or only slightly over- moperitoneum has been created, the Veress
weight (BMI 25–30 kg/m2), the lower anterior needle is removed, and the primary port tro-
abdominal wall is grasped and elevated, and car (most commonly 5 or 10 mm in diameter)
the Veress needle is inserted toward the hollow is placed at an angle identical to that used for
of the sacrum at a 45° angle (. Fig. 21.1) [8]. the Veress needle.
In the thinnest patients in this group, the ret-
roperitoneal vessels are much closer to the
abdominal wall, and the margin of error is 21.1.3 Direct Trocar Insertion
reduced, with as little as 4 cm between the skin
and these vessels. In the obese patient (BMI Direct trocar insertion is a technique whereby
>30 kg/m2; weight usually >200 lb), a more the primary trocar is inserted without having
vertical approach of approximately 70–80° is previously inserted the Veress needle and
required to enter the peritoneal cavity because insufflating the abdomen with carbon dioxide
of the increased thickness of the abdominal [8]. This could be achieved blindly or via the
wall. It is important to avoid subcutaneous optical-trocar-assisted technique. The direct
tunneling of the Veress needle and/or the tro- primary trocar is inserted at an angle similar
cars prior to puncturing the fascia of the ante- to that described above for the closed tech-
rior abdominal wall. nique. The peritoneal cavity is then insuf-
flated with carbon dioxide through the nique, fascial sutures are used to assist subse-
umbilical port. quent closure and help maintain a
The optical trocar insertion allows visual- pneumoperitoneum [9]. This method almost
ization of the layers that are being penetrated eliminates the risk of retroperitoneal vessel
during entry via a laparoscope in the cannula. injury and is preferred by many laparoscopists
It is assumed that this approach could reduce for this reason [13]. It is also suggested to pre-
the risk of injury since the technique is no lon- vent gas embolism and preperitoneal insuffla-
ger blind. However, vascular and visceral inju- tion [6]. Although open laparoscopy does not
ries are reported with this approach. On the entirely avoid the risk of bowel injury, many
other side, seeing the injury as it happens will laparoscopists use this approach in an effort
allow prompt recognition and repair, nullify- to decrease this risk in patients with previous
ing the consequences of delayed diagnosis abdominal surgery suspected of having
and management. The advantage of the direct adhesions.
trocar insertion with an optical device is that Randomized controlled trials comparing
it eliminates a blind entry. the Hasson and Veress techniques showed no
This technique also decreases the risk of significant reduction in major complications,
extraperitoneal insufflation by allowing the but the Hasson technique showed significantly
surgeon to confirm intraperitoneal placement fewer minor complications and failed entries.
of the primary trocar before insufflation. A similar conclusion was drawn from a non-
Although small randomized studies have not randomized comparison that also found no
demonstrated an increased risk of injuries, reduction in the risk of major complications
some series suggest that this technique might for open laparoscopic access [14]. CO2 leakage
increase the risk of bowel injury [8, 9]. A larger was far more common when using the Hasson
randomized study demonstrated no major technique [11]. In addition, a recent meta-
complications on comparing the two analysis concluded that there are less minor
approaches. However, minor complications complications and failed attempts when using
including preperitoneal insufflation, failed the Hasson or direct entry technique com-
entry, or more than three attempts necessary pared to the Veress method, but there is lim-
to enter the peritoneal cavity with the trocar ited evidence regarding major complications
were significantly more frequent in the Verres [11]. Finally, a review of 20,691 open laparos-
needle technique group [10]. In a recent meta- copies and 669,662 closed laparoscopies per-
nalysis comparing the Veress needle to direct formed by general surgeons and gynecologists
trocar insertion, pooled analysis showed a bor- found complication rates of 0.4% and 1% for
derline significant reduction for major compli- umbilical infection, 0.1% and 0.2% for bowel
cations based on five events in two RCTs injury, and 0% and 0.2% for vascular injury,
(n = 978) and a reduction in minor complica- respectively [15].
tions in favor of direct trocar insertion [11].
21.1.5 eft Upper Quadrant

L
21.1.4 Open Laparoscopy Technique
Open laparoscopy, first described by Dr. This approach was developed for use in
Harrith Hasson in 1971, refers to creating a patients with previous abdominal surgery
small incision in the abdomen and placing the with suspected or known periumbilical bowel
port through the incision without using a adhesions during pregnancy and with large
sharp trocar [9, 12]. The skin and anterior rec- pelvic masses. It is performed by using a LUQ
tus fascia are incised with a scalpel, and the site to place both the Veress needle and pri-
peritoneal cavity is bluntly entered with a mary laparoscopy port into the abdomen.
21 Kelly or Crile forceps. A laparoscopic port This point, sometimes referred to as Palmer’s
with a blunt-tipped trocar is then placed into point, is in the midclavicular line beneath the
the peritoneal cavity. For the “Hasson” tech- lower rib margin (. Fig. 21.2).
465 21
.. Fig. 21.2 Ideal port sites in relation to the deep and superficial vessels of the anterior abdominal wall.
(Reproduced with permission from Falcone and Hurd [133])
It is important to know the anatomy of the ing, the supraumbilical primary port place-
LUQ before using this technique. The most ment can be implemented safely irrespective
important organs that are closest to this site of the angle of entry, as all the distances are
are the stomach and left lobe of the liver [16]. greater than at the level of the umbilicus [20].
Therefore an oral-gastric tube should be
placed before insertion of trocar or Veress
needle through this access point. Although a 21.1.6 Placement of
small series has shown the risk of complica- Secondary Ports
tions to be small, the relative risk of complica-
tions with this technique remains to be Secondary ports are required to perform most
demonstrated by a large study [17]. Compared gynecologic laparoscopy procedures today.
to umbilical sites, the LUQ technique is asso- After identifying the superficial epigastric ves-
ciated with fewer attempts and fewer conver- sels by transillumination and visualizing the
sions to alternative sites [18]. deep epigastric vessels intra-abdominally
Often times, a supraumbilical entry site is through the laparoscope, 1–4 secondary ports
selected over the umbilicus for a variety of are placed, depending on the procedure [21].
indications with large masses [19]. A recent The inferior (deep) epigastric vessels are not
study evaluated distances to vital retroperito- visualized by transillumination.
neal vasculature that were encountered with The inferior epigastric vessels are visual-
45° and 90° angle entry from the umbilicus ized medial to the insertion of the round liga-
and two commonly described supraumbilical ment into the deep inguinal ring (. Fig. 21.3).
entry points at 3 and 5 cm cephalad from the A midline port is often placed 3–4 cm
umbilicus. According to the theoretic model- above the pubic symphysis. Lateral ports are
21.1.7 emoval of Ports and Port

R
Site Closure
At the conclusion of the procedure, port
removal should be performed in a way to
minimize patient risk. Secondary ports
should be removed under direct visualization
to detect any bleeding that might have been
masked by the port or the intra-abdominal
pressure. All carbon dioxide used for pneu-
.. Fig. 21.3 Left round ligament entering the deep
inguinal ring. Medial to the insertion of the round liga-
moperitoneum should be allowed to escape
ment, the inferior epigastric are seen. They typically prior to removal of the umbilical port to min-
consist of two veins and an artery imize postoperative shoulder pain and to
avoid pushing bowel into the incision sites as
placed approximately 8 cm from the mid- residual gas escapes.
line and 5 cm above the pubic symphysis
to avoid the inferior epigastric vessels (see
. Fig. 21.2) [22]. This lateral site corresponds 21.1.8 Multifunctional
to McBurney’s point in the right lower quad- Laparoscopic Instruments
rant and is approximately one-third of the dis-
tance from the anterior iliac crest to the pubic Traditionally, power instruments were used
symphysis (. Fig. 21.2). Additional lateral during laparoscopy because suture ligation,
ports for the principal surgeon are required the most common hemostatic method used
for most operative laparoscopy cases. The site during laparotomy, is difficult to perform lap-
chosen is typically at the level of the umbili- aroscopically. Electrocoagulation was perhaps
cus lateral to the rectus muscle. This site offers the first power instrument used during lapa-
the surgeon a comfortable use of both hands roscopy. This instrument is heated by passing
and allows access to most areas of the pelvic electrical current through the tip of a grasping
or abdominal cavity. instrument, which is then used to coagulate
Secondary ports are placed with sharp tissue.
trocars under direct laparoscopic visualiza- In the last four decades, other methodolo-
tion to avoid injuring intraperitoneal struc- gies have been developed, most notably elec-
tures. These trocars should be placed directly trosurgery. Unipolar electrosurgery passes
into the peritoneal cavity without tunneling. current through the patient to cut or coagu-
After removal, the intra-abdominal gas pres- late tissue. In these instruments there is an
sure is reduced to observe for signs of hem- active electrode at the tip of the instrument
orrhage indicative of abdominal wall vessel and a dispersive electrode that returns the
injury. If the port diameter is ≥10 mm, the electrical current from the surgical site back to
fascia and peritoneum should be closed with the generator. This is placed away from the
a full-thickness suture to reduce the risk of surgical site. It is colloquial called a “ground-
subsequent herniation. When comparing ing pad.” Bipolar electrosurgery was devel-
bladed to radially expanding trocars, three oped in an effort to minimize the risk of
studies (n = 408) showed less minor compli- inadvertent injury to adjacent tissue, particu-
cations and a trend toward pain reduction larly the bowel. Bipolar electrosurgery offers
when using a radially expanding trocars [11]. an increased margin of safety because the
Radially expanding trocars reduce minor vas- electrical current is confined to the tip of the
cular complications when compared to bladed instrument. Neither instrument should be
trocars [11]. called “cautery.”
21
467 21
Lasers offer a precise, rapid, and accurate
method of thermally destroying the tissue;
however, hemostatic effects are reduced and
lasers are costly. The ultrasonic scalpel is an
ultrasonically activated instrument that moves
longitudinally at a rate of 55,000 vibrations
per second and is able to cut tissue and coagu-
late small vessels without heat or electrical
energy. Tips available for this instrument
include grasper/scissors, a hook blade, and a
ball tip. .. Fig. 21.4 Note the midportion dilation of the
Over the past decade, significant improve- appendix. Removal was performed. A mucocele was
identified
ments in the design and functionality of these
instruments were achieved. The most impor-
tant refinement was the additional cutting fol-
lowing coagulation. This technology uses the
combination of pressure and energy to create
the seal by melting the collagen and elastin in
the vessel walls and reforming it into a perma-
nent seal. Subsequently, the tissue is then
divided using an internal blade. The technol-
ogy reduces thermal spread to 2 mm.
Controlled coagulation and cutting are
achieved by a wide variety of commercially
available instruments including LigaSure,
LigaSure Advance, Gyrus, harmonic scalpel, .. Fig. 21.5 Anatomy of the left upper abdomen. (Repro-
and EnSeal. duced with permission from Falcone and Hurd [133])
car at the level of the umbilicus lateral to the

21.1.9 Laparoscopic Procedures rectus muscle will allow the principal surgeon
to operate comfortably and have access to the
21.1.9.1 Diagnostic Laparoscopy pelvis. If tubal patency is a concern, a dilute
Laparoscopy has been used effectively as a dye can be injected transcervically, a proce-
valuable diagnostic tool for a wide variety of dure termed chromopertubation.
abdominal and pelvic pathologies. It has been Before initiating any surgery, the perito-
used for the assessment of acute or chronic neal cavity should be thoroughly inspected
pain, suspected ectopic pregnancy, endome- using a systematic approach. With the sur-
triosis, adnexal torsion, or other extragenital geon controlling the movement of the lapa-
pelvic pathologies. In most cases, the laparo- roscope, each quadrant of the abdomen and
scope is placed through an infraumbilical then the pelvis should be carefully inspected.
port, and a probe is placed through a second Care should be taken to inspect the appen-
suprapubic port to manipulate the pelvic dix (. Fig. 21.4), omentum, peritoneal sur-
organs, if only a diagnostic laparoscopy is faces, stomach, surface of the bowel,
performed. However, for operative laparos- diaphragms, and liver (. Figs. 21.5, 21.6,
copy other than the simplest procedures, the and 21.7) [23]. The spleen is usually difficult
suprapubic port is not useful and is quite to see except in thin women (see . Fig. 21.4).
uncomfortable. If operative laparoscopy is If any suspicious lesions are observed, fluid
performed, the accessory trocars should be should be obtained for cytology (pelvic
placed in the right and left lower quadrants. washings) prior to biopsy of the lesion for
For advanced laparoscopy, an accessory tro- frozen section.
origin at the uterine cornua to their insertion

in the deep inguinal rings. Zone II is the area
between the two uterosacral ligaments from
their origin from the back of the uterus to
their insertions in the sacrum posteriorly.
Zone III is the area between the uterosacral
ligament inferiorly and the entire length of
the fallopian tube and the infundibulopelvic
ligament superiorly. Zone III contains the
tubes and the ovaries. Zone IV is the triangu-
lar area lateral to the fallopian tube and the
infundibulopelvic ligament and medial to the
external iliac vessels up to the round liga-
.. Fig. 21.6 Subdiaphragmatic adhesions of Fitz-
ment. This system was validated in a retro-
Hugh-Curtis syndrome. These two physicians, Dr. Cur-
tis in 1930 and Dr. Fitz-Hugh in 1934, described the spective study, and prospective evaluation is
relationship with gonococcal infection. (Reproduced ongoing [24].
with permission from Falcone and Hurd [133])
21.1.10 Tubal Sterilization
Tubal sterilization is one of the most com-

monly used methods of birth control.
Laparoscopy is one of the most common
techniques used for permanent sterilization
in the world. Original laparoscopic tech-
niques used electrosurgery to coagulate the
midportion of the tubes. Other techniques,
including clips and silastic bands, have gained
popularity. The pregnancy rates vary by age
of the patient, ranging from 1% to 3% after
10 years [25, 26]. Given the recent discoveries
.. Fig. 21.7 Liver hemangioma. (Reproduced with indicating that the fallopian tube is the site of
permission from Falcone and Hurd [133]) origin of ovarian cancer, the uptake of sal-
pingectomy increased significantly as a
Laparoscopic pelvic assessment is often method of sterilization in different parts of
performed in a non-standardized fash- the world [27].
ion depending on the surgeon’s discretion.
Reporting positive or negative findings is
random, and lesions in atypical locations 21.1.11 ysis of Adhesion and
L
such as the anterior and posterior cul-de-sac, Tubal Reconstructive
deep inguinal rings, and ovarian fossa may be Surgery
missed, and patient care would be less than
optimal. We proposed a method for system- Adhesions are frequently encountered pelvic
atic pelvic assessment based on anatomical pathology. They are usually the result of pre-
landmarks [24]. vious pelvic infections secondary to PID or a
In this system, the pelvis was topographi- ruptured appendix, endometriosis, or previ-
cally divided into two midline zones (zones I ous surgery. These adhesions may contribute
and II) and two paired (right and left) lateral to infertility or chronic pelvic pain. Lysis of
21 zones (zones III and IV). Zone I is the area adhesions is performed bluntly or by sharp
between the two round ligaments from their dissections using scissors or a power source.
469 21
Extreme caution should be used if adhesions 21.1.12 Excision and Fulguration
<1 cm from ureter or bowel are lysed using of Endometriosis
unipolar electrosurgery because of the
unpredictable nature of current arcing. Lysis Laparoscopy is the primary surgical approach
with scissors without energy is recom- used to treat endometriosis. Endometriosis
mended. lesions may be resected or ablated, using scis-
Tubal reconstructive surgery is still per- sors or any of the power instruments. These
formed even in the era of in vitro fertilization treatment approaches have been shown in ran-
(IVF) and is almost exclusively performed domized controlled trials to improve fertility
laparoscopically. Fertility-enhancing proce- and decrease pelvic pain. A study of 1836
dures include adhesiolysis, fimbrioplasty, and outcomes demonstrated that laparoscopic
terminal neosalpingostomy. Prior to and dur- surgery for endometriosis has low rates of
ing these procedures, chromopertubation is reoperation and provided long-term improve-
carried out to document proximal tubal ment in patient quality of life [29]. It appears
patency by injecting dilute indigo carmine or that for superficial endometriosis, fulguration
methylene blue dye through the cervix using a and excision give similar results [30]. However,
cannula. Laparoscopic surgery is performed for deep endometriosis, excision is preferred.
using the principles of microsurgery to avoid Reoperation rates continued to be high even
tissue damage, including delicate handling of in experienced hands.
tissues and minimal use of electrosurgery for
hemostasis.
Laparoscopic fimbrioplasty or neosalpin- 21.1.13 Ectopic Pregnancy
gostomy has been shown to be effective in
Treatment
young women with hydrosalpinges with no
other infertility factors; however, the evidence
Laparoscopy has become the surgical
is fair. On the other side, there is a good evi-
approach of choice for most ectopic pregnan-
dence to recommend laparoscopic salpingec-
cies [31]. The embryo and gestational sac are
tomy or proximal tubal occlusion in the case
removed either through a longitudinal inci-
of surgically irreparable hydrosalpinges to
sion (linear salpingotomy) or by removing the
improve IVF outcome. In addition, there is
tube (salpingectomy). Both were compared
enough evidence to support the value of
in a recent RCT. The cumulative ongoing
microsurgical anastomosis for tubal ligation
pregnancy rate was similar after salpingot-
reversal even in women above the age of
omy (60.7%) compared to 56.2% after sal-
40 years old [28].
pingectomy. However, persistent trophoblast
Patients with mild tubal disease and pres-
occurred more frequently following salpingot-
ervation of fimbria have excellent pregnancy
omy compared to salpingectomy. Recurrent
rates after laparoscopic surgery. Although
ectopic pregnancy rate was 8% following sal-
these patients remain at risk for subsequent
pingotomy and 5% following salpingectomy
ectopic pregnancy, the risk of multiple gesta-
[32]. Even a ruptured tubal pregnancy can be
tions associated with IVF is avoided for
treated laparoscopically, as long as the patient
patients who subsequently achieve a viable
is hemodynamically stable.
intrauterine pregnancy.
Unfortunately, adhesions often reform
after lysis. Multiple techniques have been used
21.1.14 Ovarian Cystectomy
in an effort to decrease reformation. Gentle
tissue handling and good hemostasis also and Oophorectomy
appear to be important. Barrier methods have
been shown in clinical trials to decrease adhe- Ovarian pathological conditions, including
sions but have yet to be proven to improve cysts, commonly result in gynecologic com-
pain relief or future fertility. plaint such as pain. The underlying pathology
ranges from physiologic and self-limiting ously the predominant approach, in patients
functional cysts to ovarian torsion and other with a high number of fibroids, laparoscopic
benign conditions to ovarian malignancy. myomectomy may be associated with higher
Ovarian cysts are usually characterized ultra- postoperative recurrence rates [40]. However,
sonographically and treated when necessary this continues to be controversial since the
by laparoscopy or laparotomy, depending risk of recurrence may not be different with
upon the size of the cyst and the level of sus- fewer fibroids.
picion for malignancy [33]. The most impor-
tant concept in adnexal surgery is to avoid
spilling the cyst content whenever possible. 21.1.16 Laparoscopic Management
of Pelvic Pain
21.1.15 Myomectomy Many women have severe dysmenorrhea that
is unresolved despite medical management but
Many women with symptomatic fibroid wish to maintain future childbearing potential.
uterus prefer a myomectomy over hysterec- In these patients, two laparoscopic approaches
tomy to preserve fertility or the uterus [34]. In have been attempted. Laparoscopic uterosac-
some cases, myomectomy can be performed ral nerve ablation (LUNA) is performed by
laparoscopically. The challenges in the case of stretching and dividing each uterosacral liga-
intramural myomas are related to hemostasis, ment using electrosurgery or laser alone or in
effective closure of the resulting myometrial combination with scissors. Care must be taken
defect, and removal of the specimen from the to avoid injuring the ureters. This procedure
abdomen. Dilute vasopressin can be injected has been shown to have some temporary suc-
into the uterus to help maintain hemostasis. cess, but a Cochrane review has questioned
The excised fibroid can be removed by mor- the validity of this procedure [41]. We do not
cellation or colpotomy. Power morcellators recommend its use.
are available to expedite the process. Barrier Laparoscopic presacral neurectomy
techniques may be used to decrease subse- (LPSN) is a second approach for central pain.
quent adhesion formation. Some early case This technically challenging procedure is per-
series have reported increased risk of subse- formed by careful retroperitoneal dissection
quent uterine rupture during pregnancy after between the common iliac artery on the right
laparoscopic myomectomy compared to those and the inferior mesenteric artery where it
performed by laparotomy [35]. However sev- crosses over both the left common iliac artery
eral randomized clinical trials have shown no and vein on the left. The superior hypogastric
increased risk in expert hands [35]. A totally plexus contains sympathetic nerve fibers and
laparoscopic approach should be attempted gives the right and left hypogastric nerves.
only by gynecologists skilled in laparoscopic These nerves join the pelvic splanchnic nerves
suturing. Recently, the specimen extrac- (parasympathetic fibers from S2, S3, to S4) to
tion following laparoscopic approach for form the inferior hypogastric plexus. The
laparoscopic myomectomy and laparoscopic superior hypogastric plexus is dissected from
hysterectomy was challenged by the FDA the left common iliac vein and periosteum of
recommendation against power morcellation the sacral promontory, and a 2–3 cm segment
[36]. However, in-bag morcellation is accept- is resected. Surgical risks include vascular
able using electromechanical tools within the complications, and long-term risks, such as
FDA-approved PneumoLiner System [37, 38] constipation, are more common than with
or using scalpel with applied medical device LUNA [41]. In the era of nerve-sparing sur-
approved by the FDA [39]. gery, the use of this procedure has fallen out
A study in 2018 showed that when com- of favor given its impact on pelvic organ
21 pared to open myomectomy, which was previ- function.
471 21
21.1.17 Hysterectomy hysterectomy is performed laparoscopically.
This approach is often used when there is little
Laparoscopy hysterectomy, first described by or no uterine descent, which makes the vagi-
Dr. Harry Reich in 1992, is commonly per- nal approach unfeasible.
formed today [42]. The three basic laparo- After the infundibulopelvic (or utero-
scopic approaches for hysterectomy are ovarian) and round ligaments are occluded
laparoscopic-assisted vaginal hysterectomy and divided, the bladder is dissected away
(LAVH), laparoscopic hysterectomy, and lap- from the anterior uterus. The ureters are
aroscopic supracervical hysterectomy (LSH). identified, and the uterine vessels and utero-
Although the basic techniques for each of sacral ligaments are occluded and divided.
these approaches are fairly standardized, con- The posterior cul-de-sac is incised, the vagina
troversy exists over the risks, benefits, and is circumferentially separated from the cervix,
most appropriate indication of each. and the specimen is removed vaginally. The
cuff is closed laparoscopically or vaginally.
21.1.18 Laparoscopic-Assisted 21.1.20 Supracervical

Vaginal Hysterectomy Hysterectomy
LAVH is the most commonly employed and
The LSH is a third common laparoscopic
technically straightforward of the three. Using
approach to hysterectomy for benign indica-
3–4 ports, the peritoneal cavity is surveyed, and
tions [43]. The technique begins in a manner
the lysis of adhesions is performed if necessary.
identical to LAVH and LH. However, prior to
Then the infundibulopelvic or utero- ovarian
reaching the level of the uterine arteries, the
ligaments are occluded and divided, depending
fundus is transected at the uterocervical junc-
on whether the ovaries will be removed. The
tion. In order to minimize residual cyclic vagi-
round ligament is divided, the utero-vesicle
nal bleeding and decrease the risk of
peritoneum incised, and the bladder dissected
developing cervical dysplasia or cancer, the
from the anterior uterus. This step results in an
glandular tissue endocervix is cored out or
increased risk of bladder injury compared to
cauterized. The uterine specimen is removed
either abdominal or vaginal hysterectomy. At
through a 12 mm port abdominally using a
this point, the uterine arteries laparoscopically
power morcellator. The recent debate about
are sometimes occluded and divided, although
tissue extraction following the laparoscopic
this is associated with an increased risk of ure-
approach for myomectomy and hysterectomy
ter injury compared to either abdominal or
is yet to be settled [36].
vaginal hysterectomy. Finally, the posterior cul-
This approach eliminates both the vaginal
de-sac is incised.
and abdominal incision, thus decreasing the
The surgeon proceeds vaginally for the
risk of infection. The risk of ureteral injury is
remainder of the case, dissecting the vesico-
also decreased, since the procedure stops
vaginal septum anteriorly to enter the anterior
above the level of the uterine artery. However,
cul-de-sac, ligating the uterine vessels if not
a risk of subsequently developing cervical
previously done, removing the uterus and ova-
dysplasia or cancer remains due to the pres-
ries if appropriate, and closing the vaginal cuff.
ence of the cervical stump. For this reason,
routine Pap smears are required, and some
patient will require additional surgery related
21.1.19 Laparoscopic to cervical abnormalities. Furthermore, at
Hysterectomy least two randomized clinical trials have failed
to show superior results in bladder function
Laparoscopic hysterectomy (LH), the second or sexual function [44, 45]. These studies did
most common approach, is performed ini- show a higher reoperation rate for bleeding
tially like the LAVH, except that the entire and prolapse.
Although small trials have tried to assess pected uterine sarcoma following surgery for
the value of laparoscopic hysterectomy, a large a presumed benign indication is approxi-
multicenter, randomized trial that compared mately 1 in 350, and the rate of leiomyosar-
laparoscopic with abdominal hysterectomy coma is 1 in 500 [50]. However, the rates of
and laparoscopic with vaginal hysterectomy leiomyosarcoma are poorly studied. A meta-
has provided insight into the role of this proce- analysis has described as low as 1 in 8300
dure [46]. The study confirmed that the laparo- when including only prospective studies and
scopic approach offers no advantage over the 1 in 1428 surgeries when including both pro-
vaginal approach. It also confirmed that the spective and retrospective studies [51].
laparoscopic approach is associated with less If undiagnosed sarcoma is morcellated,
postoperative pain, shorter hospital stays, and that will indeed worsen the prognosis and neg-
faster convalescence compared with the atively affect the overall survival. It is impera-
abdominal approach. It demonstrated that the tive that preoperative endometrial biopsy
laparoscopic approach was associated with a and cervical assessment to avoid morcella-
slightly higher risk of urinary tract injury. The tion of potentially detectable malignant and
shorter length of hospitalization with laparo- premalignant conditions are strongly recom-
scopic hysterectomy offsets some of the addi- mended [52]. Morcellation is contraindicated
tional costs incurred by longer operating room for patients with hereditary cancer syndromes
times and the expense of disposable instru- and in women with established or suspected
ments [47]. On the other hand, a recent study cancer where a gynecologic oncology consul-
found that vaginal hysterectomy has distinct tation is mandatory. Irrespective of the current
benefits compared to other hysterectomy local hospital policy about power morcella-
routes, including LAVH, and should be the tion, each patient should be counselled about
technique of choice for benign indications the possible risks associated with the use of
because it was associated with lower incidence morcellation, including the risks associated
of bladder injury and shorter operative time with underlying malignancy. Modified mor-
and postoperative hospital stays [48]. cellation techniques including the use of bags
for containment are currently being tested for
safety and efficacy (. Fig. 21.8). Despite the
21.1.21 Power Morcellation fact that the FDA has approved the first tissue
Following Laparoscopic containment system for use with certain lapa-
Surgery roscopic power morcellators to isolate uterine
tissue that isn’t suspected to be cancerous,
Morcellation is used to allow removal of large there is no clear evidence to support that their
specimens that cannot be retrieved otherwise. It use would nullify or prevent the dissemination
enabled the laparoscopic option to treat patients of undiagnosed uterine sarcomas [53].
with large uteri or uterine myoma. One of the
major limitations of this technology is the possi-
ble spread of undiagnosed cancer. This concern
led the FDA to issue a warning against the use of
such technology [36]. That led to many gynecolo-
gists to refrain and many institutions to recom-
mend against the use of the minimally invasive
approach for women where tissue morcellation is
required. In the United States, there was a signifi-
cant decrease in the proportion of minimally inva-
sive hysterectomies and myomectomies performed
during the 8 months after the FDA warning state-
21 ment on the use of power morcellation [49].
Overall, uterine sarcomas are difficult to .. Fig. 21.8 Morcellation of myoma within a contain-
diagnose preoperatively. The risk of an unex- ment bag
473 21
Current research shows that unconfined Mountain View, CA, USA). The FDA
power morcellation also has negative conse- approved it for use in abdominal surgeries in
quences for nonmalignant conditions. A study 2000. There are three main components: the
of 5154 women who underwent laparoscopic surgeon console, the surgical cart, and the
supracervical hysterectomy with unconfined vision cart. The surgeon sits at a console sepa-
power morcellation found that of the 279 rate from the surgical field. Movement of han-
requiring reoperation, 20.4% received patho- dles at the console results in movement of
logic diagnosis of endometriosis for the first surgical instruments at the operative field. In
time [54]. Subsequent pathology of reopera- this system, the surgeon looks into a console
tive cases also showed 18 cases of dissemi- that has a dual lens system within the 12-mm
nated leiomyomatosis and 11 cases of new laparoscope. The system provides true binoc-
malignancy. For this reason, we advocate for ular three-dimensional vision that is similar to
in-bag morcellation in the majority of cases. looking into a microscope that enables the
surgeon to see fine structures up to a tenfold
magnification. Movement of the laparoscope
21.1.22 Oncologic Procedures is accomplished through the movement of the
handles at the console.
Laparoscopy originally was used in gyneco- The most impressive part of the system is
logic oncology for second-look procedures the intra-abdominal articulation of the microin-
after surgical and chemical treatment of the struments 2 cm from the tip. This articulation
malignancy. More recently, laparoscopy has serves the same function as a human wrist,
been used for the initial staging of gyneco- mimicking the movements of a hand. This artic-
logic cancer, including hysterectomy, perito- ulating wrist has 7° of freedom of the instru-
neal washes with biopsy, partial omentectomy, ments, providing an opportunity for better
and pelvic and periaortic lymphadenectomy. suturing, dissection, and reconstructing tissue
Techniques have also been developed for by allowing the surgeon access to deep pelvic
laparoscopically assisted radical vaginal
structures. The movement of the instrument tip
hysterectomy. is intuitive and requires minimal training.
The laparoscopic approach to gynecologic The cart contains the instrument arms and
cancer remains controversial. There is some camera arm. The vision cart allows all mem-
concern that laparoscopy might increase the bers of the surgical team to visualize the pro-
risk of intraperitoneal spread of ovarian can- cedure. Not only does this system provide
cer. Until the risk, benefits, and the effect on visual advantages for more precise surgery,
long-term prognosis have been shown to be improved dexterity, surgeon comfort with less
equal to laparotomy, the laparoscopic hand fatigue, and improved instrument artic-
approach will remain under close scrutiny. ulation, but it also eliminates unintentional
hand tremors.
There are some limitations with the use of
21.1.23 Robotically Assisted robotic technology. One is the initial system
Laparoscopic Surgery cost, maintenance costs, and expense of dis-
posable instruments. Another is the lack of
Robotic technology has attempted to address tactile feedback during the procedure, requir-
the limitations of conventional laparoscopic ing the use of visual cues to properly carry out
surgery. The use of a remotely controlled surgical tasks. However, the Senhance surgical
robot has the potential to facilitate these pro- system, one of the many competitors to the da
cedures by allowing the surgeon to be seated Vinci system, has successfully addressed this
comfortably while providing the surgeon a limitation with its ability to provide true hap-
three-dimensional view with improved dexter- tic feedback [56]. For appropriate docking of
ity and access [55]. the robot, it is imperative that a dedicated
The most commonly used robotic system staff specifically trained on the device is avail-
is the “da Vinci system” (Intuitive Surgical, able during all procedures.
Another limitation of the robotic system is

.. Table 21.1 Advantages and disadvantages of
its bulky size. Increased surgical operation the da Vinci robotic system
time is a main limitation of the robotic sys-
tem. This is attributed to the time required for Advantages Disadvantages
robot preparation and docking as well as con-
sole time. Sait reported an operative time of Three-dimensional Initial system cost
visualization
92.4 min for a laparoscopic hysterectomy,
compared to 119.4 min for a hysterectomy Improved ergonomics No tactile feedback
with robotic assistance. However, they also Improved dexterity Lack of research on
showed a significant learning curve, shorten- efficiency
ing the length of operation times with increas-
7° of freedom Insufficient cases to
ing robotic experience [57]. Similar results train residents
were independently corroborated in a ran-
Elimination of Large size of systems
domized controlled trial [58].
fulcrum effect
Cost is an important limitation that should
be considered. Robotic surgical systems are Motion scaling
very costly, adding approximately $3500 per Improved suture
procedure and approximately $2.5 billion capabilities and knot
nationally per year. This is a huge expense tying
considering little evidence of improved out-
comes over standard laparoscopy. Added to
these costs, Medicare and most US private
insurers do not pay additional fees for use of Box 21.1 Current uses of robotics
robotics. To overcome this, hospitals most in reproductive surgery, gynecologic
likely will increase charges for procedures or oncology, and reconstructive pelvic
diagnoses for which robots are used [59, 60]. surgery
The reality is that robotics overall is more Reproductive surgery
costly than laparoscopy, but if it allows more Simple hysterectomy
surgeons to perform MIS, then maybe in the Myomectomy
end it will end up being less costly. Wherever USO, BSO
and whenever feasible, robotic-assisted lapa- Tubal reanastomosis
roscopic surgery should not replace conven- Resection of endometriosis
tional laparoscopic or vaginal procedures for Ovariopexy
women undergoing benign gynecologic dis- Gynecologic oncology
eases. This is was supported by the findings of Pelvic and para-aortic lymphadenectomy
a 2012 Cochrane review [61]. The advantages Appendectomy
and the disadvantages of the robotic systems LAVH
are summarized in . Table 21.1. USO, BSO
Sentinel lymph node biopsy
Omentectomy
21.1.24 Robotic Gynecologic LARVH
Surgery Ovarian cystectomy
Radical parametrectomy
Robotic systems have the potential to convert Radical vaginal trachelectomy
surgical procedures that we presently perform Radical cystectomy
by laparotomy to laparoscopy and are Reconstructive pelvic surgery
currently utilized in the fields of reproductive Bladder repair
endocrinology and fertility, gynecologic Hysterectomy
21 oncology, and female pelvic medicine/recon- Vesicovaginal fistula repair
structive surgery (7 Box 21.1). It has been Sacrocolpopexy
used in robotically assisted tubal anastomosis.
475 21
21.1.25 Robotically Assisted Tubal operative time improved significantly with
Reanastomosis surgical experience [63]. In a recent study
examining the learning curve of robotically
For a variety of reasons, reversal of tubal liga- assisted tubal anastomosis, the surgeon’s
tion is a cost-effective alternative to IVF, par- mean operative time demonstrated highly sig-
ticularly for patients below the age of 35. Over nificant decreases every year, decreasing from
the past two decades, robot-assisted tubal 140.7 ± 27.0 minutes in the study’s first year to
reanastomosis has been gaining widespread 60.0 ± 9.1 minutes 5 years later [63]. Given the
popularity. Traditional approaches such as increasingly widespread use of robotic surgi-
laparotomy were limited by operative compli- cal systems, studies should reexamine its oper-
cations, postoperative pain, and prolonged ative efficiency and change the perspectives
recovery time and hospital stays. The laparo- established over a decade ago.
scopic approach has demonstrated success in
mitigating these effects while producing com-
parable success rates [62]. However, laparo- 21.1.26 Robotically Assisted
scopic tubal anastomosis has a steep learning Myomectomy
curve and requires high skill level to master
challenging procedures such as intracorporeal Myomectomy remains the best choice of
knot tying, often exacerbated by surgeon treatment of symptomatic fibroids in patients
fatigue and intention tremors [63]. The major desiring to preserve their fertility, even with
difficulty with laparoscopic tubal anastomo- the new modalities such as uterine artery
sis, with or without robotic assistance, is the embolization [35, 68]. Open myomectomy
limited needle angles to the tubes due to oper- used to be the treatment modality until the
ating through fixed ports. These challenges emergence on minimally invasive technique.
can be overcome using the robotic approach, Laparoscopy yielded better cosmesis and
which provides benefits including improved shorter postoperative pain and hospital stay.
ergonomics, superior visualization and mag- However, this procedure was very challenging.
nification, and stabilized wrist articulation A limitation included needing to precisely dis-
without tremor, contributing to the ease of sect the fibroid without unnecessary breach-
suturing and its suitability for minimally inva- ing of the endometrial cavity. Since
sive tubal anastomosis [63]. laparoscopic suturing is a difficult skill to
The first robot-assisted tubal reversal was master, it is complicated to suture the fibroid
performed at the Cleveland Clinic in 1999 [5]. beds in layers with precise approximation of
Historically, research has shown that while edges, which is needed to prevent uterine rup-
robotic tubal reanastomosis using the da ture during labor. These challenges limited the
Vinci system had similar tubal patency, ecto- enthusiasm and acceptance of this technique.
pic pregnancy, clinical pregnancy rates, and Many studies have demonstrated the feasi-
reduced time to return to work, it was associ- bility of robotically assisted myomectomy [35,
ated with significantly longer operative and 69]. Most recently, the operative and immedi-
anesthesia time and increased surgical cost ate postoperative surgical outcomes of roboti-
when compared to laparoscopy or laparotomy cally assisted laparoscopic myomectomy,
[64–67]. All of the tubal anastomoses were standard laparoscopic myomectomy, and
performed with the use of three or four open myomectomy were compared. Blood
robotic arms, three or four robotic instru- loss, operative time, and hospital stay were
ments, and one assistant trocar. However, lower for the robot-assisted group. These
these studies are dated; in fact, current results showed an association of robotic-
research shows that in regard to operative assisted myomectomy with decreased blood
time and cost, robotic approaches outperform loss and length of hospital stay compared
traditional laparoscopy and laparotomy [63]. with traditional laparoscopy and to open
Furthermore, a recent analysis showed that myomectomy [70]. The robotic approach also
has improved cosmesis due to smaller skin comparable between the two groups. There
incisions, less analgesic use, shorter time to was no difference between the two groups
return to normal activity, less complications, regarding estimated blood loss and uterine
and quicker recover of bowel function [70, weight. Pathological evaluation confirmed the
71]. Other benefits of the robotic approach endometriosis diagnosis in all patients [75]. In
are that it can be safely performed in patients a more recent series, operating time was identi-
with different body mass indices; obesity does fied as the only risk factor for the length of the
not affect surgical outcome [72], and this sur- hospital stay and the postoperative complica-
gical approach does not require steep tions in patients with stage III and stage IV
Trendelenburg, which may not be suitable for disease [76]. In 2017, Soto et al. investigated
certain patients [73]. Increased dexterity pro- robot-assisted versus conventional laparos-
vided by the robot allows surgeons to dissect copy for endometriosis treatment and found
and handle tissues more gently, favoring the mean operative time for the robotic pro-
reproductive outcomes [71]. Taken together, cedure was 106.6 ± 48.4 minutes, compared
robotically assisted myomectomy is a safe and to 101.6 ± 63.2 minutes for conventional
minimally invasive alternative that should be laparoscopy, indicating no significant differ-
considered for select patient cases [71]. ences between operative times. Differences
in quality-of-life outcomes and preoperative
outcomes were also not observed [77].
21.1.27 Robotically Assisted The complexity of cases achieved with
Resection of Endometriosis robotic assistance is one notable advantage;
this approach has demonstrated safe and
Nezhat et al. compared robotic treatment of effective resection of deep infiltrating endo-
stage I or II endometriosis to conventional metriosis involving the rectum, sigmoid colon,
laparoscopy in a retrospective cohort con- and ureters [71, 78] .
trolled study in 2010. Forty patients were
treated for endometriosis by robot-assisted
laparoscopy, and 38 patients were treated by 21.1.28 Clinical Applications
standard laparoscopy. There were no signifi- in Gynecologic Oncology
cant differences between these groups in blood
loss, hospitalization, or complications, but the The traditional approach to gynecologic
mean operative time with the robot was oncology surgeries involves a total hysterec-
191 min (135–295) compared with 159 min tomy, bilateral salpingo-oophorectomy, and
(85–320) during standard laparoscopy. Since dissection of both pelvic and para-aortic
both treatments have excellent outcomes and lymph nodes. These surgeries and others are
the robotic technique required a longer opera- now being conducted with the use of robotic
tive time, it was concluded that the robot has surgical systems in select patients.
no added value for the treatment of early- The specific advantages of robotic-assisted
stage endometriosis [74]. endoscopic procedures in gynecologic oncol-
Most recently, we reported on the safety ogy arise from the da Vinci system’s enlarged
and feasibility of robotic surgical treatment of operative field without the need for large fascial
advanced pelvic endometriosis. Fifty women incisions. This allows for more easily identifi-
underwent a robotic procedure for advanced able pelvic anatomy while patients experience
endometriosis. Twenty-one (42%) had stage III decreased postoperative morbidity and faster
and 29 (58%) had stage IV endometriosis. The recovery to permit rapid initiation of adjuvant
median total operative time was 209 (range: radiotherapy or chemotherapy. The safety pro-
97–368) min, including patient positioning, file of the da Vinci system utilized for gyneco-
robot docking, performing surgery, and clo- logic oncology applications appears reassuring,
21 sure of the port sites. Median actual operative with less blood loss and a low complication
time was 154 (range: 67–325) min, and both rate in managing ovarian, endometrial, and
total OR time and actual operative time were cervical cancers, respectively [79–81].
477 21
In a recent survey of the Society of Like in other disciplines, it has been shown
Gynecologic Oncology (SGO) members to that the robotic approach is longer and more
evaluate the current patterns of use of mini- costly than the conventional approach in uro-
mally invasive surgical procedures, including gynecologic disorders [87].
traditional, robotic-assisted, and single-port
laparoscopy, and to compare the results to
prior 2004 and 2007 surveys, a significant 21.1.30 Single-Port Laparoscopy
increase in the uptake of the MIS approach
was found. A 2020 study found that since the The concept of natural orifice surgery has
introduction of robotic surgery platforms, been recently revisited. Advancements in sur-
minimally invasive surgeries in gynecologic gical instruments, optics, and ports have
oncology rose from 15% to 91% and resulted allowed the development of single-port lapa-
in significant cost-savings, shortened hospital roscopy or LESS. Today, single-port laparos-
stays, and reduced blood loss [82]. copy is widely used across the globe to treat
Overall, the indications for laparoscopy benign gynecologic conditions, gynecologic
have expanded beyond endometrial cancer cancers, and tubal ectopic pregnancies [88–90].
staging to include surgical management of Recent studies indicate that the procedure
ovarian cancers, but the use of single-port lap- has low rates of complications and similar
aroscopy remains limited. This significant rise surgical outcomes compared to conventional
included radical hysterectomy or trachelec- laparoscopy [90–93]. LESS has also been
tomy and pelvic lymphadenectomy for cervi- found to be associated with a reduction of gas
cal cancer and total hysterectomy and staging leakage. The use of LESS has the advantages
for endometrial cancer. However, following of reduced postoperative pain, earlier return
the publication of an RCT showing that mini- to daily activities, reduced incidence of port-
mally invasive hysterectomy was associated site hernias and hemorrhage, and improved
with lower rates of disease-free survival and cosmesis and patient satisfaction. However,
overall survival when compared to open data on long-term effectiveness are lacking
abdominal hysterectomy in women with early- [94]. Despite being the least invasive approach,
stage cervical cancer, the use of laparoscopy the popularity of single-port laparoscopy is
for treatment of cervical cancer declined [83]. impeded by surgical difficulties including tri-
angulation and instrument crowding, as well
as the high cost of specialized instruments
21.1.29 Clinical Applications [89]. However, single-port surgeries have been
performed using conventional laparoscopic
in Female Pelvic Medicine instruments and found by several recent stud-
and Reconstructive ies to be suitable and safe [89, 95].
Surgery LESS is now being used to treat benign
and malignant adnexal disease and for hyster-
In the literature, robotics have been utilized in ectomy. For adnexal disease, LESS can be
the repair of both vesicovaginal fistulas and in used to remove ovarian cysts and, for salpingo-
the treatment of post-hysterectomy vaginal oophorectomy, to remove endometriosis and
vault prolapse with sacrocolpopexy [84]. It malignant masses. Single-port access total
has been shown that the involvement of hysterectomy is more commonly used now,
obstetrics and gynecology and urology resi- with various advancements in place to over-
dents has no effect on the surgical outcome of come the limited free movement and technical
robotic-assisted sacrocolpopexy (RASCP) difficulty. It has also been adopted for staging
[85]. The question remains that although the endometrial cancer [96]. Combining LESS
use of robotics combines the outcomes of an with the da Vinci robot system allows further
open procedure, the benefits of minimally benefits, including better cosmesis, reduced
invasive surgery, and easy adoptability, does it morbidity from injury during trocar place-
outweigh the increased cost and time [86]? ment, a reduced incidence of postoperative
wound infections and hernia formation, and located in the anterior abdominal wall and the
improved dexterity [94]. major blood vessels located in the retroperito-
In a review of 6 RCTs and 15 observational neal space. Injury of major abdominal blood
studies including a total of 2085 patients (899 vessels is a rare but treatable life-threatening
single-incision laparoscopies and 1186 con- complication of laparoscopy, which occurs in
ventional laparoscopies), the surgical out- approximately 3 per 10,000 laparoscopies [99].
comes were evaluated. In the pooled analysis, These injuries most commonly occur during
there was no difference in the risk of compli- insertion of the Veress needle or primary
cations between single-incision laparoscopy trocar.
and conventional laparoscopy in gynecologic
surgery. However, some studies suggest that
single-incision laparoscopy may have longer 21.1.33 Prevention
operative time for adnexal surgery, but not for
hysterectomy [97]. It remains uncertain if such The majority of retroperitoneal vessel injuries
a new technology is cost-effective with compa- during laparoscopy occur during blind place-
rable long-term surgical outcomes. ment of the Veress needle or primary trocar
through a periumbilical incision [100]. To
minimize this risk, surgeons need to be aware
21.1.31 Laparoscopic of anatomic considerations so that they can
Complications determine the most appropriate direction and
angle of insertion for each patient, as dis-
Overall, laparoscopy has a relatively favorable cussed above. The different approaches for
complication profile compared to the same primary prevention of vessel injuries are dis-
procedure performed via laparotomy. In addi- cussed in the following sections.
tion to the procedure-related complications,
laparoscopy is associated with uncommon but
significant complications related to trocar 21.1.34 Awareness of the Patient’s
insertion. These injuries involve primarily Position
blood vessels, bowel, and bladder. Given its
mostly blind nature, insertion of the Veress For greatest safety, the surgeon should be
needle and primary trocar for initial entry by aware of the patient’s position in relation to
trocar insertion remains the most hazardous horizontal prior to laparoscopic instrument
part of laparoscopy, accounting for 40% of all placement. Most laparoscopic surgeries are
laparoscopic complications and the majority performed in the Trendelenburg position to
of the fatalities. Despite decades of research keep bowel away from the operative field in the
and development to find safer methods for pelvis. If the patient is placed in Trendelenburg
initial laparoscopic entry, major vessel injuries position with the feet elevated 30° relative to
have been reported using virtually all types of the head prior to instrument insertion, instru-
trocar insertion methods [98]. The following is ments inserted at 45° from horizontal will
a brief discussion of avoidance and manage- actually be placed at 75° from the horizontal
ment of these complications. plane of the patient’s spine, which is likely to
increase the risk of major vessel injury, par-
ticularly in slender patients [101].
21.1.32 Retroperitoneal
Vessel Injury
21.1.35 High-Pressure Entry
Techniques used to place primary and second-
ary laparoscopic ports into the peritoneal cav- Another technique used in conjunction with
21 ity are often accompanied by a small but closed laparoscopy in an effort to decrease
unavoidable risk of injury to blood vessels the risk of major vessel injury is “high-
479 21
pressure entry.” Rather than inserting the 21.1.37 Other Laparoscopic
primary umbilical trocar after obtaining Entry Methods
intra-
abdominal pressure of 18–20 mmHg,
many surgeons increase the pressure to Multiple insertion methods and instruments
25–30 mmHg. The rationale is to make the have been developed in an effort to decrease
anterior abdominal wall stiffer such that the the risk of trocar complications. Although
downward pressure exerted by trocar inser- each method has theoretical advantages
tion does not decrease the distance of the compared to the traditional closed techniques,
umbilicus to the retroperitoneal vessels [102]. none has completely eliminated the risk of
Although no controlled studies large enough major vessel injury.
to demonstrate an advantage have been pub-
lished, large series including more than 8000
cases suggest that the risk of major vessel 21.1.38 Open Laparoscopy
injury using this technique is approximately
1 in 10,000 cases (0.01%), compared to a risk Open laparoscopy is a widely used alternative
of 4 in 10,000 cases (0.04%) reported using technique for placement of the primary lapa-
standard pressures [103]. roscopic port. The Hasson technique is funda-
A recent study recommends high-pressure mentally a minilaparotomy incision followed
trocar placement under direct vision, defined by placement of the primary port directly into
as insufflation pressures of 25–30 mmHg, to the peritoneal cavity [108]. Open laparoscopy
prevent major injury [104]. Transient high- almost completely prevents the risk of major
pressure pneumoperitoneum offers a safer vessel injury, decreasing the rate to 0.01%,
entry approach and does not have adverse compared to a rate of 0.04% associated with
effects on the cardiorespiratory function of closed techniques using a Veress needle [103].
women [105, 106].
21.1.39 Direct Trocar Insertion

21.1.36 Verify Veress Needle
Location Direct trocar insertion is a laparoscopic entry
technique wherein the primary trocar is placed
The use of the Veress needle to insufflate without prior insufflation, with or without ele-
the peritoneal cavity is associated with a vation of the anterior abdominal wall manually
small risk of intravascular insufflation and or with towel clips. This approach is slightly
venous gas embolism, reported to occur in faster than standard closed laparoscopy and
approximately 1 in 100,000 laparoscopic avoids the risks of Veress needle placement.
procedures [107]. Unfortunately, this technique might increase
Several methods have been used to dem- this risk of major vessel injury. Large series
onstrate the intraperitoneal location of the (>10,000 cases) report a major vessel injury risk
Veress needle tip. Although many tech- of 0.06–0.09% compared to 0.04% using a
niques have been used to confirm entry such standard closed technique [109]. This risk of
as observing if a drop of water at the open major vessel injury might be one reason why
end of the needle to observe if enters the direct trocar insertion is one of the least fre-
low pressure peritoneum, the only technique quently used techniques by gynecologists.
that is reliable is observing a low intraperi-
toneal pressure reading on the insufflation
apparatus. 21.1.40 Left Upper Quadrant
Once insufflation is begun, the strongest
predictor of intraperitoneal placement LUQ insertion of the Veress needle and pri-
appears to be an initial filling pressure of mary trocar through a site in the LUQ is rec-
<10 mmHg. ommended by some surgeons to decrease the
risk of complications associated with bowel When a major vascular injury is suspected,
adhesions in women with prior abdominal the following steps should be taken without
surgeries. The LUQ insertion site (Palmer’s delay. The nursing personnel should prepare
point) is located 3 cm below the middle of the for emergency laparotomy, and anesthesia
left costal margin in the midclavicular line, personnel should consider placing additional
and instruments are routinely inserted per- intravenous lines and calling for blood prod-
pendicular to the patients’ skin. ucts and additional assistance. The surgeon
Major vessel injuries have not been should immediately perform a laparotomy via
reported using this technique. Anatomic stud- a midline incision, and blood loss should be
ies indicate that the abdominal wall is uni- minimized using direct pressure over the
formly thin in this location and the distance injury site. When the injury occurs in a medi-
from the skin to the retroperitoneal structures cal center, a trauma surgeon or vascular sur-
is >11 cm in most patients [24]. However, geon should be called in to identify and repair
because this distance can be <7 cm in many the vascular injuries.
slender patients, it is recommended that, in The treatment approach is different when a
slender patients, instruments placed through major vessel injury occurs in a facility where
Palmer’s point be directed 45° caudally rela- vascular surgery personnel and equipment are
tive to the patient’s spine [110]. not available. In these instances, a laparoscopic
surgeon without experience in vascular surgery
should not attempt to open the retroperitoneal
21.1.41 Alternative Primary area to repair the vessel [109]. This approach
Trocar Design can further injure the vessels, and resultant lack
of circulation to the lower extremities can have
Alternative primary trocars have been devel- catastrophic results. Rather, the abdomen
oped, including shielded disposable trocars, should be packed tightly with dry laparotomy
optical trocars, and radially expanding trocars pads, and the abdomen should be quickly
[109]. Unfortunately, their use does not pre- closed with either running full-thickness sutures
vent major blood vessel injuries. Currently, or towel clips [111]. The patient should then be
there is no evidence of benefit of one tech- transported by the most expedient method to
nique or instrument over another in terms of the nearest fully equipped trauma center.
preventing major vascular injury. When com-
paring bladed to radially expanding trocars,
studies showed less minor complications and 21.1.43 Abdominal Wall
a trend toward pain reduction when using a Vessel Injury
radially expanding trocars [11].
Anterior abdominal wall vessels at risk for
injury can be divided into two groups: superfi-
21.1.42 Treatment cial and deep [22]. The superficial vessels con-
sist of the superficial epigastric and circumflex
Major vessel injuries are a rare but unavoid- iliac arteries, which are located in the subcuta-
able laparoscopic complication associated neous tissue. The deep vessel at risk is the deep
with the closed entry techniques. Every lapa- inferior epigastric artery, which is located
roscopic surgeon that uses a closed technique beneath the rectus abdominus muscles imme-
should develop a plan of action for major ves- diately above the peritoneum.
sel injury. The surgeon should also become Damage to the superficial vessels is often
familiar with the availability of laparotomy asymptomatic at the time of surgery, whereas
instruments, blood products, vascular clamps, damage to a deep vessel usually leads to
and surgical consultants. This is especially immediate and rapid blood loss. If unrecog-
21 important when these procedures are per- nized, damage to either type of vessels can
formed in a free-standing outpatient surgical result in postoperative hemorrhage or
facility. hematoma.
481 21
21.1.44 Prevention sure instruments. These sutures should be tied
deep to the skin above the fascia. This
The primary method for avoiding injury to approach is successful in most cases.
any of these vessels is to visualize the vessels If hemostasis cannot otherwise be
via transillumination and direct laparoscopic achieved, the incision should be widened and
visualization prior to lateral trocar insertion. the injured vessels individually ligated. The
Transillumination of the anterior abdominal port-site incision should be enlarged trans-
wall with the laparoscopic light source is an versely to at least 4–6 cm, the fascia of the
effective way to visualize the superficial ves- anterior rectus sheath incised, and the lateral
sels in almost 90% of patients [21]. The infe- edge of the rectus abdominus muscle retracted
rior (deep) epigastric vessels cannot be seen by medially. The bleeding vessels can be grasped
transillumination since they lie beneath the with hemostatic forceps and selectively ligated
rectus abdominus muscle and fascia but can above and below the injury.
be directly visualized laparoscopically imme- Delayed bleeding can occur when the
diately beneath the peritoneum in the major- abdominal pressure decreases after removal
ity of patients where they lie between the of the carbon dioxide, especially if the method
insertion of the round ligament at the ingui- used to occlude an injured vessel becomes
nal canal and the medial umbilical fold. In loose as the patient awakes from anesthesia
obese patients they cannot be visualized, but and is moved [112]. Signs of hemodynamic
they can be presumed to be in this location as instability in the recovery room necessitate a
defined by those anatomic landmarks. Since return to surgery because uncontrolled bleed-
both the deep and superficial vessels are ing from a lacerated inferior epigastric artery
located an average 5.5 cm from the midline, can be life-threatening.
risk of vessel injury can be minimized by plac-
ing secondary trocars 8 cm lateral to the mid-
line and 8 cm above the pubic symphysis [22]. 21.1.46 Gastrointestinal Injury
Despite the continued development of both

21.1.45 Treatment laparoscopic instruments and techniques, gas-
trointestinal injury continues to be a common,
When a superficial vessel is found to be bleed- yet potentially avoidable complication of lap-
ing after the port is removed, the most effec- aroscopy. In the last four decades, the risk of
tive approach is to grasp the vessel with a this complication appears to have increased
Crile “hemostat” forceps, followed by electro- from approximately 3 per 10,000 procedures
surgery or ligation. In cases where the injured to as high as 13 per 10,000 procedures [99,
vessel cannot be grasped, a pressure dressing 113]. Most bowel injuries occur during place-
is often sufficient. ment of the Veress needle or primary trocar
When an inferior epigastric vessel is and usually when the bowel is adherent to the
injured, the result is immediate and brisk anterior abdominal wall from previous sur-
bleeding from the port site into the peritoneal gery [114]. Other gastrointestinal injuries
cavity. Anesthesiology personnel should be result from operative procedures including
alerted because additional intravenous lines adhesiolysis, tissue dissection, devasculariza-
and blood products might be required if the tion injury, and thermal injury.
patient becomes hemodynamically unstable. It is essential to minimize morbidity
If another port is available, an attempt should related to gastrointestinal injuries both by
be made to occlude the injured vessel with a prevention and early recognition. Despite an
laparoscopic bipolar electrosurgery instru- increasing awareness of these risks, gastroin-
ment above and below the injury. testinal injuries continue to be the most
If bipolar electrosurgery is unsuccessful, lethal type of injuries associated with lapa-
precisely positioned sutures can be placed roscopy, with a mortality rate reported as
above and below the injury using port-site clo- high as 3.6% [113].
21.1.47 Preventive Measures 21.1.48.2 Stomach Injuries

Injury to the stomach during laparoscopy is
No method has yet to be discovered that com- relatively uncommon and was reported to
pletely prevents gastrointestinal injuries dur- occur in less than 3 in 10,000 cases in the ear-
ing laparoscopic port placement [115]. lier days of laparoscopy [120]. Risk factors
However, it is well established that patients include a history of upper abdominal surgery
with previous abdominal surgery are at and difficult induction of anesthesia, as a gas-
increased risk of gastrointestinal injury dur- distended stomach can be below the level of
ing laparoscopy since adhesions to the ante- the umbilicus. Routine decompression of the
rior abdominal wall occur in approximately stomach with a nasogastric tube prior to
25% of these patients. For this reason, certain Veress needle or trocar placement has virtu-
measures have been used in an effort to ally eliminated this risk, even when a LUQ
decrease the risk of gastrointestinal injuries in approach is used.
these patients. Trocar injury to the stomach requires sur-
Two commonly used techniques for high- gical repair, either via laparotomy or laparos-
risk patients are open laparoscopy, as first copy [121]. The defect should be repaired in
described by Hasson, and a LUQ closed tech- layers with a delayed absorbable suture by a
nique utilizing Palmer’s point [115, 116]. surgeon experienced in gastric surgery. The
These alternative approaches are highly rec- abdominal cavity should be irrigated, being
ommended in a patient with a previous mid- careful to remove all food particles as well as
line incision. Unfortunately, neither of these gastric juices.
techniques has been shown in prospective
comparison studies to decrease the risk of 21.1.48.3 Small Intestine Injuries
intestinal injury relative to the open technique Intraoperative injuries to the small intestine
[2, 14, 115]. often go unrecognized during surgery. Injury
Another alternative approach is the use of should be suspected whenever multiple ante-
an optical-access trocar. These devices are rior abdominal wall adhesions are present.
designed to increase safety by visualizing each When the primary trocar and sleeve penetrate
layer of the abdominal wall during port place- completely through both walls of bowel
ment. Unfortunately, these devices have not adherent near the umbilicus, the injury will
been shown to decrease the risk of gastroin- not be visible. Whenever the routine 360° sur-
testinal injuries [117]. vey of the abdominal cavity reveals bowel
adherent near the point of insertion, a 5-mm
laparoscope should be placed through a lower
21.1.48 Recognition and Treatment quadrant port to view the umbilical port site
and search for injury. An injury to nonadher-
21.1.48.1 Veress Needle Injuries ent bowel with the Veress needle or a trocar
The spring-loaded tip of the 14-gauge Veress during initial port placement or during lysis
needle does not prevent perforation of of adhesions may fall out of view into the
adherent bowel or bowel with limited excur- abdomen. If such an injury is suspected, the
sion related to physiologic attachments, such bowel should be run with laparoscopic bowel
as the transverse colon [118]. Most bowel graspers or manually using a laparotomy inci-
perforations caused by the Veress needle do sion until an injury is satisfactorily excluded.
not need to be repaired as long as the punc- Postoperatively, unrecognized trocar inju-
ture is not actively bleeding or associated ries to the small intestine usually presents with
with a tear (Loffer, 1975 #68). Even in the symptoms of nausea, vomiting, anorexia,
case of colonic puncture, nonoperative man- abdominal pain, peritoneal signs, and possi-
agement with copious irrigation appears to bly fever on the second to fourth postopera-
21 be sufficient if there is no leak of bowel tive day. Although the bacterial load of the
content [119]. small intestine is low, the contents are not
483 21
sterile, and sepsis is a common result of undi- inflammation usually makes a diverting colos-
agnosed injuries. tomy necessary.
A full-thickness injury to the small intestine
should be repaired in two layers, sewing perpen- 21.1.48.5 Port-Site Hernia
dicular to the long axis of the intestine to avoid For the first two decades of laparoscopy, ports
stricture formation. This can be accomplished were placed almost exclusively in the midline,
with an initial interrupted layer of 3-0 delayed where the anterior and posterior rectus fascia
absorbable suture to approximate the mucosa fuse. These midline ports usually consisted of
and muscularis. A serosal layer of 3-0 delayed a 10-mm port at the umbilicus and a 5-mm
absorbable suture is commonly placed in an suprapubic port. Port-site hernias at these
interrupted fashion. This can be performed by locations are rare, and those reported are usu-
laparotomy, minilaparotomy at the umbilical ally limited omental herniation through the
site, where the injured bowel loop is pulled umbilical site.
through to the skin surface and repaired or lapa- The use of lateral ports for more complex
roscopically [122]. Sometimes resection-reanas- operative laparoscopy has resulted in a dra-
tomosis of the injured loop could be necessary. matic increase in the risk of port-site hernia-
tion. In one retrospective review, port-site
21.1.48.4 Large Intestine Injuries hernias occurred in 5 of 3500 (0.17%) proce-
Trocar injuries to the large intestines are dures, with all hernias occurring where ports
reported to occur with frequency of approxi- with diameters ≥10 mm were placed lateral to
mately 1 per 1000 cases [123]. Due to the high the midline [125]. Since the rectus fascia splits
concentration of coliform bacteria in the large laterally to form both anterior and posterior
intestine, unrecognized injuries can result in sheaths below the arcuate line, bowel hernia-
serious intra-abdominal infections that can tion can occur between these two fascial layers
quickly become life-threatening. in what has been called a “Spigelian hernia.”
Whenever a large intestine injury is sus- Recent literature review of 18,533 patients
pected, the area should be carefully inspected reported that trocar site hernias occurred in
using atraumatic bowel graspers. If adhesions 0.104% of cases, a rate that is significantly
or anatomy makes laparoscopic inspection influenced by trocar type and location [126]. It
difficult, laparotomy is reasonable. An occult was found that using non-bladed trocars (any
injury to the rectosigmoid colon may be size) resulted in lower port-site hernia rates
detected using the “flat tire test,” in which the than using bladed trocars, and midline trocar
posterior cul-de-sac is filled with normal location resulted in higher rates than off-
saline and air is injected into the rectum using midline. In contrast, fascia closure (5-mm and
a proctosigmoidoscope or a catheter-tipped 10-mm ports) had no influence on the inci-
bulb syringe [124]. Visible bubbles indicate a dence rate; researchers concluded that leaving
large intestine injury. the fascia open is beneficial for reducing oper-
The management of large intestine injuries ative time, the risk of needlestick injuries, and
depends upon size, site, and time between the overall operative cost [126].
injury and diagnosis. In general, once the
diagnosis of colonic injury is made, broad- 21.1.48.6 Prevention
spectrum antibiotics should be administered, To minimize the risk of port-site herniation,
and consultation should be sought with a sur- both the anterior and posterior fascial sheaths
geon who experienced with these types of should be closed after removal of all ports
injury. In the case of a small tear with mini- 8 mm and larger. This closure is usually per-
mal spillage of bowel contents, the defect is formed with the aid of one of a number of
closed in two layers with copious irrigation. commercially available devices or needles that
When a larger injury has occurred or the incorporate the peritoneum as well as both
injury involves the mesentery, a diverting fascial layers. Unfortunately, port-site hernia-
colostomy is sometimes necessary. In the case tion is not completely prevented by careful
of delayed (postoperative) diagnosis, tissue fascial closure [127].
21.1.48.7 Recognition and Treatment it seems prudent to place the suprapubic tro-
Trocar-site hernias usually present as a palpa- car above any previous transverse skin inci-
ble mass beneath a lateral trocar-site skin incisions. In all patients, an attempt should be
sion that manifests during a Valsalva made to visualize the superior bladder margin
maneuver. Ultrasonography can distinguish laparoscopically prior to suprapubic trocar
herniated bowel from a hematoma. A persis- placement [21]. In cases where the superior
tent mass associate with pain indicates an margin of the bladder cannot be seen, the
incarcerated hernia and represents a surgical bladder can be filled with 300 mL to better
emergency. define its margin. An alternative approach is
Herniated bowel can often be reduced lap- to use a lateral port site rather than a midline
aroscopically, followed by careful inspection suprapubic site, although the decreased risk
of the affected segments. Although simple of bladder injury may be offset by an increased
repair of the peritoneal and fascial defects is risk of vessel injury.
all that is required in most healthy patients, in
some cases synthetic mesh may be needed. 21.1.48.10 Recognition
Laparoscopic bladder injuries are often diffi-
21.1.48.8 Bladder Injuries cult to recognize intraoperatively. Visible
Injury to the bladder related to laparoscopic leakage of urine at the time of injury is
port placement is relatively uncommon and unlikely in patients with a Foley catheter in
usually related to insertion of the primary tro- place. A common sign of bladder injury is
car in the presence of a distended bladder or significant bleeding from a suprapubic port
insertion of a suprapubic midline trocar in a site placed in the relatively avascular midline.
patient whose bladder dome had extended Frank hematuria suggests a full-thickness
cephalad secondary to previous surgery [128]. injury. An uncommon, but pathognomonic
Full-thickness bladder injury could also hap- sign of bladder injury during laparoscopy is
pen secondary to the use of multifunctional insufflation of the Foley catheter bag with
devices to dissect the urinary bladder carbon dioxide [129].
(. Fig. 21.9). If bladder injury is suspected during lapa-
roscopy, an indigo carmine solution can be
21.1.48.9 Prevention instilled retrograde through a urethral cathe-
The risk of trocar injuries to the bladder can ter to detect small leaks. Cystoscopy may be
be decreased by draining the bladder with a used to inspect the bladder mucosa in ques-
catheter prior to primary trocar placement. In tionable cases or to determine the extent of a
patients with prior lower abdominal surgery, known injury and to ensure that there is no
ureteral involvement.
Postoperative recognition of a bladder
injury can likewise be difficult. Whenever a
patient returns within days of laparoscopy
with significant abdominal findings, the pos-
sibility of an occult bladder injury should be
considered [128]. Bladder injury should be
included in the differential diagnosis in the
presence of painful urination and microscopic
hematuria. Elevation of blood urea nitrogen
(BUN) and a serum creatinine suggests intra-
abdominal spill of urine with transperitoneal
reabsorption. Drainage from a suprapubic
incision can be evaluated further by instilla-
.. Fig. 21.9 Full-thickness bladder injury cause by
21 LigaSure dissection of adhesions repaired successfully tion of a dilute indigo carmine solution into
in two layers the bladder.
485 21
21.1.48.11 Treatment
When a bladder injury is diagnosed in the
postoperative period, a retrograde cystogram
should be performed to determine the extent
of the injury. If surgery is indicated because
of peritoneal signs of uncertain etiology, cys-
toscopy prior to laparotomy may be extremely
helpful in determining surgical approach.
Small, uncomplicated, and isolated inju-
ries of superior portion of the bladder can
be treated with catheter drainage alone [130].
.. Fig. 21.10 Illuminated ureteric stents used in patient
A retrograde cystogram should be per-
with stage IV endometriosis
formed after 10 days of continuous drainage
and will document spontaneous healing in
85% of patients with small injuries. Primary
surgical repair is required for larger injuries cularization injury. Postoperatively the
and those that involve the dependent por- patient presents with fever, abdominal pain,
tions of the bladder, including the trigone, and distention with an elevated serum creati-
especially if there is a risk of concomitant nine. Intravenous pyelography will confirm a
injury to the urethra or ureter. Closure leak. An attempt can be made to stent the
should be performed using a water-tight, ureters via cystoscopy. If unsuccessful, a per-
multilayered repair with absorbable suture. cutaneous nephrostomy is required with
Laparoscopic repair may be performed by repair after 6 weeks.
those with adequate surgical expertise as
long as there is adequate exposure and
the ureters and bladder neck are not 21.2 Review Questions
compromised [131].
??1. A 25-year-old woman is undergoing a
21.1.48.12 Ureter Injuries laparoscopy for pelvic pain. A 5-mm
Ureter injuries are commonly the result of left upper quadrant optical trocar will
direct injury at the time of laparoscopic hys- be inserted below the left costal margin
terectomy or urogynecologic procedure, or at the midclavicular line. The closest
endometriosis surgery. Injury can be due to organ to the insertion site is
suture occlusion, electrosurgery, or laceration A. Spleen
from an instrument, typically a scissors. B. Pancreas
Recognition of ureter injuries during surgery C. Kidney
is difficult, and the majority of ureteral inju- D. Stomach
ries during hysterectomy are not identified
intraoperatively [132]. For this reason it is ??2. A 25-year-old woman with a BMI of 33
recommended to visualize the ureters clearly is undergoing a laparoscopy for chronic
or dissect them before performing pelvic side pelvic pain. A 5-mm accessory trocar
wall surgery or hysterectomy. The use of illu- is inserted in the right lower quadrant.
minated stents could be of value in surgically Immediately after insertion blood is
challenging case (. Fig. 21.10). If the ureters noted from the trocar site. The most
were clearly seen throughout their course, likely injured vessel is
then no further action is required. Cystoscopy A. Superficial epigastric artery
with visualization of urine coming through B. External iliac artery
the ureteral orifices confirms non-occlusion C. Lateral circumflex iliac artery
but does not rule out electrosurgical or devas- D. Inferior epigastric artery
??3. During a laparoscopic excision of endo- 2. Vilos G. Laparoscopic bowel injuries: forty liti-
metriosis, the surgical assistant notices gated gynaecological cases in Canada. J Obstet
Gynaecol Can/JOGC Journal d’obstetrique et
air in the Foley bag. The most likely
gynecologie du Canada. 2002;24(3):224–30.
explanation is 3. Litynski GS. Laparoscopy–the early attempts:
A. Injury to the bladder. spotlighting Georg Kelling and Hans Christian
B. Foley catheter balloon ruptured. Jacobaeus. JSLS. 1997;1(1):83–5.
C. Foley catheter was accidentally 4. Semm K. Endocoagulation: a new and completely
safe medical current for sterilization. Int J Fertil.
introduced into the vagina.
1976;22(4):238–42.
D. Air in the Foley bag is normal. 5. Falcone T, Goldberg J, Garcia-Ruiz A, Margossian
H, Stevens L. Full robotic assistance for laparo-
??4. The reason that the primary trocar is scopic tubal anastomosis: a case report. J Laparo-
inserted with the patient flat and not in endosc Adv Surg Tech A. 1999;9(1):107–13.
6. Vilos GA, Ternamian A, Laberge PY, Vilos AG,
the Trendelenburg position is because
Abu-Rafea B, Scattolon S, et al. Guideline no. 412:
A. The Trendelenburg position laparoscopic entry for gynaecological surgery. J
changes the axis of insertion to Obstet Gynaecol Can. 2021;43(3):376. 89 e1
make vascular injury more likely. 7. Yuzpe A. Pneumoperitoneum needle and trocar
B. The flat position allows for an eas- injuries in laparoscopy. A survey on possible con-
tributing factors and prevention. J Reprod Med.
ier entry of the primary trocar.
1990;35(5):485–90.
C. The Trendelenburg position moves 8. Hurd W, Bude R, DeLancey J, Gauvin J, Aisen
the bowel under the umbilicus. A. Abdominal wall characterization with magnetic
D. The flat position decreases the dis- resonance imaging and computed tomography.
tance from the umbilicus to the The effect of obesity on the laparoscopic approach.
J Reprod Med. 1991;36(7):473–6.
great vessels compared with the
9. Hasson H. Open laparoscopy: a report of 150
Trendelenburg position. cases. J Reprod Med. 1974;12(6):234–8.
10. Byron JW, Markenson G, Miyazawa K. A random-
ized comparison of Verres needle and direct trocar
21.3 Answers insertion for laparoscopy. Surg Gynecol Obstet.
1993;177(3):259–62.
11. Cornette B, Berrevoet F. Trocar injuries in laparos-
vv1. D
copy: techniques, tools, and means for prevention.
A systematic review of the literature. World J Surg.
vv2. D 2016:1–11.
12. Hurd WW, Ohl DA. Blunt trocar laparoscopy. Fer-
vv3. A til Steril. 1994;61:1177–80.
13. Garry R. Towards evidence-based laparoscopic
entry techniques: clinical problems. Gynaecol
vv4. A Endosc. 1999;8:315–26.
14. Chapron C, Cravello L, Chopin N, Kreiker G,
Blanc B, Dubuisson JB. Complications during set-
Acknowledgments The authors would like to up procedures for laparoscopy in gynecology: open
laparoscopy does not reduce the risk of major
thank Irene Jianga for updating the references
complications. Acta Obstet Gynecol Scand.
and recreating . Figs. 21.1 and 21.2. 2003;82(12):1125–9.
aDepartment of Obstetrics and Gynecology,
15. Hasson H. Open laparoscopy as a method of
University of British Columbia, Vancouver, access in laparoscopic surgery. Gynaecol Endosc.
BC, Canada 1999;8:353–62.
16. Tulikangas PK, Nicklas A, Falcone T, Price
LL. Anatomy of the left upper quadrant for can-
nula insertion. J Am Assoc Gynecol Laparosc.
References 2000;7(2):211–4.
17. Tulikangas PK, Robinson DS, Falcone T. Left
1. Wright JD, Ananth CV, Lewin SN, Burke WM, Lu upper quadrant cannula insertion. Fertil Steril.
Y-S, Neugut AI, et al. Robotically assisted vs 2003;79(2):411–2.
21 laparoscopic hysterectomy among women with
18. Vilos AG, Vilos GA, Abu Rafea B, Oraif A, Abdul-
benign gynecologic disease. JAMA. 2013;309(7): jabar H. Randomized comparison of veress needle
689–98. intraperitoneal placement (VIP) at caudally dis-
487 21
placed umbilicus versus left upper quadrant (LUQ) 33. Mettler L, Semm K, Shive K. Endoscopic manage-
during laparoscopic entry. J Minim Invasive Gyne- ment of adnexal masses. JSLS J Soc Laparoendosc
col. 2015;22(6S):S104. Surg. 1997;1(2):103.
19. Bedaiwy M, Pope R, Farghaly T, Hurd W, Liu J, 34. Miller CE. Myomectomy: comparison of open and
Zanotti K. Surgical anatomy for supraumbilical laparoscopic techniques. Obstet Gynecol Clin
port placements: implications for laparoscopic sur- North Am. 2000;27(2):407–20.
gery. Fertil Steril. 2013;100(3):S397. 35. Falcone T, Bedaiwy MA. Minimally invasive man-
20. Stanhiser J, Goodman L, Soto E, Al-Aref I, Wu J, agement of uterine fibroids. Curr Opin Obstet
Gojayev A, et al. Supraumbilical primary trocar Gynecol. 2002;14(4):401–7.
insertion for laparoscopic access: the relationship 36. Food U, Administration D. Laparoscopic uterine
between points of entry and retroperitoneal vital power morcellation in hysterectomy and myomec-
vasculature by imaging. Am J Obstet Gynecol. tomy: FDA safety communication. 2014. Online:
2015;213(4):506.e1–5. http://www.f da.g ov/medicaldevices/safety/alert-
21. Hurd WW, Amesse LS, Gruber JS, Horowitz GM, sandnotices/ucm393576htm.
Cha GM, Hurteau JA. Visualization of the epigas- 37. UPDATE: The FDA recommends performing con-
tric vessels and bladder before laparoscopic trocar tained morcellation in women when laparoscopic
placement. Fertil Steril. 2003;80(1):209–12. power morcellation is appropriate. 2020. Available
22. Hurd WW, Bude RO, DeLancey JO, Newman from: https://www.fda.gov/medical-devices/safety-
JS. The location of abdominal wall blood vessels in c o m mu n i c at i o n s / u p d at e -f d a -re c o m m e n d s -
relationship to abdominal landmarks apparent at performing-contained-morcellation-women-when-
laparoscopy. Am J Obstet Gynecol. laparoscopic-power-morcellation.
1994;171(3):642–6. 38. De Novo Classification Request for Pneumoliner.
23. Tulandi T, Falcone T. Incidental liver abnormali- 2015. Available from: https://www.accessdata.fda.
ties at laparoscopy for benign gynecologic condi- gov/cdrh_docs/reviews/DEN150028.pdf.
tions. J Am Assoc Gynecol Laparosc. 39. 510(k) Summary. 2010. Available from: https://
1998;5(4):403–6. w w w.a c c e s s d at a .f d a .g ov / c d r h _ d o c s / p d f 1 0 /
24. Bedaiwy MA, Pope R, Henry D, Zanotti K, Maha- K100959.pdf.
jan S, Hurd W, et al. Standardization of laparo- 40. Kotani Y, Tobiume T, Fujishima R, Shigeta M,
scopic pelvic examination: a proposal of a novel Takaya H, Nakai H, et al. Recurrence of uterine
system. Minim Invasive Surg. 2013;2013:153235. myoma after myomectomy: open myomectomy
25. Peterson HB, Xia Z, Hughesa JM, Wilcox LS, versus laparoscopic myomectomy. J Obstet Gynae-
Tylora LR, Trussell J, et al. The risk of pregnancy col Res. 2018;44(2):298–302.
after tubal sterilization: findings from the US Col- 41. Proctor M, Farquhar C, Sinclair O, Johnson
laborative Review of Sterilization. Am J Obstet N. Surgical interruption of pelvic nerve pathways
Gynecol. 1996;174(4):1161–70. for primary and secondary dysmenorrhoea. The
26. Westhoff C, Davis A. Tubal sterilization: focus on Cochrane Library; 1999.
the US experience. Fertil Steril. 2000;73(5):913–22. 42. Reich H, DeCaprio J, McGlynn F. Laparoscopic
27. McAlpine JN, Hanley GE, Woo MM, Tone AA, hysterectomy. J Gynecol Surg. 1989;5(2):
Rozenberg N, Swenerton KD, et al. Opportunistic 213–6.
salpingectomy: uptake, risks, and complications of 43. Johns A. Supracervical versus total hysterectomy.
a regional initiative for ovarian cancer prevention. Clin Obstet Gynecol. 1997;40(4):903–13.
Am J Obstet Gynecol. 2014;210(5):471.e1–e11. 44. Kuppermann M, Summitt RL Jr, Varner RE,
28. Medicine PCotASfR. Committee opinion: role of McNeeley SG, Goodman-Gruen D, Learman LA,
tubal surgery in the era of assisted reproductive et al. Sexual functioning after total compared with
technology. Fertil Steril. 2012;97(3):539–45. supracervical hysterectomy: a randomized trial.
29. Moawad NS, Laguerre M, Arkerson B, Robinson Obstet Gynecol. 2005;105(6):1309–18.
N. 1836 Outcomes of laparoscopic management of 45. Thakar R, Ayers S, Clarkson P, Stanton S, Man-
chronic pelvic pain and endometriosis. J Minim yonda I. Outcomes after total versus subtotal
Invasive Gynecol. 2019;26(7):S191. abdominal hysterectomy. N Engl J Med.
30. Duffy JM, Arambage K, Correa FJ, Olive D, Far- 2002;347(17):1318–25.
quhar C, Garry R, et al. Laparoscopic surgery for 46. Garry R, Fountain J, Mason S, Hawe J, Napp V,
endometriosis. Cochrane Database Syst Rev. Abbott J, et al. The eVALuate study: two parallel
2014;(4):CD011031. randomised trials, one comparing laparoscopic
31. Tulandi T, Saleh A. Surgical management of ecto- with abdominal hysterectomy, the other comparing
pic pregnancy. Clin Obstet Gynecol. 1999;42(1): laparoscopic with vaginal hysterectomy. BMJ.
31–8. 2004;328(7432):129.
32. Mol F, van Mello NM, Strandell A, Strandell K, 47. Falcone T, Paraiso MFR, Mascha E. Prospective
Jurkovic D, Ross J, et al. Salpingotomy versus sal- randomized clinical trial of laparoscopically
pingectomy in women with tubal pregnancy (ESEP assisted vaginal hysterectomy versus total abdomi-
study): an open-label, multicentre, randomised nal hysterectomy. Am J Obstet Gynecol.
controlled trial. Lancet. 2014;383(9927):1483–9. 1999;180(4):955–62.
48. Chrysostomou A, Djokovic D, Libhaber E, 64. Goldberg JM, Falcone T. Laparoscopic microsur-
Edridge W, van Herendael BJ. Formal institutional gical tubal anastomosis with and without robotic
guidelines promotes the vaginal approach to hys- assistance*. Hum Reprod. 2003;18(1):145–7.
terectomy in patients with benign disease and non- 65. Rodgers AK, Goldberg JM, Hammel JP, Falcone
prolapsed uterus. Eur J Obstet Gynecol Reprod T. Tubal anastomosis by robotic compared with
Biol. 2021;259:133–9. outpatient minilaparotomy. Obstet Gynecol.
49. Barron KI, Richard T, Robinson PS, Lamvu 2007;109(6):1375–80.
G. Association of the US Food and Drug Admin- 66. Bedaiwy MA, Barakat EM, Falcone T. Robotic
istration morcellation warning with rates of mini- tubal anastomosis: technical aspects. J Soc Lapa-
mally invasive hysterectomy and myomectomy. roendosc Surg. 2011;15(1):10.
Obstet Gynecol. 2015;126(6):1174–80. 67. Dharia Patel SP, Steinkampf MP, Whitten SJ, Mal-
50. Parker WH, Fu YS, Berek JS. Uterine sarcoma in izia BA. Robotic tubal anastomosis: surgical tech-
patients operated on for presumed leiomyoma and nique and cost effectiveness. Fertil Steril.
rapidly growing leiomyoma. Obstet Gynecol. 2008;90(4):1175–9.
1994;83(3):414–8. 68. Goldberg J, Pereira L. Pregnancy outcomes follow-
51. Pritts EA. The prevalence of occult leiomyosar- ing treatment for fibroids: uterine fibroid emboliza-
coma in women undergoing presumed fibroid sur- tion versus laparoscopic myomectomy. Curr Opin
gery and outcomes after morcellation. Curr Opin Obstet Gynecol. 2006;18(4):402–6.
Obstet Gynecol. 2018;30(1):81–8. 69. Advincula AP, Xu X, Goudeau S, Ransom
52. Singh SS, Scott S, Bougie O, Leyland N, Wolfman SB. Robot-assisted laparoscopic myomectomy ver-
W, Allaire C, et al. Technical update on tissue mor- sus abdominal myomectomy: a comparison of
cellation during gynaecologic surgery: its uses, short-term surgical outcomes and immediate costs.
complications, and risks of unsuspected malig- J Minim Invasive Gynecol. 2007;14(6):698–705.
nancy. J Obstet Gynaecol Can. 2015;37(1):68–78. 70. Barakat EE, Bedaiwy MA, Zimberg S, Nutter B,
53. Voelker R. New morcellation system does not elim- Nosseir M, Falcone T. Robotic-assisted, laparo-
inate cancer risk. JAMA. 2016;315(19):2057. scopic, and abdominal myomectomy: a compari-
54. Zhang HM, Christianson LA, Templeman CL, son of surgical outcomes. Obstet Gynecol.
Lentz SE. Non-malignant sequelae after uncon- 2011;117(2, Part 1):256–66.
fined power morcellation. J Minim Invasive Gyne- 71. Arian SE, Munoz JL, Kim S, Falcone T. Robot-
col. 2019;26(3):434–40. assisted laparoscopic myomectomy: current status.
55. Peters BS, Armijo PR, Krause C, Choudhury SA, Robot Surg. 2017;4:7–18.
Oleynikov D. Review of emerging surgical robotic 72. George A, Eisenstein D, Wegienka G. Analysis of
technology. Surg Endosc. 2018;32(4):1636–55. the impact of body mass index on the surgical out-
56. Camarillo DB, Thomas MS, Krummel M, et al. comes after robot-assisted laparoscopic myomec-
Robotic technology in surgery: Past, present, and tomy. J Minim Invasive Gynecol. 2009;16(6):730–3.
future. Am J Surgery. 2004;188(4):2−15. 73. Ghomi A, Kramer C, Askari R, Chavan NR, Ein-
57. Sait KH. Early experience with the da Vinci® sur- arsson JI. Trendelenburg position in gynecologic
gical system robot in gynecological surgery at King robotic-assisted surgery. J Minim Invasive Gyne-
Abdulaziz University Hospital. Int J Womens col. 2012;19(4):485–9.
Health. 2011;3:219. 74. Nezhat C, Lewis M, Kotikela S, Veeraswamy A,
58. Paraiso MFR, Ridgeway B, Park AJ, Jelovsek JE, Saadat L, Hajhosseini B, et al. Robotic versus stan-
Barber MD, Falcone T, et al. A randomized trial dard laparoscopy for the treatment of endometrio-
comparing conventional and robotically assisted sis. Fertil Steril. 2010;94(7):2758–60.
total laparoscopic hysterectomy. Am J Obstet 75. Bedaiwy MA, Rahman MYA, Chapman M, Fra-
Gynecol. 2013;208(5):368.e1–7. sure H, Mahajan S, von Gruenigen VE, et al.
59. Barbash GI, Glied SA. New technology and health Robotic-assisted hysterectomy for the management
care costs—the case of robot-assisted surgery. N of severe endometriosis: a retrospective review of
Engl J Med. 2010;363(8):701–4. short-term surgical outcomes. JSLS J Soc Laparo-
60. Shukla PJ, Scherr DS, Milsom JW. Robot-assisted endosc Surg. 2013;17(1):95.
surgery and health care costs. N Engl J Med. 76. Magrina JF, Espada M, Kho RM, Cetta R, Chang
2010;363(22):2174. Y-HH, Magtibay PM. Surgical excision of
61. Liu H, Lu D, Wang L, Shi G, Song H, Clarke advanced endometriosis: perioperative outcomes
J. Robotic surgery for benign gynaecological dis- and impacting factors. J Minim Invasive Gynecol.
ease. Cochrane Database Syst Rev. 2012;2. 2015;22(6):944–50.
62. van Seeters JAH, Chua SJ, Mol BWJ, Koks 77. Soto E, Luu TH, Liu X, Magrina JF, Wasson MN,
CAM. Tubal anastomosis after previous steriliza- Einarsson JI, et al. Laparoscopy vs. Robotic Sur-
tion: a systematic review. Hum Reprod Update. gery for Endometriosis (LAROSE): a multicenter,
2017;23(3):358–70. randomized, controlled trial. Fertil Steril.
21 63. Ghomi A, Nolan W, Rodgers B. Robotic-assisted 2017;107(4):996–1002 e3.
laparoscopic tubal anastomosis: single institution 78. Neme RM, Schraibman V, Okazaki S, Maccapani
analysis. Int J Med Robot. 2020;16(6):1–5. G, Chen WJ, Domit CD, et al. Deep infiltrating
489 21
colorectal endometriosis treated with robotic- ventional laparoscopy in benign adnexal diseases:
assisted rectosigmoidectomy. JSLS. a systematic review and meta-analysis. J Minim
2013;17(2):227–34. Invasive Gynecol. 2017;24(7):1083–95.
79. Field JB, Benoit MF, Dinh TA, Diaz-Arrastia 92. Bedaiwy MA, Sheyn D, Eghdami L, Abdelhafez
C. Computer-enhanced robotic surgery in gyneco- FF, Volsky JG, Fader AN, et al. Laparoendoscopic
logic oncology. Surg Endosc. 2007;21(2):244–6. single-site surgery for benign ovarian cystectomies.
80. Magrina JF, Kho RM, Weaver AL, Montero RP, Gynecol Obstet Invest. 2015;79(3):179–83.
Magtibay PM. Robotic radical hysterectomy: com- 93. Park JY, Kim DY, Kim SH, Suh DS, Kim JH, Nam
parison with laparoscopy and laparotomy. Gyne- JH. Laparoendoscopic single-site compared with
col Oncol. 2008;109(1):86–91. conventional laparoscopic ovarian cystectomy for
81. Mabrouk M, Frumovitz M, Greer M, Sharma S, ovarian endometrioma. J Minim Invasive Gynecol.
Schmeler KM, Soliman PT, et al. Trends in laparo- 2015;22(5):813–9.
scopic and robotic surgery among gynecologic 94. Bedaiwy MA, Starks D, Hurd W, Escobar PF. Lap-
oncologists: a survey update. Gynecol Oncol. aroendoscopic single-site surgery in patients with
2009;112(3):501–5. benign adnexal disease: a comparative study.
82. Abitbol J, Munir A, How J, Lau S, Salvador S, Gynecol Obstet Invest. 2012;73(4):294–8.
Kogan L, Kessous R, Breitner L, Frank R, 95. Su X, Jin X, Wen C, Xu Q, Cai C, Zhong Z,
Kucukyazici B, Gotlieb WH. The shifting trends et al. Outcome of gynecologic laparoendoscopic
towards a robotically-assisted surgical interface: single-
site surgery with a homemade device
clinical and financial implications. HPT. and conventional laparoscopic instruments in
2020;9(2):157–65. a Chinese teaching hospital. Biomed Res Int.
83. Ramirez PT, Frumovitz M, Pareja R, Lopez A, 2020;2020:5373927.
Vieira M, Ribeiro R, et al. Minimally invasive ver- 96. Barnes H, Harrison R, Huffman L, Medlin E,
sus abdominal radical hysterectomy for cervical Spencer R, Al-Niaimi A. The adoption of single-
cancer. N Engl J Med. 2018;379(20):1895–904. port laparoscopy for full staging of endometrial
84. Elliott D, Chow G, editors. Management of vagi- cancer: surgical and oncology outcomes and evalu-
nal vault prolapse repair with robotically-assisted ation of the learning curve. J Minim Invasive
laparoscopic sacrocolpopexy. Annales d’urologie; Gynecol. 2017;24(6):1029–36.
2007. 97. Murji A, Patel VI, Leyland N, Choi M. Single-
85. Sener A, Chew BH, Duvdevani M, Brock GB, incision laparoscopy in gynecologic surgery: a sys-
Vilos GA, Pautler SE. Combined transurethral tematic review and meta-analysis. Obstet Gynecol.
and laparoscopic partial cystectomy and robot- 2013;121(4):819–28.
assisted bladder repair for the treatment of bladder 98. Shirk GJ, Johns A, Redwine DB. Complications of
endometrioma. J Minim Invasive Gynecol. laparoscopic surgery: how to avoid them and how
2006;13(3):245–8. to repair them. J Minim Invasive Gynecol.
86. Swan K, Advincula AP. Role of robotic surgery in 2006;13(4):352–9.
urogynecologic surgery and radical hysterectomy: 99. Mintz M. Risks and prophylaxis in laparoscopy: a
how far can we go? Curr Opin Urol. 2011;21(1): survey of 100000 cases. J Reprod Med.
78–83. 1977;18(5):269–72.
87. Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A sys- 100. Saville L, Woods M. Laparoscopy and major retro-
tematic review and meta-analysis of conventional peritoneal vascular injuries (MRVI). Surg Endosc.
laparoscopic sacrocolpopexy versus robot-assisted 1995;9(10):1096–100.
laparoscopic sacrocolpopexy. Int J Gynecol Obstet. 101. Soderstrom RM. Injuries to major blood vessels
2016. 132:284-291. during endoscopy. J Am Assoc Gynecol Laparosc.
88. Bedaiwy MA, Escobar PF, Pinkerton J, Hurd 1997;4(3):395–8.
W. Laparoendoscopic single-site salpingectomy in 102. Kaloo P, Cooper M, Molloy D. A survey of entry
isthmic and ampullary ectopic pregnancy: prelimi- techniques and complications of members of the
nary report and technique. J Minim Invasive Gyne- Australian gynaecological endoscopy society
col. 2011;18(2):230–3. (AGES). Aust N Z J Obstet Gynaecol.
89. Huang KJ, Lin KT, Wu CJ, Li YX, Chang WC, 2002;42(3):264–6.
Sheu BC. Single incision laparoscopic surgery 103. Molloy D, Kaloo PD, Cooper M, Nguyen TV. Lap-
using conventional laparoscopic instruments ver- aroscopic entry: a literature review and analysis of
sus two-port laparoscopic surgery for adnexal techniques and complications of primary port
lesions. Sci Rep. 2021;11(1):4118. entry. Aust N Z J Obstet Gynaecol. 2002;42(3):
90. Gasparri ML, Mueller MD, Taghavi K, Papadia 246–54.
A. Conventional versus single port laparoscopy for 104. Vilos GA, Vilos AG, Abu-Rafea B, Hollett-Caines
the surgical treatment of ectopic pregnancy: a J, Nikkhah-Abyaneh Z, Edris F. Three simple steps
meta-analysis. Gynecol Obstet Invest. 2018; during closed laparoscopic entry may minimize
83(4):329–37. major injuries. Surg Endosc. 2009;23(4):758–64.
91. Schmitt A, Crochet P, Knight S, Tourette C, Loun- 105. Abu-Rafea B, Vilos GA, Vilos AG, Ahmad R, Hol-
dou A, Agostini A. Single-port laparoscopy vs con- lett-Caines J, Al-Omran M. High-pressure laparo-
scopic entry does not adversely affect 119. Taylor R, Weakley FL, Sullivan B. Non-operative
cardiopulmonary function in healthy women. J management of colonoscopic perforation with
Minim Invasive Gynecol. 2005;12(6):475–9. pneumoperitoneum. Gastrointest Endosc.
106. Philips G, Garry R, Kumar C, Reich H. How much 1978;24(3):124–5.
gas is required for initial insufflation at laparos- 120. Loffer FD, Pent D. Indications, contraindications
copy? Gynecol Endosc. 1999;8:365–74. and complications of laparoscopy. Obstet Gynecol
107. Bonjer H, Hazebroek E, Kazemier G, Giuffrida M, Surv. 1975;30(7):407–27.
Meijer W, Lance J. Open versus closed establish- 121. Spinelli P, Di Felice G, Pizzetti P, Oriana R. Lapa-
ment of pneumoperitoneum in laparoscopic sur- roscopic repair of full-thickness stomach injury.
gery. Br J Surg. 1997;84(5):599–602. Surg Endosc. 1991;5(3):156–7.
108. Dunne N, Booth M, Dehn T. Establishing pneu- 122. Nezhat C, Nezhat F, Ambroze W, Pennington
moperitoneum: verres or Hasson? The debate con- E. Laparoscopic repair of small bowel and colon.
tinues. Ann R Coll Surg Engl. 2010;93(1):22–4. Surg Endosc. 1993;7(2):88–9.
109. Pickett SD, Rodewald KJ, Billow MR, Giannios 123. Krebs H-B. Intestinal injury in gynecologic sur-
NM, Hurd WW. Avoiding major vessel injury dur- gery: a ten-year experience. Am J Obstet Gynecol.
ing laparoscopic instrument insertion. Obstet 1986;155(3):509–14.
Gynecol Clin North Am. 2010;37(3):387–97. 124. Nezhat C, Seidman D, Nezhat F, Nezhat C. The
110. Giannios NM, Gulani V, Rohlck K, Flyckt RL, role of intraoperative proctosigmoidoscopy in lap-
Weil SJ, Hurd WW. Left upper quadrant laparo- aroscopic pelvic surgery. J Am Assoc Gynecol
scopic placement: effects of insertion angle and Laparosc. 2004;11(1):47–9.
body mass index on distance to posterior perito- 125. Kadar N, Reich H, Liu C, Manko GF, Gimpelson
neum by magnetic resonance imaging. Am J Obstet R. Incisional hernias after major laparoscopic
Gynecol. 2009;201(5):522.e1–5. gynecologic procedures. Am J Obstet Gynecol.
111. Sandadi S, Johannigman JA, Wong VL, Blebea J, 1993;168(5):1493–5.
Altose MD, Hurd WW. Recognition and manage- 126. Gutierrez M, Stuparich M, Behbehani S, Nahas
ment of major vessel injury during laparoscopy. J S. Does closure of fascia, type, and location of tro-
Minim Invasive Gynecol. 2010;17(6): car influence occurrence of port site hernias? A
692–702. literature review. Surg Endosc. 2020;34(12):
112. Hurd WW, Pearl ML, DeLancey JO, Quint EH, 5250–8.
Garnett B, Bude RO. Laparoscopic injury of 127. Montz F, Holschneider C, Munro M. Incisional
abdominal wall blood vessels: a report of three hernia following laparoscopy: a survey of the
cases. Obstet Gynecol. 1993;82(4):673–6. American Association of Gynecologic Laparosco-
113. Debnath D. Bowel injury as a complication of lap- pists. Obstet Gynecol. 1994;84(5):881–4.
aroscopy (Br J Surg 2004; 91: 1253–1258). Br J 128. Godfrey C, Wahle GR, Schilder JM, Rothenberg
Surg. 2004;91(12):1652. JM, Hurd WW. Occult bladder injury during lapa-
114. Bateman B, Kolp L, Hoeger K. Complications of roscopy: report of two cases. J Laparoendosc Adv
laparoscopy--operative and diagnostic. Fertil Surg Tech. 1999;9(4):341–5.
Steril. 1996;66(1):30–5. 129. Classi R, Sloan PA. Intraoperative detection of
115. Jansen FW, Kolkman W, Bakkum EA, de Kroon laparoscopic bladder injury. Can J Anaesth.
CD, Trimbos-Kemper TC, Trimbos JB. Complica- 1995;42(5):415–6.
tions of laparoscopy: an inquiry about closed- 130. Gomez RG, Ceballos L, Coburn M, Corriere JN,
versus open-entry technique. Am J Obstet Gynecol. Dixon CM, Lobel B, et al. Consensus statement on
2004;190(3):634–8. bladder injuries. BJU Int. 2004;94(1):27–32.
116. Hasson H. A modified instrument and method 131. Nezhat F, Nezhat C, Admon D, Gordon S, Nezhat
laparoscopy. Am J Obstet Gynecol. C. Complications and results of 361 hysterecto-
1971;110(6):886–7. mies performed at laparoscopy. J Am Coll Surg.
117. Sharp HT, Dodson MK, Draper ML, Watts DA, 1995;180(3):307–16.
Doucette RC, Hurd WW. Complications associ- 132. Adelman MR, Bardsley TR, Sharp HT. Urinary
ated with optical-access laparoscopic trocars. tract injuries in laparoscopic hysterectomy: a sys-
Obstet Gynecol. 2002;99(4):553–5. tematic review. J Minim Invasive Gynecol.
118. Chee SS, Godfrey CD, Hurteau JA, Schilder JM, 2014;21(4):558–66.
Rothenberg JM, Hurd WW. Location of the trans- 133. Falcone T, Hurd WW. In: Falcone T, Hurd WW,
verse colon in relationship to the umbilicus: impli- eds. Clinical reproductive medicine and surgery. St.
cations for laparoscopic techniques. J Am Assoc Louis: Mosby/Elsevier; 2007.
Gynecol Laparosc. 1998;5(4):385–8.
21
491 22
Uterine Leiomyomas
Gregory M. Christman
Contents
22.1 Prevalence – 493
22.2 Classification – 494
22.3 Clinical Impact – 494

22.3.1 bnormal Uterine Bleeding – 494
A
22.3.2 Chronic Pelvic Pain – 495
22.3.3 Reproductive Function – 495
22.4 Epidemiology of Uterine Leiomyomas – 495
22.5 Pathology and Pathophysiology – 496

22.5.1 enetics – 496
G
22.5.2 Pathology – 496
22.5.3 Endocrinology – 496
22.5.4 Pregnancy and Leiomyomas – 498
22.6 Diagnostic Imaging and Leiomyomas – 498

22.6.1 ltrasound – 498
U
22.6.2 Hysterosalpingography – 499
22.6.3 Magnetic Resonance Imaging – 499
22.7 Treatment of Leiomyomas – 499
22.8 Medical Treatment of Leiomyomas – 500

22.8.1 onadotropin-Releasing Hormone (GnRH) Agonists
G
and GnRH Antagonists – 500
22.8.2 Selective Estrogen Receptor Modulators – 501
22.8.3 Selective Progesterone Receptor Modulators – 501
22.8.4 Aromatase Inhibitors – 502
22.9 Surgical Therapy of Leiomyomas – 503

22.9.1 ysterectomy – 503
H
22.9.2 Myomectomy – 503

https://doi.org/10.1007/978-3-030-99596-6_22
22.9.3 L aparoscopic Myomectomy – 504
22.9.4 Robotic-Assisted Myomectomy – 504
22.10 Technical Considerations – 504
22.11 Uterine Artery/Leiomyoma Embolization – 505
22.12 MRI-Guided Focused Ultrasound Therapy – 506
22.13 Cryomyolysis – 507
22.14 Laparoscopic Uterine Artery Ligation – 508
22.16 Answers – 508
References – 508
Uterine Leiomyomas
493 22
Key Points 55 High-intensity focused ultrasound sur-

55 Intermenstrual bleeding can indicate the gery (HIFU), with either MRI or US
presence of an intracavitary myoma or for guidance, has been used for treat-
specific endometrial pathology; there- ing symptomatic uterine fibroids in a
fore, a more detailed evaluation of the noninvasive manner. The therapeutic
uterine cavity is warranted in these cases. HIFU component focuses ultrasound
55 Aromatase p450 is overexpressed by energy with resulting thermogenesis in
leiomyomas. Therefore, in addition to order to ablate leiomyoma tissue in a
circulating estrogen acting on the estro- precise and controlled fashion.
gen receptor, the local conversion of cir-
culating androgens to estrogens may be
important in potentiating the actions of
estrogen in the leiomyocyte. Case Vignette
55 Robotic assisted myomectomy has been
A 28-year-old nulligravid woman presents
associated with decreased intraopera-
with a chief complaint of a 2-year history
tive blood loss as well as a shorter length
of infertility and a 2-year history of pro-
of hospital stay as compared with lapa-
gressively heavier periods. She has been
roscopic and abdominal myomectomy.
married for 4 years and the patient used
55 Nulliparous women have higher rates of
oral contraceptives for the first two years of
leiomyomas than multiparous women,
her marriage. Her menses occur every
and the risk of developing leiomyomas
27–30 days, with heavy menstrual flow
decreases consistently with each subse-
requiring up to 8–10 pads every 24 hours on
quent term birth.
the first 2 days of flow and her menstrual
55 Myomas are responsive to both estro-
flow lasts for 7 days with occasional
gen and progesterone and are therefore
1–3 days of light spotting between her peri-
more likely to increase in size and cause
ods. Her partner has had a normal semen
associated symptoms in women of
analysis.
reproductive age. Growth of leiomyo-
Diagnosis: Type I submucous leiomyoma
mas is the result of accelerated cellular
Imaging: 2.5 cm leiomyoma seen on saline
proliferation that outpaces the inhibi-
infusion sonography with 17 mm projecting
tory effect of apoptosis. Apoptosis has
into the myometrium
been shown to be inhibited in uterine
Recommended treatment for patient’s con-
leiomyomas.
cerns of menorrhagia and infertility: Hys-
55 Successful pregnancies have occurred
teroscopic myomectomy followed initially
following uterine artery embolization
with observation and timed intercourse.
(UAE). There is a risk of inducing pre-
Intermenstrual spotting highlights the need
mature ovarian insufficiency in older
to strongly consider the presence of an
women. Several studies have shown an
intracavitary leiomyoma or need to evalu-
increased risk of intrauterine growth
ate for other intracavitary or endometrial
restriction and placentation problems
pathology.
in pregnancies following UAE.
55 GnRH agonists and GnRH antagonists
are effective therapy for reducing uter-
ine bleeding and correction of anemia 22.1 Prevalence
from uterine leiomyomas. Due to poten-
tial concerns with bone health, their use Uterine leiomyomas (also known as fibroids
is generally restricted to short term or or myomas) are the most common benign
limited duration administration. pelvic tumors found in women. As many as
50% of reproductive-age women have clini-
494 G. M. Christman
cally apparent uterine leiomyomas and 25%

of women have symptomatic leiomyomas. On
pathological examination, 77% of hysterec-
tomy specimens contain one or more uterine
leiomyomas [1].
Although generally benign, uterine leio-
myomas are associated with significant mor-
bidity, including abnormal uterine bleeding
and anemia, chronic pelvic pain, impaired fer-
tility, and recurrent pregnancy loss.
In the United States, leiomyomas are cited
as the primary indication for hysterectomy .. Fig. 22.1 Hysterectomy specimen demonstrating
with over 250,000 cases per year and account the presence of intramural, submucosal, and subserosal
for well over $5 billion in healthcare costs leiomyomas
annually [2].
22.3 Clinical Impact

22.2 Classification
Although at least 50% of uterine leiomyomas
Uterine leiomyomas are typically classified are asymptomatic, many women have signifi-
into subgroups by their position relative to the cant symptoms that impact their quality of
layers of the uterus. Subserosal myomas occur life and warrant treatment. The major clini-
near the serosal surface of the uterus. They cal manifestations of uterine leiomyoma can
may have either a broad or pedunculated base be roughly classified into three categories:
and can extend between the folds of the broad increased uterine bleeding, pelvic pressure or
ligament. Intramural myomas originate within pain, and reproductive dysfunction.
the myometrium and may enlarge enough to
distort the uterine cavity or the serosal sur-
face. Submucosal myomas develop just below 22.3.1 Abnormal Uterine Bleeding
the endometrium and, with progression, pro-
trude into the uterine cavity. Subserosal and Abnormal uterine bleeding is the most com-
submucosal myomas can also be either pedun- mon symptom reported by women with leiomy-
culated or broad-based. Cervical myomas, omas. The most common types of leiomyomas
on the other hand, are derived from cells in associated with heavy bleeding are intramural
the cervix as opposed to the uterine corpus or submucosal myomas. The typical bleeding
(. Fig. 22.1). patterns are menorrhagia or hypermenorrhea.
Leiomyomas can occur as a solitary mass Intermenstrual bleeding can indicate the pres-
but are most often present as multiple masses ence of an intracavitary myoma or specific
within a uterus. They vary greatly in size endometrial pathology; therefore, a more
from microscopic to multi-lobulated tumors detailed evaluation of the uterine cavity is war-
that can weigh as much as 50 lb. and give the ranted in these cases. Heavy vaginal bleeding
patient the appearance of gravid uterus. On can lead to problems such as iron-deficiency
physical exam, the size of a uterus containing anemia, which can be severe enough to require
leiomyomas (“a fibroid uterus”) is frequently blood transfusions, and frequent changes of
described in terms of weeks comparable to a sanitary protection can cause significant dis-
gravid uterus. tress in work or social situations [3].
22
Uterine Leiomyomas
495 22
22.3.2 Chronic Pelvic Pain sible that large leiomyomas may impair the
rhythmic uterine contractions that facilitate
Pelvic pain or pressure is the second most com- sperm motility [8]. It has further been docu-
mon complaint and is frequently described as mented that endometrial histology and endo-
analogous to the discomfort associated with metrial gene transcription vary in relation to
uterine growth during pregnancy. The pain the location of the leiomyoma. Submucosal
can occur both during and between bleeding leiomyomas may be associated with localized
episodes. Posterior leiomyomas may give rise endometrial atrophy as well as alterations in
to low back pain, whereas anterior leiomyo- the vascular blood flow, which may impede the
mas may compress the bladder. Leiomyomas implantation of an embryo, the delivery of hor-
that become large enough to fill the pelvis may mones or growth factors involved in implan-
potentially interfere with voiding and defeca- tation, or interfere with the normal immune
tion or cause dyspareunia. Very large leiomy- response to pregnancy [9–11]. Submucosal
omas can, on occasion, outgrow their blood leiomyomas, which distort the uterine cavity,
supply, leading to tissue ischemia and necrosis are associated with first-trimester pregnancy
clinically manifested as acute, severe pelvic loss, preterm delivery, abnormal presentation
pain. Pedunculated leiomyomas can suffer in labor, and postpartum hemorrhage [12].
torsion, which can lead to ischemia and acute In regard to the effectiveness of assisted
pain. During pregnancy, leiomyomas have reproductive technology, submucosal and
been known to undergo “red degeneration,” intramural leiomyomas are associated with a
where hemorrhage occurs within the myoma, reduction in the effectiveness of assisted repro-
leading to acute pain [3]. ductive procedures. Evidence demonstrates
that both pregnancy and implantation rates
are significantly lower in patients with intra-
22.3.3 Reproductive Function mural or submucosal leiomyomas [13, 14]. In
one study, the presence of an intramural leio-
Uterine leiomyomas are believed to influence myoma decreased the chances of an ongoing
reproduction in several ways; however, their pregnancy by 50% following in vitro fertiliza-
direct effect on fertility is still a subject of tion [15]. Evidence suggests that patients with
much debate. The incidence of infertility and subserosal leiomyomas have assisted repro-
uterine leiomyomas increases with advanc- ductive technology similar to patients without
ing maternal age, and no specific data exist to leiomyomas [14, 16, 17].
ascertain if the proportion of infertile women
with leiomyomas is greater than the propor-
tion of fertile women with leiomyomas. 22.4 Epidemiology of Uterine
Yet the indirect evidence is substantial. In Leiomyomas
one review, pregnancy rates among women
with leiomyomas distorting and not distorting The diagnosis of uterine leiomyomas increases
the uterine cavity were 9% and 35%, respec- with age throughout the reproductive years,
tively, as compared to 40% among controls with the highest prevalence occurring in
with no leiomyomas [4]. Furthermore, the the fifth decade of a woman’s life. African-
multiple reports of successful pregnancies American women have a two- to threefold
among infertile women after myomectomy greater relative risk of leiomyomas compared
strongly suggest a connection [5–7]. to Caucasian women and tend to be diag-
Though exact physiologic mechanisms for nosed at an earlier age and have more severe
reproductive dysfunction are unclear, many disease (larger leiomyomas and greater inci-
plausible theories exist. There is a potential for dence of anemia) as compared to Caucasian
reduced fecundity if a myoma occurs in the women [18, 19].
cornual region of the uterus due to mechani- Nulliparous women have higher rates of
cal occlusion of a fallopian tube [3]. It is pos- leiomyomas than multiparous women, and
496 G. M. Christman
the risk of developing leiomyomas decreases not all, myomas contain nonrandom cytoge-
consistently with each subsequent term birth netic abnormalities, while the myometrium
[20]. Early age at menarche is associated with has a normal karyotype. Most of the muta-
a two- to threefold increased risk of develop- tions occur in genes that are involved in cellu-
ing leiomyomas [21]. lar growth or are responsible for architectural
Leiomyomas clearly demonstrate their transcription.
hormonal responsiveness in the fact that Two hereditary disorders have been
they form after puberty, have the potential to reported in which uterine leiomyomas are part
enlarge during pregnancy, and regress after of a syndrome complex that demonstrates the
menopause. However, studies of exogenous potential genetic contribution to myoma for-
hormone treatments, including oral contra- mation. The first is hereditary leiomyomato-
ceptives and hormone replacement therapy, sis and renal cell cancer complex. This is an
reveal conflicting data, and no clear associa- autosomal dominant syndrome with smooth
tion can be inferred [22]. muscle tumors of the uterus, skin, and kid-
Twin and family studies suggest a familial ney. The second is a syndrome of pulmonary
predisposition to developing leiomyomas [22]. leiomyomatosis and lymphangiomyomato-
These studies are hampered by the extremely sis (LAM) that is the result of mutations in
high incidence of leiomyoma formation in the one of the two genes responsible for tuberous
general population. sclerosis, a syndrome that results in multiple
According to some studies, an increase in hamartomas.
body mass index has been found to increase
the risk for uterine leiomyomas by a factor of
2–3, and the evidence suggests that it is adult- 22.5.2 Pathology
onset obesity rather than excessive weight in
childhood that infers this risk. However, other Grossly, myomas usually appear as discrete,
studies have not observed similar associations round masses that are lighter in color than the
with increased BMI [21]. surrounding myometrium, with a glistening,
The majority of epidemiologic studies pearly white appearance. Histological features
find that cigarette smokers are at a 20–50% include smooth muscle fibers that form inter-
reduced risk for the development of uterine lacing bundles, with excessive fibrous tissue in
leiomyomas perhaps via a reduction in estra- between the bundles.
diol levels and that the inverse association was
independent of BMI. It is unclear whether
this relationship varies as a function of pack 22.5.3 Endocrinology
years. No clear relationship has been shown
between leiomyomas and specific dietary fac- The influence of steroidal hormones is central
tors or physical activity [21]. to the theory of clonal expansion of leiomyo-
mas. Myomas are responsive to both estro-
gen and progesterone and are therefore more
likely to increase in size and cause associated
22.5 Pathology symptoms in women of reproductive age.
and Pathophysiology Serum concentrations of circulating estrogen
or progesterone have not been found to be
22.5.1 Genetics increased.
Tumor initiators and yet undetermined
Leiomyomas are defined as monoclonal pro- genetic factors are involved in key somatic
liferations of benign smooth muscle [23]. mutations that facilitate the progression of a
Each monoclonal myoma may be associated normal myocyte into a leiomyocyte responsive
with various chromosomal translocations, to estrogen and progesterone. Estrogen recep-
duplications, and deletions [24]. Many, but tor (ER), progesterone receptor (PR), and
22
Uterine Leiomyomas
497 22
epidermal growth factor receptor (EGFR) are symptomatic myomas, studies have shown that
integral in the development of leiomyomas progesterone may play a much greater role as
[25]. Studies have shown that, in comparison a mediator of myoma growth than previously
with the normal myometrium, leiomyomas thought [31]. The antiprogestin RU486 (mife-
have an increased concentration of ER and pristone) has been shown to decrease the size
PR [26, 27]. of myomas [32, 33], and another study showed
Aromatase p450 is overexpressed by leio- that myomas in the secretory phase have
myomas [28, 29]. Therefore, in addition to increased mitotic counts compared to those in
circulating estrogen acting on the ER, the the proliferative phase [34].
local conversion of circulating androgens to Growth of leiomyomas is the result of
estrogens may be important in potentiating accelerated cellular proliferation that outpaces
the actions of estrogen in the leiomyocyte the inhibitory effect of apoptosis. Apoptosis
(. Fig. 22.2) [30]. has been shown to be inhibited in uterine
Traditionally, estrogen was thought to be leiomyomas. Progesterone has been shown
the primary hormonal mediator of myoma to increase the antiapoptotic protein, bcl-2
growth. Although progestins have been applied [35]. Therefore, the stimulation of myoma
.. Fig. 22.2 Sex steroid hormone action. Estrogen and response elements. Binding of estrogen and progesterone
progesterone exert action through binding of their spe- at a variety of genes has different effects in various cells.
cific receptors, which then bind to DNA at specific (Figure provided to the public by Fisher Scientific, Inc.)
for the treatment of excessive bleeding from expansion may be a function of the suppres-
498 G. M. Christman
sion of apoptosis by progesterone. It has been 22.6 Diagnostic Imaging

observed in vitro that the addition of proges- and Leiomyomas
terone to cultured leiomyoma cells increased
the expression of bcl-2 when compared to Imaging has become an integral aspect of the
controls [35]. Normal myometrium did not evaluation of leiomyomas. Myoma size and
express increased levels of bcl-2 in the presence location can be assessed to varying degrees,
of progesterone. depending on the imaging technology applied
The complex process of apoptosis involves to the evaluation process. Ultrasonography,
not only the bcl-2 family but also Fas/FasL hysterosalpingography, and magnetic reso-
and Rb-1 [36]. Martel et al. have described the nance imaging (MRI) are currently the modali-
various apoptotic pathways deficient in leio- ties most commonly utilized to image myomas.
myomas and potential corresponding targets
for therapy of myomas.
The synergistic interplay between estro- 22.6.1 Ultrasound
gen and progesterone signaling in the patho-
physiology of leiomyoma growth has been Traditional ultrasound is a cost-effective tech-
observed as well. The increase in progesterone nology for assessing uterine leiomyomas. The
receptors as a result of increased estrogen has transvaginal approach is more accurate than
been well established. abdominal ultrasound. However, abdominal
An in vitro study showed that progesterone ultrasound may be a useful adjunct to trans-
upregulates the expression of EGF and estro- vaginal ultrasound, if a large uterine size war-
gen also increases the expression of EGFR [25]. rants such an approach [22]. The presence of
myomas may be detected by ultrasound as
evidenced by uterine enlargement or a nod-
22.5.4 Pregnancy and Leiomyomas ular contour of the uterus. They may also
appear as discrete, focal masses within the
The influence of the pregnancy-induced endo- myometrium [37, 38]. Myomas can appear
crine milieu on a leiomyoma is complex. There hypoechoic or heterogeneous when compared
are many reports of dramatic leiomyoma with the appearance of the myometrium on
growth in pregnancy; however, all prospec- ultrasound, and they may be characterized by
tive studies have shown that most leiomyomas calcification and posterior shadowing [37, 39].
demonstrate little to no change in diameter Sagittal and axial views aid in providing infor-
from the first trimester to delivery. Essentially, mation on the location and size of myomas.
it is impossible to predict which myoma will Additional information regarding intra-
or may grow. The main potential complica- cavitary masses, such as submucous myo-
tions in pregnancy are pain and pregnancy mas, may be obtained by means of saline
wastage. Pain can be the result of myoma- infusion sonohysterography. This imaging
tous degeneration. This phenomenon can be technique consists of real-time transvagi-
the consequence of necrosis from decreased nal ultrasound during which sterile saline is
blood supply to a subserosal or pedunculated injected into the uterine cavity. The saline is
myoma. Usually there is localized pain and injected transcervical via a catheter of small
a cystic or heterogeneous pattern on ultra- caliber. As the uterine cavity is distended by
sound. Pregnancy wastage is often due to ret- the saline, intracavitary masses may be visual-
roplacental myomas that may cause abruptio ized as echogenic structures against the echo-
placenta, bleeding, and premature rupture of lucent background of the distending media
membranes. Lower uterine segment myomas [40]. Intramural myomas within close prox-
may increase the probability of Cesarean sec- imity of the endometrial cavity may also be
tion due to obstruction or malpresentation.
22
Uterine Leiomyomas
499 22
assessed by sonohysterography. In addition, 22.6.3 Magnetic Resonance
entities such as endometrial polyps and uter- Imaging
ine anomalies such as adhesions may also be
detected. Sonohysterography can be used not MRI is increasingly being utilized for imaging
only to diagnose submucous myomas but also leiomyomas. The location of myomas can be
to assess and plan potential surgical interven- accurately documented, more so with MRI
tion [41]. than with ultrasound. It is often used to evalu-
Three-dimensional ultrasound [42] and ate the precise location for surgical planning or
color Doppler ultrasound [43] are increasingly prior to uterine artery embolization mapping.
being applied to the evaluation of m yomas Disadvantages of MRI include increased
for imaging. Color Doppler ultrasound high- cost and inability to perform the procedure in
lights vascular flow, which is usually increased patients with morbid obesity or severe claus-
at the periphery of myomas and decreased trophobia. Traditionally, cost had been more
centrally [42, 43]. of a disadvantage; however, as the expense of
MRI decreases, it is more commonly employed
in clinical and presurgical evaluation. MRI is
22.6.2 Hysterosalpingography contraindicated in patients with pacemakers,
defibrillators, metallic foreign bodies, and in
Hysterosalpingography is a screening test for rare cases of allergy to gadolinium [45].
intracavitary anatomic defects and entails In T2-weighted images, the endometrial
retrograde injection of iodine contrast dye stripe is visualized as a central, high signal;
transcervically, via a catheter, into the uter- the junctional zone is a low signal; and the
ine cavity with radiologic assessment under myometrial areas are an intermediate signal
fluoroscopy. Hysterosalpingography should [46]. Leiomyomas are represented by variable
be performed in the follicular phase of the signal density. Most of the time, they appear
menstrual cycle in order to avoid interfer- as hypodense, well-demarcated masses; how-
ing with a potential pregnancy. Since the ever, increased cellularity [47] and degenera-
hysterosalpingography instillation medium tion may be seen as high signal intensity [46].
contains iodine, an iodine-allergic patient There is less distinction of the endome-
would require premedication with glucocor- trial lining, junctional zone, and myometrium
ticoids and antihistamines prior to the pro- in T1-weighted images. These components
cedure [44]. are usually homogeneous and, consequently,
Hysterosalpingography allows visualiza- obscured in appearance. Fatty or hemorrhagic
tion of submucous myomas, as the uterine degeneration may be represented by a high
cavity is distended by the contrast medium. signal intensity [48].
The size and contour of the uterine cav-
ity may be altered by submucous myomas.
Intramural myomas may enlarge the uter- 22.7 Treatment of Leiomyomas
ine cavity in a globular manner, and fundal
myomas may enlarge the space between the Treatment of leiomyomas has traditionally
cornua. Subserosal myomas are not noted been interventional. In patients with a men-
on hysterosalpingography; however, if large strual abnormality, an initial trial of birth con-
enough, they may be detected as a mass effect trol pills has often been used successfully, and
on the uterine cavity [37]. In cases where a the presence of a leiomyoma is not considered
submucous myoma must be differentiated a contraindication. If the oral contraceptive
from an endometrial polyp on hysterosalpin- failed, typically surgery was offered. However,
gography, hysteroscopy and sonohysterogra- newer medical therapies and options have
phy play roles as complementary, potentially changed this classic approach.
confirmatory adjuncts.
500 G. M. Christman
The important concept in the manage- subsequent decrease in FSH and LH secretion
ment of leiomyomas is that intervention is not [49]. This subsequently results in decreased
required in asymptomatic women. Reasons estrogen production.
no longer considered as acceptable primary GnRH agonists have been shown to
indications for surgical intervention include directly inhibit local aromatase p450 expres-
inability to palpate the adnexa or preemp- sion in leiomyoma cells [50], thereby presum-
tive intervention for asymptomatic fibroids ably resulting in decreased local conversion of
in order to circumvent a potentially more dif- circulating androgens to estrogens within the
ficult surgery in the future. Rapid growth of leiomyocyte. Several studies have concluded
a leiomyoma traditionally was considered a that GnRH agonists can directly induce
potential sign of malignancy. However, this apoptosis and also suppress the cellular pro-
sign in isolation of other manifestations is not liferation of myomas presumably via action
considered prognostic of a leiomyosarcoma. on peripheral GnRH receptors.
Surgery is indicated with a history of Maximum reduction of the mean uterine
pregnancy complications. Surgical treatment volume occurs within 3 months of GnRH
specifically for infertility is indicated if there agonist administration. The decrease in
is distortion of the uterine cavity. Surgical volume is usually in the range of 40–80%.
removal of uterine fibroids is sometimes con- However, after the discontinuation of GnRH
sidered in patients with longstanding infer- agonists, myomas will rapidly grow back to
tility and when no other identifiable cause their pretreatment size, usually in the span of
is found, although the latter indication is several months [51].
strongly debated. Advantages of GnRH agonists include
their use in the perimenopausal transition
with add-back therapy for the goal of avoid-
22.8 Medical Treatment ing hysterectomy. Additionally, laparoscopic
of Leiomyomas myomectomy may be made more feasible with
GnRH-agonist pretreatment, and GnRH ago-
Medical treatment of leiomyomas is indicated nists can also be beneficial in a patient who is
for the treatment of pain, abnormal bleeding to undergo hysterectomy to facilitate a vaginal
secondary to leiomyomas, or menstrual dys- approach rather than an abdominal incision.
function. Medical therapy of myomas has not In a randomized clinical trial comparing the
been developed for the management of infer- study group (patients receiving GnRH ago-
tility or pregnancy-related complications. nist and iron) to a control group (iron alone),
preoperative hematologic parameters were
improved [52].
Although decreased tumor bulk and a
22.8.1 Gonadotropin-Releasing decrease in associated symptoms are attained,
Hormone (GnRH) Agonists the potential for unwanted long- term side
and GnRH Antagonists effects exist; therefore, treatment with GnRH
agonist alone is recommended for no more
Gonadotropin-releasing hormone (GnRH) than 6 months. Common side effects include
agonists are an effective means of medically hot flashes, vaginal dryness, headache, and
treating patients with symptomatic leiomyo- mood swings. Most importantly, in terms
mas. After affecting an initial flare of LH and of bone health status, there is a recognized
FSH, GnRH agonists downregulate the hypo- decrease in bone mineral density during
thalamic- pituitary-ovarian axis via action on GnRH agonist therapy [53]. Although add-
pituitary receptors. The flare effect is due to back doses of steroid hormones can be used
an initial stimulation of FSH and LH owing with the aim of decreasing this bone loss, the
to the binding of pituitary receptors, after long-term use of GnRH agonists with add-
which these receptors are desensitized, with a
22
Uterine Leiomyomas
501 22
back is impractical and not recommended, examples include the use of tamoxifen and
especially in younger patients. raloxifene. Tamoxifen, a triphenylethylene,
GnRH antagonists are the most recent has antagonist activity in the breast and dis-
addition to the options for the treatment of plays a desirable agonist activity in the bone
uterine fibroids. Elagolix, an oral GnRH and the cardiovascular system as well as a
receptor antagonist, administered in com- mild agonist activity in endometrial tissue [54,
bination with hormonal add-back therapy 55]. Raloxifene, a benzothiophene, has a simi-
(estradiol 1 mg and norethindrone acetate lar profile and the added benefit of not acting
0.5 mg once daily; E2/NETA) was the first as an agonist in the endometrium [56].
FDA-approved (May 2020) oral treatment In animal models, SERMs have been
option for uterine fibroids and is indicated shown to be effective in decreasing the growth
for the management of Heavy Menstrual of myomas. Eker rats are a rat strain with a
Bleeding (HMB) associated with fibroids in tuberous sclerosis 2 (TS-2) gene defect that
premenopausal women for up to 24 months. can spontaneously develop leiomyomas. In
The Elaris Uterine Fibroids 1 and 2 studies studies, the administration of SERMs was
were identically designed as 6-month, phase 3 associated with the inhibition of leiomyoma
randomized trials that evaluated the efficacy formation in Eker rats [57, 58]. Guinea pigs
and safety of elagolix with add-back therapy require long-term exposure to estrogen in
in women with fibroid-associated heavy men- order for leiomyoma formation to occur. Two
strual bleeding. Findings from these studies groups of oophorectomized guinea pigs, an
indicated that patients taking elagolix with estrogen-only group and an estrogen plus ral-
add-back therapy experienced significantly oxifene group, were compared for myoma for-
less HMB associated with uterine fibroids mation. A decrease in the size of the induced
compared with patients taking placebo [49]. myomas was observed in the estrogen plus ral-
Elagolix is also highly effective in decreasing oxifene group [59].
fibroid volume; however, the effects of elagolix In humans, raloxifene appears effective in
on fibroid size are diminished with add-back decreasing the size of myomas in postmeno-
therapy. Another GnRH antagonist, relugo- pausal women [60], but beneficial effects were
lix, was approved by the FDA in May 2021 in not significant in premenopausal women [61].
combination with E2/NETA for the manage- A recent study has demonstrated that a com-
ment of HMB in premenopausal women. This bination of raloxifene and GnRH agonist is
approval followed the recent publication of more effective in reducing leiomyoma volume
two 24-week randomized, placebo-controlled, [62] and preventing a decrease in bone mineral
phase 3 clinical studies that demonstrated sig- density [63] than the use of GnRHa alone. A
nificantly higher reductions in fibroid-associ- Cochrane review of three studies showed no
ated HMB and pain, reduced uterine volume consistent evidence from a limited number
(suggesting decreased fibroid burden), and of studies that SERMs reduce fibroid size or
increased hemoglobin levels with relugolix improve clinical outcomes [64].
and E2/NETA compared with placebo.
22.8.3 Selective Progesterone

22.8.2 elective Estrogen Receptor
S Receptor Modulators
Modulators
This class of compounds has either agonist or
Selective estrogen receptor modulators antagonist effects on the progesterone recep-
(SERMs) are compounds that bind to the ER tor, based on tissue specificity [65]. Asoprisnil
and confer either an agonist or antagonist was one of the first selective progesterone
effect, depending on tissue specificity. They receptor modulators (SPRM) studied for
have been applied to the treatment and pre- the treatment of uterine fibroids. Along with
vention of estrogen-responsive breast cancer; its major metabolite, J912, Asoprisnil has
502 G. M. Christman
HO nor is FDA approval being sought for its use

N in treating symptomatic uterine fibroids.
H OCH3
CH2-O-CH3
22.8.4 Aromatase Inhibitors
H
Aromatase inhibitors (AI) were originally
used for the treatment of breast cancer, and
this class of medications is FDA- approved
H for this purpose. In recent years, the use of AI
O has expanded within the field of reproductive
medicine, and its application in the poten-
.. Fig. 22.3 Chemical structure of asoprisnil tial treatment of uterine fibroids has been
investigated in several studies. The rationale
high affinity for the PR, moderately binds behind AI is due to the finding that aroma-
growth hormone receptor, and has a very tase p450 enzyme concentrations are elevated
low binding potential for androgen recep- at the local level in leiomyoma tissues [28,
tors (. Fig. 22.3). Asoprisnil has virtually 29]. Interestingly, aromatase expression has
no affinity for ER or mineralocorticoid recep- been shown to be highest among African-
tors [66]. It differs from the long-term effect American women (83-fold) when compared
of progesterone on the endometrium in that to that of Caucasian (38-fold) and Japanese
amenorrhea is rapidly established without women (33- fold) [70]; this higher expres-
breakthrough bleeding [67]. sion may be one underlying mechanism that
The oral SPRM ulipristal acetate suc- may explain the higher prevalence of uterine
cessfully completed clinical trials and was fibroids among African-American women
approved for use in the European Union and when compared to women of other ethnic
Canada. It never received FDA approval for backgrounds.
use in the United States [68]. A randomized In a prospective study by Gurates et al., a
trial of ulipristal acetate vs. placebo for fibroid 3-month course of the AI letrozole at 5 mg per
treatment before surgery demonstrated that day was found to significantly decrease uter-
treatment for 13 weeks effectively controlled ine and leiomyoma volume without changes
excessive bleeding and reduced the size of in lumbar spine BMD or biochemical markers
fibroids [69]. Selective progesterone receptor of bone metabolism; in addition, heavy men-
modulators were initially considered promis- strual bleeding associated with leiomyoma
ing treatment options in effectively reducing was improved [71]. Furthermore, an RCT that
fibroid volume, treating symptoms of heavy compared the effects of AI treatment with
bleeding, and delayed surgical intervention. GnRHa on myoma volume and hormonal
However, these therapies have recently been status in premenopausal women with leio-
put on hold because of safety concerns, spe- myomas showed promise as well. Treatment
cifically, the rare occurrence of liver dysfunc- duration for both groups was 12 weeks.
tion leading to liver failure. In several clinical Leiomyoma volume was significantly reduced
trials, ulipristal acetate demonstrated signifi- in the AI and GnRHa groups without a dif-
cant reductions in fibroid volume and heavy ference between groups. The AI group did not
menstrual bleeding along with improvements have a significant change in hormonal milieu
in hemoglobin levels. However, ulipristal ace- from baseline in contrast to the GnRHa
tate was withdrawn in Canada and Europe in group. The authors concluded that uterine
2020 after cases of drug-induced liver toxicity leiomyomata may be successfully managed
were reported. In the United States, ulipristal by the use of AI, which may be most useful
acetate is no longer under clinical evaluation in the setting of pretreatment for surgery.
Advantages of AI over GnRHa may include
22
Uterine Leiomyomas
503 22
rapid onset of action as well as the avoidance skill are factors that may determine the feasi-
of the GnRHa flare [72]. bility of a vaginal hysterectomy approach.
Laparoscopy-assisted vaginal hysterec-
tomy, total laparoscopic hysterectomy, and
22.9 Surgical Therapy laparoscopic supracervical hysterectomy are
of Leiomyomas minimally invasive surgical methods that are
associated with decreased postoperative pain
Surgical treatment is the mainstream therapy and recovery time in comparison to vagi-
for leiomyomas. Hysterectomy represents nal and abdominal hysterectomy [76]. These
the only definitive curative therapy; however, surgical modalities may incur increased hos-
myomectomy, endometrial ablation, and high- pital costs in terms of equipment and operat-
intensity focused ultrasound are alternative ing room time, but they have the recognized
therapeutic procedures. Indications for surgi- advantages listed above. In addition, these
cal intervention include failure to respond to options provide the ability to assess the pelvis
medical treatment, worsening vaginal bleed- if the patient also complains of pelvic pain.
ing, suspicion of malignancy, or treatment of
recurrent pregnancy loss. In postmenopausal
women with an enlarging pelvic mass and 22.9.2 Myomectomy
abnormal bleeding, surgery should be strongly
considered. In this population, the incidence Hysterectomy has long been considered the
of a leiomyosarcoma is still very uncommon definitive treatment for symptomatic uterine
but higher than the incidence found in the leiomyomas. Yet as more and more women
premenopausal population. The incidence of delay childbearing, the incidence of uterine leio-
leiomyosarcoma in patients undergoing sur- myomas among patients suffering with infer-
gery for uterine leiomyomas is extremely rare tility increases, and hysterectomy becomes an
(1 case per 2000 procedures) with more than unacceptable management option. Therefore,
80% of these patients found in patients who abdominal, laparoscopic, and hysteroscopic
are menopausal [73]. myomectomies have become increasingly com-
mon treatment modalities for women with leio-
myomas and infertility.
22.9.1 Hysterectomy Myomectomy is the surgery of choice for
treating women with symptomatic myomas
Hysterectomy has been described as the defini- in those who desire to preserve fertility or to
tive management for symptomatic leiomyo- otherwise keep their uteri. It is most useful for
mata. When employed, it is highly effective for subserosal, especially pedunculated subsero-
the carefully selected patient with symptomatic sal, myomas as well as intramural leiomyomas.
leiomyomata who does not desire future fer- Myomectomy entails the surgical removal of
tility. Traditionally, the abdominal route was myomas by enucleation. It is preferable to use
chosen approximately 75% of the time based as few incisions as possible to remove myomas
on data from the late 1980s and early 1990s from the uterus, in order to minimize adhe-
[74]. Hysterectomies are increasingly being sion formation as well as to minimize any
performed for symptomatic leiomyomata compromise of the myometrial integrity. The
using laparoscopy and/or robotic assistance. surgeon must be diligent regarding the ori-
Vaginal hysterectomy is associated with a entation of the uterus, especially during the
lower complication rate and decreased need repair, in order to preserve the integrity of the
for blood transfusion. Another advantage of endometrial cavity. Several techniques have
vaginal hysterectomy is the association with been described to decrease blood loss with an
shorter operating times [75]. Myoma size and abdominal myomectomy and include the use
location, total uterine size, and the surgeon’s of tourniquets around the lower segment of
504 G. M. Christman
the uterus to occlude the uterine arteries and was noted in patients that initially underwent
the use of dilute vasopressin. a laparoscopic approach to their myomec-
Methods employed to minimize postop- tomy. Similar observations were made in two
erative adhesion formation include the use of other studies [80, 81].
permanent or absorbable barriers and good Disadvantages of laparoscopic myomec-
surgical technique minimizing trauma to the tomy include the lack of opportunity to pal-
tissues, use of nonreactive suture material, pate the uterus intraoperatively, resulting in
and the avoidance of tissue desiccation or the potential for a higher rate of subsequent
aggressive cautery. Due to the potential risk of recurrence of myomas [82, 83], which is sup-
uterine rupture, a trial of labor after myomec- ported by several studies and refuted by oth-
tomy is not recommended by the American ers [84].
College of Obstetricians and Gynecologists
(ACOG) [77].
22.9.4 Robotic-Assisted
Myomectomy
22.9.3 Laparoscopic Myomectomy
The advantages of robotic-assisted myo-
Laparoscopic myomectomy offers many mectomy (RAM) compared with conven-
advantages for this minimally invasive surgery tional laparoscopic myomectomy include
technique to remove myomas. This procedure, the potential for greater technical feasibility
however, requires appropriate training and of removing uterine fibroids via a minimally
advanced endoscopic skills from the surgeon. invasive surgical approach [85] due to three-
It is most useful in cases in which myomas are dimensional vision, ergonomic considerations,
easily visualized and readily accessible. seven degrees of freedom in terms of wrist
Several studies have shown advantages of movement with distal aspect of the robotic
the laparoscopic approach to myomectomy. arms, and no fulcrum effect [86]. RAM has
Mars et al. randomized 20 patients under- been associated with decreased intraopera-
going myomectomy to laparoscopy and 20 tive blood loss as well as a shorter length of
patients to laparotomy. The laparoscopy hospital stay as compared with laparoscopic
group had lower postoperative pain as well as and abdominal myomectomy [86]. A large,
a greater number of patients that were anal- retrospective, multicenter study showed that
gesia-free on postoperative day 2, discharged women who underwent RAM by experienced
home by postoperative day 3, and fully recov- robotic surgeons had similar pregnancy out-
ered on postoperative day 15 [78]. Among a comes as those who underwent laparoscopic
group of 131 patients randomly assigned to myomectomy; in addition, 11% were found to
myomectomy via laparoscopy or laparotomy, have pelvic adhesions at subsequent Cesarean
Seracchioli et al. found that laparoscopic section [87].
myomectomy is associated with lower intra-
operative blood loss and shorter postoperative
length of stay in the hospital. Moreover, no 22.10 Technical Considerations
significant difference in subsequent fecund-
ability, spontaneous miscarriage rate, preterm Laparoscopic myomectomy and RAM are
delivery rate, and Cesarean section rate was usually performed with the standard three to
found between the groups. A lower incidence four ports. Dilute vasopressin, although not
of postoperative febrile morbidity was yet approved by the FDA for this indication, is
another advantage found in this study [73]. diluted 20 units in 100 mL of normal saline and
Adhesion formation was evaluated in a injected into the myoma. An incision is then
retrospective study of 28 patients who under- made into the myoma and enucleated bluntly
went laparoscopy or laparotomy for myomec- (. Fig. 22.4). After enucleation, the defect
tomy followed by a second-look laparoscopy (. Fig. 22.5) is closed in two to three layers,
[79]. A lower incidence of adhesion formation typically a deep layer and then a seromuscular
22
Uterine Leiomyomas
505 22
.. Fig. 22.4 Dissection of the myoma bed is usually .. Fig. 22.6 The myometrial defect is tightly closed.
accomplished bluntly, as in open cases. (Picture pro- (Picture provided by Dr. T. Falcone)
vided by Dr. T. Falcone)
utilized as a primary treatment of leiomyomas

since 1995 [88]. It has been associated with
positive clinical outcomes and a high rate of
patient satisfaction. Success rates of over 90%
have been reported [89, 90]. Decreases in the
size of the uterus and dominant leiomyomas
of 45% have been reported [39]. ACOG has
found that UAE in properly selected patients
is safe and effective [91].
Pre-embolization imaging with MRI aids
in precisely locating the position of leiomyo-
mas prior to the procedure. Embolization of
the uterine arteries with polyvinyl alcohol or
tris-acryl gelatin microspheres involves femo-
.. Fig. 22.5 A large myometrial defect is left behind.
ral artery catheterization under fluoroscopic
This requires closure with two to three layers of delayed
absorbable sutures. (Picture provided by Dr. T. Fal- guidance. Typically, uterine fibroid emboliza-
cone) tion is performed with the patient under mild
conscious sedation [45].
Post-embolization follow-up consists of
layer. Intra- and extracorporeal knot tying are clinical evaluation as well as a follow-up MRI
acceptable. This step is the most critical part in order to assess and monitor the final result-
of a laparoscopic myomectomy, and the defect ing volume of leiomyomas and the uterus. The
should be closed tightly (. Fig. 22.6). degeneration and devascularization of leiomy-
omas can be visualized on MRI as increased
signals on T1-weighted and decreased signals
22.11 Uterine Artery/Leiomyoma on T2-weighted images [92–94]. After uterine
Embolization fibroid embolization, the size of leiomyomas
can continue to decrease for 1 year or more.
Uterine artery embolization (UAE), also The high rate of patient satisfaction [89] is
referred to as uterine fibroid embolization due to the improvements in menorrhagia and
(UFE), is a minimally invasive alternative to pressure symptoms as well as pain relief expe-
hysterectomy and myomectomy that has been rienced by a high percentage of women under-
applied to the treatment of symptomatic leio- going uterine fibroid embolization.
myomas. UAE was initially developed for the A systematic review and meta-analysis of
control of pelvic hemorrhage and has been 54 studies with a total of over 8000 patients
506 G. M. Christman
examined the complication rates and effec- uterine fibroid embolization compared with
tiveness of UAE in the treatment of uterine the 1/1000 rate from hysterectomy [107].
fibroids. There were no reported deaths, and Post-embolization syndrome is relatively
rate of significant complications was 2.9%. common occurrence and consists of nausea,
During a 0.25- to 2-year follow-up, clinical vomiting, pain, and a temporary increased
symptomatic improvement ranged from 78% WBC count following the procedure. This syn-
to 90% [95]. A Cochrane review of six RCTs drome affects most patients to some extent in
that totaled 732 women found moderately the first 48 h after the procedure but is severe
good evidence that patient satisfaction rates at in approximately 15% of those who undergo
2 and 5 years were similar between UAE and uterine fibroid embolization [108].
either hysterectomy or myomectomy. UAE
was also found to be associated with a shorter
length of hospital stay and a quicker return 22.12 MRI-Guided Focused
to daily activities. However, UAE is associated Ultrasound Therapy
with higher rates of minor complications and
future surgical reintervention [96]. Over the last decade, high-intensity focused
It is important to note that successful ultrasound surgery (HIFU), with either MRI
pregnancies have occurred following this pro- or US for guidance, has been used for treating
cedure [97, 98]. There is risk of inducing pre- symptomatic uterine fibroids in a noninvasive
mature ovarian insufficiency in older women. manner. The therapeutic HIFU component
Several studies have shown an increased focuses ultrasound energy with resulting ther-
risk of intrauterine growth restriction and mogenesis in order to ablate leiomyoma tissue
placentation problems in pregnancies fol- in a precise and controlled fashion. By placing
lowing uterine fibroid embolization. A sys- an ultrasound transducer on the abdomen of a
tematic review showed that after UAE, there patient and focusing the ultrasound energy at a
were higher rates of miscarriage, Cesarean specific, controllable depth and position, leio-
section, and postpartum hemorrhage as myoma tissue is destroyed within the focal zone.
compared with controls [99]. There are cur- The therapeutic ultrasound effect is often mon-
rently no studies that establish the successful itored by MRI, which precisely records the tem-
pregnancy rate after UAE [100]. Although perature elevation from the heat generated over
there are confounding variables in the exist- time. Once the temperature reaches 57 °C for
ing studies and a Cochrane review showed 1 s, tissue is rapidly destroyed within the focal
very low evidence suggesting better fertil- zone. Tissue within 2–3 mm of the focal zone is
ity outcomes with myomectomy over UAE unaffected owing to the very precise demarca-
[97], short-term reproductive outcomes favor tion between normal and destroyed tissues.
myomectomy over UAE [101]; for women MRI-guided focused ultrasound surgery
seeking pregnancy, myomectomy is favored (MRgFUS or MRgHIFU) is considered supe-
over UAE. rior to US guidance due to increased soft tissue
Complications of uterine fibroid emboli- resolution as well as capability of tissue tem-
zation include angiography-related problems perature mapping; in addition, ultrasound-
[45], allergic reactions [102], perforation of guided HIFU is not FDA-approved, whereas
the uterus [103], and infection [94, 102]. If MRgFUS as a therapy for leiomyomata
the collateral blood supply to the ovary is received FDA approval in October 2004
embolized, then infertility, amenorrhea, and [109]. The ExAblate System (ExAblate 2000,
premature menopause are potential risks [90, ExAblate 2010; InSightex, Haifa, Israel) was
104]. Sciatic nerve injury leading to buttock the first medical device approved for the treat-
claudication is a recognized potential compli- ment of leiomyomas as its primary indica-
cation of uterine fibroid embolization [103]. tion. General patient selection criteria include
Deep venous thrombosis and pulmonary leiomyomas between 4 and 10 cm, maximum
embolus are rare risks, as is death [103, 105, depth of subcutaneous tissue to the leiomy-
106], which has a reported 3/10,000 rate with oma <12 cm, completion of childbearing, pre-
22
Uterine Leiomyomas
507 22
menopausal status, and leiomyomas that can a less invasive approach. Cryomyolysis involves
be clearly visualized on MRI. Based on results placement of a 2-cm diameter cryo-probe,
of a 6-month follow-up study, the mean leio- directly into a uterine leiomyoma. After the
myoma reduction in volume after HIFU cryo-probes are advanced and placed into posi-
was 13.5 cm3, and the mean volume of non- tion, the probes are then cooled by liquid nitro-
perfused tissue was 51.2 cm3. Furthermore, gen instillation or by differential gas exchange,
79.3% of patients reported a greater than reducing the local temperature within the leio-
10-point reduction in symptom scores and myoma to less than −90 °C, resulting in a 3.5-
improvement in quality-of-life measures on to 5-cm ice ball, ultimately resulting in tissue
the questionnaire used in the study [110]. necrosis. Because the temperature at the edge
Adverse events included minor skin burns in of the ice ball is 0 °C and not destructive to
4% of patients, worsening menorrhagia in 4% surrounding tissue, the imaging of the ice ball
of patients, hospitalization for nausea in only can predict the limits of targeted tissue [115].
1% of patients, and nontargeted sonication of Laparoscopic cryomyolysis for women with
the uterine serosa in 1% of patients [110]. leiomyomas as well as a combination of abnor-
Two other studies have assessed longer- mal uterine bleeding, pelvic pain/pressure, and/
term clinical outcomes. In a 24-month fol- or urinary frequency was shown to be effective
low-up study, improvement in symptoms in a study of 20 patients [116].
and moderate volume reductions in types MRI-guided cryomyolysis was devised as
of uterine fibroids with lower MRI image a less invasive and more precise approach.
intensity than the myometrium was observed MRI can be employed to accurately visualize
after MRgFUS [111]. In a 12-month study of ice-ball formation, which eventually encom-
patients who underwent MRgFUS, relief of passes the leiomyomas appearing black due to
symptoms was reported in 86%, 93%, and 88% the slow or absent hydrogen ion spins of water
of patients at 3-, 6-, and 12-month follow-up, molecules in the ice.
respectively [112]. Reintervention rates are A report of MRI-guided cryomyoly-
low and comparable to those with UAE [112]. sis used to treat leiomyomas in 10 patients
The effect that MRgFUS may have on showed MRI evidence of marked uterine
fertility is not clear; however, there have volume reduction between 48 and 334 days
been reports of successful pregnancies after after the procedure. The mean volume reduc-
MRgFUS. A published series of all pregnan- tion was 65%. All patients reported improve-
cies after MRgFUS reported to the manufac- ment of symptoms, whether they were due
turer and the FDA, as part of post-approval to bleeding and/or pressure symptoms. One
device monitoring, showed that normal preg- patient had uterine bleeding for 2 months
nancy outcomes and deliveries are possible. post-procedure, with subsequent sponta-
The series reported a 41% live birth rate, 20% neous resolution. Another patient had a
ongoing pregnancy rate, 11% rate of elective residual submucosal leiomyoma that had to
termination, and 28% spontaneous abortion be resected hysteroscopically at a later date.
rate after MRgFUS for the treatment of uter- Complications included a patient with lacera-
ine fibroids [113]. Furthermore, in a retrospec- tion of a serosal vessel covering a leiomyoma,
tive study, seven women who unintentionally which required a laparotomy and open myo-
became pregnant after ultrasound-guided mectomy for repair. Another complication
HIFU continued their pregnancies without was peroneal nerve involvement and a mild
complications [114]. foot drop that resolved over several months.
Nausea and mild abdominal discomfort that
was relieved by NSAIDs were reported as
22.13 Cryomyolysis minor complications [117].
Another study of 14 women evaluated
Cryomyolysis of uterine leiomyomas has been the efficacy of 2 months of pretreatment
performed by laparoscopy, and in recent years, with GnRH agonist prior to laparoscopically
MRI-guided cryomyolysis has been devised as directed cryomyolysis [118]. The GnRH ago-
508 G. M. Christman
nist was discontinued immediately prior to the D. Early age of menarche

procedure. Four months after cryomyolysis, E. African-American ethnicity
the follow-up MRI showed a mean volume
decrease of 10% among the frozen leiomyo- ??2. Advantages of laparoscopic or robotic
mas, whereas other uterine tissue returned to assisted myomectomy include all of the
their size prior to GnRH agonist treatment. following except:
Studies have shown that cryomyolysis can A. Greater number of patients that
be an effective, minimally invasive means to are analgesia-free on postoperative
treat symptomatic uterine fibroids [118, 119]. day 2, discharged home by postop-
Myoma volume was reduced by 50%, along erative day 3, and fully recovered
with a corresponding reduction in symptoms, by postoperative day 15
6 months after the procedure [93]. Follow-up B. Lower intraoperative blood loss
data have shown that at 12 months, further and shorter postoperative length
myoma shrinkage up to 62% from baseline of stay in the hospital
occurred and heavy menstrual bleeding was C. A lower incidence of adhesion for-
reduced [120]. Because long-term effects of mation
cryomyolysis on future fertility are limited to D. Lack of opportunity to palpate the
only a very small series of nine women where uterus intraoperatively, resulting in
fertility remained preserved [119], the poten- the potential for a higher rate of
tial for post procedure adhesions and sub- subsequent recurrence of myomas
sequent compromised fertility compared to E. Lower incidence of postoperative
other available options suggest that the tech- febrile morbidity
nique of cryomyolysis should remain experi-
mental at the present time. ??3. Medications useful in the medical man-
agement of uterine fibroids include all
of the following except:
22.14 aparoscopic Uterine Artery
L A. Aromatase inhibitors
B. Combined oral contraceptive pills
Ligation
C. Selective estrogen receptor
modulators in premenopausal
Laparoscopic uterine artery ligation is yet
women
another described option for women who
D. GnRH agonists
opt to preserve their uteri. A study compar-
E. GnRH antagonists
ing this technique to uterine artery emboli-
zation suggests that the uterine volume was
slightly reduced at 3 months and stabilized at
6 months, with an average volume reduction of 22.16 Answers
58.5% [120]. The authors concluded that both
laparoscopic uterine artery ligation and UAE vv1. B
are reasonable alternatives to hysterectomy.
vv2. D
vv3. C
??1.
Factors that can increase the risk of
developing symptomatic fibroids include References
all of the following except:
1. Cramer SF, Patel A. The frequency of uterine leio-
A. Nulliparity myomas. Am J Clin Pathol. 1990;94:435.
B. Cigarette smoking 2. Lepine LA, Hillis SD, Marchbanks PA, Koonin
C. Increased body mass index LM, Morrow B, Kieke BA, et al. Hysterectomy sur-
22
Uterine Leiomyomas
509 22
veillance—United States, 1980–1993. MMWR intracytoplasmic sperm injection. Arch Gynecol
CDC Surveill Summ. 1997;46:1–15. Obstet. 2002;266:30–3.
3. Stovall DW. Clinical symptomatology of uter- 18. Marshall LM, Spiegelman D, Barbieri RL, Gold-
ine leiomyomas. Clin Obstet Gynecol. 2001;44: man MB, Manson JE, Colditz GA, et al. Varia-
364–71. tion in the incidence of uterine leiomyoma among
4. Donnez J, Jadoul P. What are the implications premenopausal women by age and race. Obstet
of myomas on fertility? A need for debate? Hum Gynecol. 1997;90:967–73.
Reprod. 2002;17:1424–30. 19. Kjerulff HK, Langenberg P, Seidman JD, Stolley
5. Bulletti C, De Zieger D, Polli V, Flamigni C. The PD, Guzinski GM, Uterine leiomyomas. Racial
role of leiomyomas in infertility. J Am Assoc differences in severity, symptoms and age at diag-
Gynecol Laparosc. 1999;6:441. nosis. J Reprod Med. 1996;41:483.
6. Vercellini P, Maddalena S, De Giorgi O, Pesole 20. Ross RL, Pike MC, Vessey MP, Bull D, Yeates D,
A, Ferrari L, Crosignani PG. Determinants of Casagrande JT. Risk factors for uterine fibroids:
reproductive outcome after abdominal myomec- reduced risk associated with oral contraceptives.
tomy for infertility. Fertil Steril. 1999;72:109–14. Br Med J (Clin Res Ed). 1986;293:359–62.
7. Dubuisson J-B, Chapron C, Chalet X, Gregora- 21. Treloar SA, Martin NG, Dennerstein L, Raphael
kis SS. Infertility after laparoscopic myomectomy B, Heath AC. Pathways to hysterectomy: insights
of large intramural myomas: preliminary results. from longitudinal twin research. Am J Obstet
Hum Reprod. 1996;11:518–22. Gynecol. 1992;167:82.
8. Coutinho EM, Maia HS. The contractile response 22. Leibman AJ, Kruse B, McSweeney MB. Trans-
of the human uterus, fallopian tubes and ovary vaginal sonography: comparison with transab-
to prostaglandins in vivo. Fertil Steril. 1971;22: dominal sonography in the diagnosis of pelvic
539–43. masses. AJR Am J Roentgenol. 1988;151:89–92.
9. Deligdish L, Loewenthal M. Endometrial 23. Stewart EA. Uterine fibroids. Lancet. 2001;
changes associated with myomata of the uterus. 357:293–8.
J Clin Pathol. 1970;23:676–9. 24. Catherino W, Salama A, Potlog-Nahari C, Lep-
10. Farrer-Brown G, Beilby JO, Tarbit MH. Venous pert P, Tsibris J, Segars J. Gene expression stud-
changes in the endometrium of myomatous uteri. ies in leiomyomata: new directions for research.
Obstet Gynecol. 1971;38:743–6. Semin Reprod Med. 2004;22(2):83–9.
11. Ng EHY, Ho PC. Doppler ultrasound exami- 25. Shimomura Y, Matsuo H, Samoto T, Maruo
nation of uterine arteries on the day of oocyte T. Upregulation by progesterone of proliferating
retrieval in patients with uterine fibroids under- cell nuclear antigen and epidermal growth factor
going IVF. Hum Reprod. 2002;17:765–70. expression in human uterine leiomyoma. J Clin
12. Katz VL, Dotters DJ, Droegemueller W. Com- Endocrinol Metab. 1998;83:2192–8.
plications of uterine leiomyomas in pregnancy. 26. Brandon DD, Betheq CL, Strawn EY, Novy MJ,
Obstet Gynecol. 1989;73:593–6. Burry KA, Harrington MS, et al. Progesterone
13. Eldar-Geva T, Meagher S, Healy DL, MacLach- receptor messenger ribonucleic acid and protein
lan V, Breheny S, Wood C. Effects of intramural, are over expressed in human uterine leiomyomas.
subserosal and submucosal uterine fibroids on Am J Obstet Gynecol. 1993;169:78–85.
the outcome of assisted reproduction technology 27. Brandon DD, Erickson TE, Keenan EJ, Strawn
treatment. Fertil Steril. 1988;70:687–91. EY, Novy MJ, Burry KA, et al. Estrogen receptor
14. Stovall DW, Parrish SB, Van Voorhis BJ, Hahn gene expression in human uterine leiomyomata. J
SJ, Sparks AE, Syrop CH. Uterine leiomyo- Clin Endocrinol Metab. 1995;80:1876–81.
mas reduce the efficacy of assisted reproduction 28. Folkerd EJ, Newton CJ, Davidson K, Ander-
cycles: results of a matched follow-up study. Hum son MC, James VH. Aromatase activity in uter-
Reprod. 1998;13:192–7. ine leiomyomata. J Steroid Biochem. 1984;20:
15. Hart R, Khalaf Y, Yeong CT, Seed P, Taylor 1195–200.
A, Braude P. A prospective controlled study of 29. Bulun SE, Simpson ER, Word RA. Expression of
the effect of intramural uterine fibroids on the the CYP19 gene and its product aromatase cyto-
outcome of assisted conception. Hum Reprod. chrome p450 in human uterine leiomyoma tissues
2001;16(11):2411–7. and cells in culture. J Clin Endocrinol Metab.
16. Oliveira FG, Abdelmassih VG, Diamond MP, 1994;78:736–43.
Dozortsev D, Melo NR, Abdelmassih R. Impact 30. Shozu M, Sumitani H, Segawa T, Yang HJ,
of subserosal and intramural uterine fibroids that Murakami K, Kasai T, et al. Over expression
do not distort the endometrial cavity on the out- of aromatase p450 in leiomyoma tissue is driven
come of in vitro fertilization-intracytoplasmic primarily through promoter 14 of the aromatase
sperm injection. Fertil Steril. 2004;81(3):582–7. p450 gene (CYP19). J Clin Endocrinol Metab.
17. Yarali H, Bukulmez O. The effect of intramural 2002;87:2540–8.
and subserous uterine fibroids on implantation 31. Rein MS, Barbieri RL, Friedman AJ. Progester-
and clinical pregnancy rates in patients having one: a critical role in the pathogenesis of uterine
510 G. M. Christman
myomas. Am J Obstet Gynecol. 1995;172(1 Pt 48. Okizuka H, Sagimura K, Takemori M, Obayashi

1):14–8. C, Kitao M, Ishida T. MR detection of degen-
32. Kettel LM, Murphy A, Morales AJ, Yen SS. Clin- erating uterine leiomyomas. J Comput Assist
ical efficacy of the antiprogesterone RU486 in the Tomogr. 1993;17:760–6.
treatment of endometriosis and uterine fibroids. 49. Schlaff WD, Ackerman RT, Al-Hendy A, Archer
Hum Reprod. 1994;9:116–20. DF, Barnhart KT, Bradley LD, Carr BR, Fein-
33. Murphy AA, Kettel L, Morales AJ, Roberts VJ, berg EC, Hurtado SM, Kim J, Liu R, Mabey
Yen SS. Regression of uterine leiomyomata in RG Jr, Owens CD, Poindexter A, Puscheck EE,
response to the antiprogesterone RU486. J Clin Rodriguez-Ginorio H, Simon JA, Soliman AM,
Endocrinol Metab. 1993;76:513–7. Stewart EA, Watts NB, Muneyyirci-Delale
34. Kawaguchi K, Fujii S, Konishi I, Nanbu Y, Non- ON. Elagolix for heavy menstrual bleeding in
ogaki H, Mori T. Mitotic activity in uterine leio- women with uterine fibroids. N Engl J Med.
myomas during the menstrual cycle. Am J Obstet 2020;382(4):328–40.
Gynecol. 1989;160:637–41. 50. Shozu M, Sumitani H, Segawa T, Yang HJ,
35. Matsuo H, Maruo T, Samoto T. Increased expres- Murakami K, Inoue M. Inhibition of in situ
sion of Bcl-2 protein in human uterine leiomy- expression of aromatase p450 in leiomyoma of
oma and its upregulation by progesterone. J Clin the uterus by leuprolide acetate. J Clin Endocri-
Endocrinol Metab. 1997;82:293–9. nol Metab. 2001;86:5405–11.
36. Martel KM, Ko AC, Christman GM, Stribley 51. De Leo V, Morgante G, La Marca A, Musacchio
JM. Apoptosis in human uterine leiomyomas. MC, Sorace M, Cavicchioli C, et al. A benefit-risk
Semin Reprod Med. 2004;22:91–103. assessment of medical treatment for uterine leio-
37. Karasick S, Lev-Toaff AS, Toaff ME. Imaging myomas. Drug Saf. 2002;25(11):759–79.
of uterine leiomyomas. AJR Am J Roentgenol. 52. Stovall TG, Muneyyirici Delale O, Summitt RL,
1992;158:799–805. Scialli AR. GnRH agonist and iron versus pla-
38. Zawin M, McCarthy S, Scoutt LM, Comite cebo and iron in the anemic patient before surgery
F. High-field MRI and US evaluation of the for leiomyomas: a randomized controlled trial.
pelvis in women with leiomyomas. Magn Reson Leuprolide Acetate Study Group. Obstet Gyne-
Imaging. 1990;8:371–6. col. 1995;86:65–71.
39. Weintraub JL, Romano WJ, Kirsch MJ, Sampale- 53. Dawood M, Lewis V, Ramos J. Cortical and
anu DM, Madrazo BL. Uterine artery emboliza- trabecular bone mineral content in women with
tion: sonographic imaging findings. J Ultrasound endometriosis: effect of gonadotropin- releas-
Med. 2002;21:633–7. ing hormone agonist and danazol. Fertil Steril.
40. ACOG Technology Assessment No. 5; Sonohys- 1989;52:21–6.
terography. Obstet Gynecol. 2008;112:1467–9. 54. Gottardis MM, Robinson SP, Satyaswaroop PG,
41. Wamsteker KEM, de Kruif JH. Transcervical Jordan VC. Contrasting actions of tamoxifen on
hysteroscopic resection of submucous fibroids for endometrial and breast tumor growth in the athy-
abnormal uterine bleeding: results regarding the mic mouse. Cancer Res. 1988;48:812–5.
degree of intramural extension. Obstet Gynecol. 55. Guetta V, Lush RM, Figg WD, Waclawiw MA,
1993;82(5):736–40. Cannon RO III. Effects of the antiestrogen
42. Jurkovic D. Three-dimensional ultrasound in tamoxifen on low-density lipoprotein concentra-
gynecology: a critical evaluation. Ultrasound tions and oxidation in postmenopausal women.
Obstet Gynecol. 2002;19(2):109–17. Am J Cardiol. 2005;76:1072–3.
43. Fleischer AC. Color Doppler sonography of 56. Delmas PD, Bjarnason NH, Mitlak BH, Ravoux
uterine disorders. Ultrasound Q. 2003;19(4): AC, Shah AS, Huster WJ, et al. Effects of ral-
179–83. oxifene on bone mineral density, serum choles-
44. Baramki TA. Hysterosalpingography. Fertil terol concentrations, and uterine endometrium
Steril. 2005;83(6):1595–606. in postmenopausal women. N Engl J Med.
45. Mueller GC, Gemmete JJ, Carlos RC. Diagnos- 1997;337:1641–7.
tic imaging and vascular embolization for uter- 57. Fuchs-Young R, Howe S, Miles R, Walker
ine leiomyomas. Semin Reprod Med. 2004;22(2): C. Inhibition of estrogen-stimulated growth of
131–42. uterine leiomyomas by selective estrogen receptor
46. Lee JK, Gersell DJ, Balfe DM, Worthington modulators. Mol Carcinog. 1996;17:151–9.
JL, Picus D, Gapp G. The uterus: in vitro MR- 58. Walker CL, Burroughs K, Davis B, Sowell K,
anatomic correlation of normal and abnormal Everitt JI, Fuchs-Young R. Preclinical evidence
specimens. Radiology. 1985;157:175–9. for therapeutic efficacy of selective estrogen
47. Yamashita Y, Torashima M, Takahashi M, receptor modulators for uterine leiomyoma. J Soc
Tanaka N, Katabuchi H, Miyazaki K, et al. Gynecol Investig. 2000;7:249–56.
Hyperintense uterine leiomyoma at T2-weighted 59. Porter KB, Tsibris JC, Porter GW, Fuchs-Young
MR imaging: differentiation with dynamic R, Nicosia SV, O’Brien WF, et al. Effects of ral-
enhanced MR imaging and clinical implications. oxifene in a guinea pig model for leiomyomas.
Radiology. 1993;189:721–5. Am J Obstet Gynecol. 1998;179:1283–7.
22
Uterine Leiomyomas
511 22
60. Palomba S, Sammartino A, Di Carlo C, Affinito 72. Parsanezhad ME, Azmoon M, Alborzi S, Rajaeef-
P, Zullo F, Nappi C. Effects of raloxifene treat- ard A, Zarei A, Kazerooni T, et al. A randomized,
ment on uterine leiomyomas in post-menopausal controlled clinical trial comparing the effects of
women. Fertil Steril. 2001;76:38–43. aromatase inhibitor (letrozole) and gonadotro-
61. Palomba S, Orio F, Morelli M, Russo T, Pellicano pin-releasing hormone agonist (triptorelin) on
M, Nappi C, et al. Raloxifene administration uterine leiomyoma volume and hormonal status.
of women treated with gonadotropin-releasing Fertil Steril. 2010;93(1):192–8.
hormone agonist for uterine leiomyomas: effects 73. Pritts EA, Vanness DJ, Berek JS, Parker W, Fein-
on bone metabolism. J Clin Endocrinol Metab. berg R, Feinberg J, Olive DL. The prevalence of
2002;87:4476–81. occult leiomyosarcoma at surgery for presumed
62. Palomba S, Orio F, Morelli M, Russo T, Pelli- uterine fibroids: a meta-analysis. Gynecol Surg.
cano M, Zupi E, et al. Raloxifene administration 2015;12(3):165–77.
in premenopausal women with uterine leiomyo- 74. Wilcox LS, Koonin LM, Pokras R, Strauss LT,
mas: a pilot study. J Clin Endocrinol Metab. Xia Z, Peterson HB. Hysterectomy in the United
2002;87:3603–8. States, 1988–1990. Obstet Gynecol. 1994;83:
63. Palomba S, Russo T, Orio F Jr, Tauchmanovà L, 549–55.
Zupi E, Panici PL, et al. Effectiveness of com- 75. Ribeiro SC, Ribeiro RM, Santos NC, Pinotti
bined GnRH analogue plus raloxifene adminis- JA. A randomized study of total abdominal, vagi-
tration in the treatment of uterine leiomyomas: a nal and laparoscopic hysterectomy. Int J Gynecol
prospective, randomized, single- blind, placebo- Obstet. 2003;83:37–43.
controlled trial. Hum Reprod. 2002;17:3213–9. 76. Reich H, DiCaprio J, McGlynn NF. Laparoscopic
64. Deng L, Wu T, Chen XY, Xie L, Yang J. Selec- hysterectomy. J Gynecol Surg. 1989;5:213–6.
tive estrogen receptor modulators (SERMs) for 77. American College of Obstetrics and Gynecol-
uterine leiomyomas. Cochrane Database Syst
ogy. Surgical alternatives to hysterectomy in the
Rev. 2012;10:CD005287. https://doi.org/10.1002/ management of leiomyomas. ACOG Pract Bull.
14651858. CD005287.pub4. 2000;16:776–84.
65. Chwalisz K, DeManno D, Garg R, Larsen L, 78. Mais V, Ajossa S, Guerriero S, Mascia M, Solla
Mattia-Goldberg C, Stickler T. Therapeutic E, Melis GB. Laparoscopic versus abdominal
potential for the selective progesterone receptor myomectomy: a prospective, randomized trial to
modulator asoprisnil in the treatment of leiomyo- evaluate benefits in early outcome. Am J Obstet
mata. Semin Reprod Med. 2004;22(2):113–9. Gynecol. 1996;174(2):654–8.
66. Elger W, Bartley J, Schneider B, Kaufmann 79. Bulletti C, Polli V, Negrini V, Giacomucci E,
G, Schubert G, Chwalisz K. Endocrine- Flamigni C. Adhesion formation after laparo-
pharmacological characterization of proges- scopic myomectomy. J Am Assoc Gynecol Lapa-
terone antagonists and progesterone receptor rosc. 1996;3(4):533–6.
modulators (PRMs) with respect to PR-agonis- 80. Takeuchi H, Kinoshita K. Evaluation of adhe-
tic and antagonistic activity. Steroids. 2000;65: sion formation after laparoscopic myomectomy
713–23. by systematic second-look microlaparoscopy. J
67. Chwalisz K, Elger W, McCrary K, Beckman P, Am Assoc Gynecol Laparosc. 2002;9(4):442–6.
Larsen L. Reversible suppression of menstrua- 81. Dubuisson JB, Fauconnier A, Chapron C, Kreiker
tion in normal women irrespective of the effect G, Nörgaard C. Second look after laparoscopic
on ovulation with the novel selective progesterone myomectomy. Hum Reprod. 1998;13(8):2102–6.
receptor modulator (SPRM) J 867. J Soc Gynecol 82. Doridot V, Dubuisson JB, Chapron C, Fauco-
Investig. 2002;9(Suppl 1):abstract 49. nnier A, Babaki-Fard K. Recurrence of leio-
68. Talaulikar VS, Manyonda IT. Ulipristal acetate: myomata after laparoscopic myomectomy. J Am
a novel option for the medical management Assoc Gynecol Laparosc. 2001;8:495–500.
of symptomatic uterine fibroids. Adv Ther. 83. Nezhat FR, Roemisch M, Nezhat CH, Seidman
2012;29(8):655–63. DS, Nezhat CR. Recurrence rate after laparo-
69. Donnez J, Tatarchuk TF, Bouchard P, Puscasiu L, scopic myomectomy. J Am Assoc Gynecol Lapa-
Zakharenko NF, Ivanova T, et al. Ulipristal ace- rosc. 1998;5(3):237–40.
tate versus placebo for fibroid treatment before 84. Rossetti A, Sizzi O, Soranna L, Cucinelli F,
surgery. N Engl J Med. 2012;366(5):409–20. Mancuso S, Lanzone A. Long-term results of
70. Ishikawa H, Reierstad S, Demura M, Rade- laparoscopic myomectomy: recurrence rate in
maker AW, Kasai T, Inoue M, et al. High aro- comparison with abdominal myomectomy. Hum
matase expression in uterine leiomyoma tissues Reprod. 2001;16(4):770–4.
of African-American women. J Clin Endocrinol 85. Agdi M, Tulandi T. Minimally invasive
Metab. 2009;94(5):1752–6. approach for myomectomy. Semin Reprod Med.
71. Gurates B, Parmaksiz C, Kilic G, Celik H, Kumru 2010;28(3):228–34, review.
S, Simsek M. Treatment of symptomatic uter- 86. Barakat EE, Bedaiwy MA, Zimberg S, Nutter
ine leiomyoma with letrozole. Reprod Biomed B, Nosseir M, Falcone T. Robotic-assisted, lapa-
Online. 2008;17(4):569–74. roscopic, and abdominal myomectomy: a com-
512 G. M. Christman
parison of surgical outcomes. Obstet Gynecol. 101. Mara M, Maskova J, Fucikova Z, Kuzel D,
2011;117(2 Pt 1):256–65. Belsan T, Sosna O. Midterm clinical and first
87. Pitter MC, Gargiulo AR, Bonaventura LM, reproductive results of a randomized controlled
Lehman JS, Srouji SS. Pregnancy outcomes trial comparing uterine fibroid embolization
following robot-assisted myomectomy. Hum and myomectomy. Cardiovasc Intervent Radiol.
Reprod. 2013;28(1):99–108. 2008;31(1):73–85.
88. Ravina JH, Herbreteau D, Ciraru-Vigneron N, 102. Spies JB, Spector A, Roth AR, Baker CM,
Bouret JM, Houdart E, Aymard A, et al. Arterial Mauro L, Murphy-Skrynarz K. Complications
embolisation to treat uterine myomata. Lancet. after uterine artery embolization for leiomyomas.
1995;346(8976):671–2. Obstet Gynecol. 2002;100:873–80.
89. Worthington-Kirsch RL, Popky GL, Hutchins FL 103. Goodwin SC, Wong GC. Uterine artery emboli-
Jr. Uterine arterial embolization for the manage- zation for uterine fibroids: a radiologist’s perspec-
ment of leiomyomas: quality- of-life assessment tive. Clin Obstet Gynecol. 2001;44:412–24.
and clinical response. Radiology. 1998;208:625–9. 104. Chrisman HB, Saker MB, Ryu RK, Nemcek
90. Spies JB, Ascher SA, Roth AR, Kim J, Levy EB, AA Jr, Gerbie MV, Milad MP, et al. The impact
Gomez-Jorge J. Uterine artery embolization for of uterine fibroid embolization on resumption
uterine leiomyoma. Obstet Gynecol. 2001;98: of menses and ovarian function. J Vasc Interv
29–34. Radiol. 2000;11:699–703.
91. American College of Obstetricians and Gynecol- 105. Frigerio LF, Patelli G, DiTolla G, Spreafico C. A
ogists. ACOG Practice Bulletin. Alternatives to fatal complication of percutaneous transcatheter
hysterectomy in the management of leiomyomas. embolization for the treatment of fibroids. In:
Obstet Gynecol. 2008;112(2 Pt 1):387–400. Second international symposium on emboliza-
92. Burn PR, McCall JM, Chinn RJ, Vashisht A, tion of uterine myomata/Society for Minimally
Smith JR, Healy JC. Uterine fibroleiomyoma: Invasive Therapy, 11th international conference,
MR imaging appearances before and after Boston, MA; 1999.
embolization of uterine arteries. Radiology. 106. de Blok S, de Vries C, Prinssen HM, Blaauwgeers
2000;214:729–34. HL, Jorna-Meijer LB. Fatal sepsis after uterine
93. deSouza NM, Williams AD. Uterine arterial artery embolization with microspheres. J Vasc
embolization for leiomyomas: perfusion and vol- Interv Radiol. 2003;14:779–83.
ume changes at MR imaging and relation to clini- 107. Wingo PA, Huezo CM, Rubin GL, Ory HW, Peter-
cal outcome. Radiology. 2002;222:367–74. son HB. The mortality risk associated with hyster-
94. Jha RC, Ascher SM, Imaoka I, Spies JB. Symp- ectomy. Am J Obstet Gynecol. 2000;152:803–8.
tomatic fibroleiomyomata: MR imaging of the 108. Hurst BS, Stackhouse DJ, Matthews ML,
uterus before and after uterine arterial emboliza- Marshburn PB. Uterine artery embolization
tion. Radiology. 2000;217:228–35. for symptomatic uterine myomas. Fertil Steril.
95. Toor SS, Jaberi A, Macdonald DB, McInnes MD, 2000;74:855–69.
Schweitzer ME, Rasuli P. Complication rates and 109. Hesley GK, Gorny KR, Woodrum DA. MR-
effectiveness of uterine artery embolization in the guided focused ultrasound for the treatment of
treatment of symptomatic leiomyomas: a system- uterine fibroids. Cardiovasc Intervent Radiol.
atic review and meta-analysis. Am J Roentgenol. 2013;36(1):5–13.
2012;199(5):1153–63. 110. Stewart E, Gedroyc W, Tempany C, Quade BJ,
96. Gupta JK, Sinha A, Lumsden MA, Hickey Inbar Y, Ehrenstein T, et al. Focused ultrasound
M. Uterine artery embolization for symptomatic treatment of uterine fibroid tumors: safety and
uterine fibroids. Cochrane Database Syst Rev. feasibility of a noninvasive thermoablative tech-
2012;5:CD005073, review. nique. Am J Obstet Gynecol. 2003;189(1):48–54.
97. Walker WJ, Pelage JP. Uterine artery embolisa- 111. Funaki K, Fukunishi H, Sawada K. Clini-
tion for symptomatic fibroids: clinical results cal outcomes of magnetic resonance-guided
in 400 women with imaging follow up. BJOG. focused ultrasound surgery for uterine myomas:
2002;109:1262–72. 24-month follow-up. Ultrasound Obstet Gynecol.
98. Watson GM, Walker WJ. Uterine artery emboli- 2009;34(5):584–9.
sation for the treatment of symptomatic fibroids 112. Gorny KR, Woodrum DA, Brown DL, Henrich-
in 114 women: reduction in size of the fibroids sen TL, Weaver AL, Amrami KK, et al. Magnetic
and women’s views of the success of the treat- resonance-guided focused ultrasound of uter-
ment. BJOG. 2002;109:129–35. ine leiomyomas: review of a 12-month outcome
99. Homer H, Saridogan E. Uterine artery emboliza- of 130 clinical patients. J Vasc Interv Radiol.
tion for fibroids is associated with an increased risk 2011;22(6):857–64.
of miscarriage. Fertil Steril. 2010;94(1):324–30. 113. Rabinovici J, David M, Fukunishi H, Morita Y,
100. Freed MM, Spies JB. Uterine artery embolization Gostout BS, Stewart EA. MRgFUS Study Group.
for fibroids: a review of current outcomes. Semin Pregnancy outcome after magnetic resonance-
Reprod Med. 2010;28(3):235–41. guided focused ultrasound surgery (MRgFUS)
22
Uterine Leiomyomas
513 22
for conservative treatment of uterine fibroids. 118. Zreik TG, Rutherford TJ, Palter SF, Troiano RN,
Fertil Steril. 2010;93(1):199–209. Williams E, Brown JM, et al. Cryomyolysis, a
114. Qin J, Chen JY, Zhao WP, Hu L, Chen WZ, Wang new procedure for the conservative treatment of
ZB. Outcome of unintended pregnancy after uterine fibroids. J Am Assoc Gynecol Laparosc.
ultrasound-guided high-intensity focused ultra- 1998;5(1):33–8.
sound ablation of uterine fibroids. Int J Gynaecol 119. Ciavattini A, Tsiroglou D, Piccioni M, Lug-
Obstet. 2012;117(3):273–7. nani F, Litta P, Feliciotti F, et al. Laparoscopic
115. Zupi E, Sbracia M, Marconi D, Munro cryomyolysis: an alternative to myomectomy in
MG. Myolysis of uterine fibroids: is there a role? women with symptomatic fibroids. Surg Endosc.
Clin Obstet Gynecol. 2006;49(4):821–33. 2004;18(12):1785–8.
116. Zupi E, Piredda A, Marconi D, Townsend D, 120. Zupi E, Marconi D, Sbracia M, Exacoustos
Exacoustos C, Arduini D, et al. Directed lapa- C, Piredda A, Sorrenti G, et al. Directed lapa-
roscopic cryomyolysis: a possible alternative to roscopic cryomyolysis for symptomatic leio-
myomectomy and/or hysterectomy for symp- myomata: one-year follow up. J Minim Invasive
tomatic leiomyomas. Am J Obstet Gynecol. Gynecol. 2005;12(4):343–6.
2004;190(3):639–43.
117. Cowan BD. Myomectomy and MRI-directed cryo-
therapy. Semin Reprod Med. 2004;22(2):143–8.
515 23
Tubal Disease and Ectopic

Pregnancy
Mabel Lee, Rebecca Flyckt, and Jeffrey M. Goldberg
Contents
23.2 Mechanisms of Tubal Damage – 517
23.3 Imaging of the Fallopian Tubes – 518
23.4 Diagnosing Uterine Cavity Abnormalities – 519
23.5 Diagnosing Tubal Abnormalities – 519
23.6 Technical Considerations – 520
23.7 Technique and Troubleshooting – 520
23.8 Surgical Management of Tubal Disease – 521
23.9 Proximal Tubal Occlusion – 521
23.10 Sterilization Reversal – 521
23.11 Distal Tubal Disease – 522
23.12 Hydrosalpinx and IVF – 524
23.13 Ectopic Pregnancy – 524
23.14 Presentation and Diagnosis – 525
23.15 edical Management of Ectopic

M
Pregnancy – 526

https://doi.org/10.1007/978-3-030-99596-6_23
23.16 Surgical Management of Ectopic
Pregnancy – 528
23.17 Expectant Management – 530
23.19 Answers – 531
References – 531
Tubal Disease and Ectopic Pregnancy
517 23
sequelae of ectopic pregnancy. Although the
Key Points incidence of advanced ectopic pregnancies
55 Tubal factor accounts for approxi- and some reportable sexually transmitted dis-
mately 35% of female infertility cases eases is decreasing in the USA [4], early and
worldwide with infection being the accurate recognition in the diagnostic workup
leading cause. Other causes include of the infertile couple is essential.
tubal pregnancy, endometriosis, devel- Fortunately, tubal infertility is often ame-
opmental exposure to teratogens, or iat- nable to surgical intervention. With increas-
rogenic causes. ing success rates of assisted reproductive
55 Hysterosalpingogram (HSG) is the gold technologies (ART), patients are opting more
standard screening test for assessing the frequently for in vitro fertilization (IVF) to cir-
uterine cavity and fallopian tubes, cumvent damaged fallopian tubes. However,
although laparoscopic chromopertuba- surgical management is still recommended in
tion remains the gold standard for diag- cases of proximal occlusion, mild hydrosal-
nosing tubal disease. pinges, and reversal of tubal ligation.
55 Surgical management of tubal disease is In this chapter, the etiology of tubal factor
dependent on mechanism of tubal dis- infertility will be discussed, with a focus on
ease (e.g., proximal tubal occlusion, pelvic inflammatory disease (PID) and ecto-
prior tubal ligation, distal tubal disease) pic pregnancy. In addition, the assessment
and is primarily performed via mini- of tubal status with hysterosalpingogram
mally invasive methods. (HSG) will be reviewed. Finally, the surgical
55 Hydrosalpinx has a deleterious effect approaches to the treatment of tubal disease
on IVF outcomes and is typically will be addressed, with an emphasis on tubal
treated with laparoscopic salpingec- reconstructive techniques and management
tomy. of hydrosalpinges. The treatment of tubal
55 Increased risk of ectopic pregnancy is disease with ART does not differ from other
associated with tubal disease as well as conditions and is discussed separately.
the use of assisted reproductive tech-
nologies and can be managed medically
or surgically. Case Vignette
A 26-year-old G0 female is seen for primary

infertility evaluation after 1 year of regular
23.1 Introduction unprotected intercourse with her male part-
ner. She has regular cycles and no history
Tubal factor infertility remains a frequently of medical illness or prior abdominal sur-
encountered entity in gynecologic practice. geries. Her partner has had a normal semen
Analysis of data from the World Health Orga- analysis. She has a remote history of chla-
nization indicates that tubal factor accounts mydial infection. She has no history of
for approximately 35% of female infertility endometriosis or pelvic pain. She denies
cases worldwide, with a much higher preva- dyspareunia or dysmenorrhea.
lence in areas such as Africa [1]. The over-
all incidence of tubal disease in Europe or
the USA may be lower. For example, one 23.2 Mechanisms of Tubal Damage
population-based study of over 700 couples
indicated that approximately 14% of couples The fallopian tubes are delicate organs which
evaluated by an infertility specialist had tubal function in sperm transport, the pickup and
disease [2]. This figure remained stable in a fertilization of oocytes, and the transport of
more recent survey of a similar cohort [3]. embryos to the uterus. The ciliated e ndothelium
The most common causes of this condition is particularly susceptible to damage by infec-
include pelvic infection, endometriosis, and tion. However, abnormalities of the fallopian
518 M. Lee et al.
tubes can also follow tubal pregnancy, endo- nancy. Women with an episode of PID have
23 metriosis, developmental exposure to terato- approximately a 10% chance of developing an
gens, or iatrogenic causes (7 Box 23.1). ectopic pregnancy in their first pregnancy fol-
lowing documented salpingitis [5]. In one ret-
rospective cohort study examining sequelae of
Box 23.1 Causes of Tubal Infertility [11] chlamydial infection, the authors found
55 Pelvic inflammatory disease that women with two episodes of infection
55 Prior ectopic pregnancy were twice as likely, and women with three
55 Surgery/trauma to the fallopian tubes of more episodes of infection were greater
55 Endometriosis/adhesions than four times as likely, to be hospitalized for
55 Septic abortion/endometritis/salpingitis ectopic pregnancy [11].
55 Ruptured appendix
55 Inflammatory bowel disease
55 Iatrogenic 23.3 Imaging of the Fallopian Tubes
55 Diethylstilbestrol (DES) exposure
Whatever the cause of tubal damage, recog-
nizing tubal factor infertility is essential in
The most common cause of tubal infertility is the diagnostic workup of the infertile cou-
PID, which can arise after ascending infection ple. HSG has been the standard initial test
with N. gonorrhoeae or C. trachomatis [5, 6]. for assessing the uterine cavity and fallopian
Other infectious agents thought to be delete- tubes since 1925 [12], although laparoscopic
rious to tubal structure and function include chromopertubation remains the gold stan-
Mycoplasma species and tuberculosis; how- dard for diagnosing tubal disease. HSG is a
ever, a causal relationship has not been sub- radiographic imaging procedure to image the
stantiated [7]. It is known that the chance of uterine cavity and demonstrate tubal patency
post-inflammatory tubal damage rises with by injecting radiographic contrast media
repeat infections and the successful function through the cervix. The technique is easy to
of the fallopian tubes is directly related to the learn and perform, is relatively low cost, has
severity of the damage [5, 8]. According to an acceptable radiation exposure, and has few
landmark studies from Sweden involving thou- complications. Indications and contraindica-
sands of women, the incidence of tubal infer- tions for HSG are listed in 7 Boxes 23.2 and
tility after laparoscopically diagnosed PID was 23.3. Risks, benefits, and alternatives of the
10–12% after one infection, 23–35% after two procedure are outlined in 7 Box 23.4. The
infections, and 54–75% after three infections most significant additional benefit of HSG is
[8]. Longitudinal data from multiple centers an enhanced post-procedure pregnancy rate.
within the USA confirm a twofold increased Alternative methods for evaluating tubal con-
risk of infertility after recurrent PID [9]. dition (such as sonohysterosalpingography or
It appears that many women with tubal “hystero-contrast sonography,” transvaginal
disease or seropositivity for chlamydial anti- hydrolaparoscopy, falloposcopy, and salpin-
gen have not had any documented or reported goscopy) are used far less often.
history of prior infection [10]. Therefore,
it must be concluded that salpingitis and
resulting tubal damage can result even after Box 23.2 Indications for Hysterosalpin-
asymptomatic or subclinical infections [7]. A gogram (HSG)
recent study of women with subclinical PID 55 Basic infertility workup
based on endometrial histology demonstrated 55 Recurrent pregnancy loss
decreased fertility compared to controls [7]; 55 Evaluation after uterine or tubal surgery
these findings were despite treatment for 55 Suspected uterine anomaly
uncomplicated lower genital tract infections. 55 Confirming post-procedure tubal occlu-
As might be expected, a close association sion
also exists between PID and ectopic preg-
519 23
23.4 iagnosing Uterine Cavity
D
Box 23.3 Contraindications for Hystero- Abnormalities
salpingogram (HSG)
55 Active pelvic infection HSG has a high sensitivity but a low specificity
55 Cervicitis for the diagnosis of uterine cavity abnormali-
55 Severe iodine allergy ties [13]. HSG and diagnostic hysteroscopy
55 Bleeding/menstruation performed on 336 infertile women showed that
55 Known or suspected endometrial carci- HSG had a sensitivity of 98% but a specificity
noma of only 35% due to difficulties distinguishing
55 Pregnancy between polyps and myomas [14]. Thus, HSG
fulfills the requirements as a good first-line
screening test for revealing abnormalities of
the uterine cavity, though any abnormalities
Box 23.4 Risks, Benefits, and Alterna- found will likely need further evaluation to
tives to Hysterosalpingogram (HSG) make a definitive diagnosis. A uterine septum
55 Risks/complications and a bicornuate uterus cannot be differenti-
55 Vasovagal reactions ated on an HSG. Evaluation of the external
55 Post-procedure infection fundal contour by laparoscopy, MRI, or 3D
55 Granuloma formation with oil-based ultrasonography is required to make a defini-
contrast tive diagnosis. Other conditions visualized on
55 Oil embolism with oil-based contrast HSG are adhesions, diethylstilbestrol (DES)
55 Benefits changes, and adenomyosis.
55 Guides infertility treatment manage-
ment
55 Fertility enhancement
55 Alternatives 23.5 Diagnosing Tubal
55 Chlamydia antibody testing Abnormalities
55 Sonohysterography or sonohysterosal-
pingography HSG appears to be a highly valid and accurate
55 Magnetic resonance imaging test for assessing tubal patency in subfertile
55 3D ultrasonography couples; however, its reliability for diagnosing
55 Radionuclide HSG tubal occlusion is questionable. In up to 62%
55 Laparoscopy of patients, tubal blockage on HSG is not
55 Hysteroscopy confirmed by laparoscopy, the gold standard
55 Transvaginal hydrolaparoscopy for assessing tubal occlusion noted on HSG
55 Salpingoscopy and falloposcopy [15]. Even laparoscopy is imperfect, as 2% of
patients with bilateral tubal occlusion subse-
quently conceived spontaneously [16]. One
HSG should be considered a screening test; it study noted that 60% of patients with proxi-
should have high sensitivity, so as not to miss mal tubal occlusion (PTO) on HSG showed
the opportunity to treat an abnormality, but patency on repeat HSG 1 month later [17].
a low false-positive rate to prevent unneces- Surprisingly, hydrosalpinges may also be
sary additional testing and treatments. The poorly diagnosed by HSG. When detected,
accuracy of an HSG is highly dependent on they may be only mildly dilated with preserva-
technique and interpretation. The technical tion of mucosal folds or massively dilated with
quality of the HSG is important to limit mis- complete loss of the normal intratubal archi-
interpretations (i.e., eliminating air bubbles tecture (. Fig. 23.1). HSG can also diagnose
that may be confused with a polyp or myoma salpingitis isthmica nodosa, represented by
or using inadequate contrast volume or injec- diverticula from the mucosa into the muscu-
tion pressure to demonstrate tubal patency). laris (. Fig. 23.2). HSG is also not an ideal
520 M. Lee et al.
discomfort generally resolves rapidly. Several

23 studies have noted that NSAIDs do provide
significant analgesia for HSG [18–20]. Pro-
ponents of water-soluble media (WSM) vs.
oil-soluble media (OSM) have been arguing
the relative merits of their favored contrast
for decades, and there remains no clear win-
ner. WSM offers better image quality as the
higher-density OSM tends to obscure fine
details in the uterus and tubal mucosal folds.
Also, since WSM dissipates quickly, there is
no need for delayed films, whereas 1- to 24-h
delayed films are necessary with OSM. OSM
also carries increased risks for oil embolism
and granuloma formation. In the most recent
.. Fig. 23.1 Hydrosalpinx Cochrane analysis, the evidence suggests that
compared to no treatment, OSM may increase
the chance of live birth and clinical preg-
nancy, while it is less apparent whether the
same holds true for WSM [21].
23.7 Technique and Troubleshooting
The HSG cannula is attached to a 20-cc

syringe filled with contrast media, which is
flushed to expel air and prevent air bubble
artifacts. The acorn is advanced so that it is
about 1 cm from the end of the cannula. The
.. Fig. 23.2 Salpingitis isthmica nodosa cannula tip should not go beyond the inter-
nal os. Using a lubricated, open-sided bivalve
test for diagnosing pelvic adhesions because speculum, the cervix is cleansed with an anti-
it detects them in only one-half of the cases septic solution, a single-tooth tenaculum is
in which they are present [12]. Adhesions are applied to the anterior lip, and the cannula
usually diagnosed on HSG by the presence of tip is inserted into the cervical canal. Gentle
loculated spill of contrast. upward pressure on the cannula while pulling
downward on the tenaculum will seal the cer-
vix and straighten the uterine axis.
23.6 Technical Considerations Contrast media is then injected slowly.
If a filling defect is suspected to be an air
If possible, the gynecologist should perform bubble, the patient can be rotated to her side
the study; patients are comforted by having (defect side down). A polyp or myoma will
their physician present during this stress- remain stationary, whereas a bubble will rise
ful test. At a minimum, the films should be to the elevated side. Only 5–10 mL is usu-
obtained for review as the radiologists’ reports ally required to complete the study. Patients
vary greatly depending on training and expe- should be observed for several minutes after-
rience. The procedure should be performed ward for bleeding and signs of vasovagal or
during the window between the end of menses allergic reactions.
but before ovulation. Although most patients While bilateral PTO is usually indicative
experience uterine cramping during the HSG, of anatomical pathology, unilateral PTO
the duration of the procedure is short, and the is frequently transient due to spasm of the
521 23
uterotubal ostium, plugging by mucus, debris,
or air bubbles. Unilateral PTO is found in
10–24%, but 16–80% are patent on repeat
HSG or laparoscopy with chromotubation
[22]. Increasing the hydrostatic pressure and
rotating the patient may establish patency
during HSG showing PTO. The use of anti-
spasmodic agents such as glucagon to prevent
PTO has also been recommended, but this
practice is supported only by limited anec-
dotal reports in the literature.
.. Fig. 23.3 Selective salpingography. (Reproduced

23.8 urgical Management of Tubal
S with permission from Falcone and Hurd [86])
Disease
(. Fig. 23.3). Patency is confirmed by lapa-
Tubal disease may be present at multiple sites;
roscopy or fluoroscopy, respectively. Often,
however, tubal damage or blockages are often
the hydrostatic pressure will relieve an obstruc-
categorized as proximal, midtubal, or distal. The
tion. If unsuccessful, and normal distal tubal
success of surgical management will depend on
anatomy has been confirmed by laparoscopy, a
the location and degree of the damage in addi-
smaller catheter with an atraumatic guidewire
tion to nonsurgical factors, such as patient age
is introduced through the selective salpingog-
and ovarian reserve. In general, patients with
raphy catheter. The inner catheter and guide-
extensive tubal damage will be best served by
wire are advanced through the tubal ostia into
IVF, whereas those without widespread disease
the proximal isthmus. Chromotubation is then
may be good surgical candidates.
performed though the catheter to demonstrate
Minimally invasive surgical techniques are
patency through the fimbria. Although there
most appropriate for tubal surgery, but this
is a high success rate of 75–95% in terms of
approach requires some advanced training as
achieving patency, reocclusion rates average
well as meticulous dissection and hemostasis
30% [23–25]. Despite similar tubal patency
to prevent adhesions or further damage to the
rates between hysteroscopic and fluoroscopic
tubes.
tubal cannulation, pregnancy rates are sig-
nificantly higher with the former technique,
48.9% vs. 15.6% [23]. Tubal perforation occurs
23.9 Proximal Tubal Occlusion 2–10% of the time but is innocuous. Although
microsurgical resection and reanastomosis can
PTO accounts for 10–25% of tubal disease be used when tubal cannulation fails or when
and is most often caused by salpingitis isth- PTO is due to salpingitis isthmica nodosa,
mica nodosa, chronic pelvic infection, intra- IVF is the preferred treatment.
tubal endometriosis, mucus plugging, or
anatomic malformations [23]. Persistent PTO
can be treated by therapies such as selective 23.10 Sterilization Reversal
salpingography, tubal cannulation under
fluoroscopy, hysteroscopic cannulation, or Tubal sterilization is the most common con-
tubal resection and reanastomosis with a high traceptive used by women worldwide [26].
degree of success. Although it should be considered a perma-
Selective salpingography is performed by nent birth control option, 5–20% of women
injecting contrast media through a transcervi- experience regret [27], and 1–2% of women
cal catheter positioned at the tubal ostia hys- seek reversal of sterilization [28]. In a large
teroscopically or under fluoroscopic guidance prospective, multicenter cohort study of over
522 M. Lee et al.
11,000 women, regret appeared most strongly

23 associated with younger age at the time of
sterilization [27]. Compared with IVF, tubal
anastomosis offers patients desiring steriliza-
tion reversal the advantage of a one-time,
minimally invasive treatment with high suc-
cess rates. In addition, some patients prefer
the ability to attempt conception each month
as well as to conceive more than once as well
as the avoidance of the inconvenience and
risks of IVF. The disadvantages are the pos-
sibility of bleeding, infection, inadvertent
injury to other organs, and anesthetic com-
plications inherent with any surgery. There is .. Fig. 23.4 Approximation of tubal lumen. (Repro-
duced with permission from Falcone and Hurd [86])
also a higher risk for ectopic pregnancy fol-
lowing tubal reanastomosis. Other factors
involved in the decision are the IVF program’s risks of 2–10% [28, 30, 32–35]. Most of the
success rates, surgeon’s ability, presence of pregnancies occur within the first year of sur-
other infertility factors, cost, and patient pref- gery. High success rates were also reported
erence. A retrospective cohort study reported with laparoscopic tubal anastomosis, though
significantly higher cumulative pregnancy few possess the skills to perform this [28, 31].
rates for tubal anastomosis compared to IVF Robotic surgery is a technique that facili-
for women less than 37 years of age, but there tates laparoscopic tubal reanastomosis. Two
was no significant difference in women aged small studies comparing tubal anastomosis
37 years or older [29]. Furthermore, the aver- by robotic-assisted laparoscopy vs. laparot-
age cost per delivery for tubal anastomosis omy or minilaparotomy found no difference
was almost half that of IVF. in pregnancy rates, but robotic surgery took
The procedure is performed by first significantly longer and cost more, even com-
mobilizing and opening the occluded tubal pared with laparotomy with overnight hospi-
ends. A stitch is then placed in the mesosal- talization, though recovery was quicker after
pinx beneath the tubal ends to align them robotic surgery [36, 37]. Another predictor of
and relieve tension on the anastomosis. The successful anastomosis is the method by which
anastomosis is accomplished with inter- the prior tubal was performed; the reversal of
rupted sutures through the tubal muscularis sterilization procedures performed with rings
(. Fig. 23.4). The serosa is also repaired with or clips results in higher pregnancy rates than
interrupted stitches. Transcervical chromo- for sterilization performed via ligation/resec-
tubation is used to confirm tubal patency. A tion or coagulation [38].
HSG is recommended if the patient has not
conceived within six cycles postoperatively.
Tubal anastomosis has usually been per- 23.11 Distal Tubal Disease
formed utilizing an operating microscope by
laparotomy with an overnight hospitalization, The most frequent site for tubal infertility is
but outpatient minilaparotomy achieves the the distal tube, which manifests as hydrosal-
same success rate with less cost and discom- pinges and fimbrial phimosis (agglutination of
fort. The method of prior tubal ligation also fimbria leading to a narrowed tubal opening).
appears to predict successful anastomosis. These most often follow PID but can also be
Cumulative pregnancy rates after tubal preceded by peritonitis from any cause includ-
reanastomosis in women under age 40 range ing trauma from previous surgery or endome-
from 70% to over 90% [28, 30–32]. Even triosis. The decision to attempt repair of distal
women ages 40–45 years have good success tubal disease is often made intraoperatively
rates of 13–70%, with subsequent ectopic based upon the prognosis for an intrauterine
523 23
pregnancy. One study showed that there was For favorable-prognosis patients, a neosal-
a cumulative pregnancy rate of 40% after pingostomy or fimbrioplasty can be attempted
adhesiolysis of peritubal adhesions compared to open up a hydrosalpinx or narrowed tubal
to 8% when no adhesiolysis was performed opening (. Fig. 23.5). This is accomplished
[39]. According to American Fertility Society laparoscopically, with the release of adhesions
classifications, a favorable-prognosis patient and incision at the distal end of the occluded
generally has minimal, filmy adnexal adhe- or narrowed tube. The mucosa and fimbria are
sions, mild tubal dilation (<3 cm), thin and everted and attached to the serosa using fine
pliable tubal walls, and lush endosalpinx with suture or electrosurgery. Transcervical chro-
preservation of mucosal folds [40]. In con- mopertubation is used to confirm patency at
trast, poor-prognosis patients may have dense the completion of the procedure. Pregnancy
tubal adhesions; significantly dilated tubes; rates can range from 58% to 77% in favorable-
thickened, fibrotic tubal walls; and damaged prognosis patients, with ectopic rates of 2–8%
mucosa. Tubal reconstruction should not be [41]. Success rates have been shown to vary by
considered in patients with both proximal and stage of tubal disease [42]. As expected, for
distal occlusion or for women with moder- poor-prognosis patients, pregnancy rates fall
ate to severe disease, and patients should be to 0–22%, with ectopic rates of 0–17% [43].
counseled preoperatively about the possibility It should be noted that although patency can
of neosalpingostomy/fimbrioplasty vs. salpin- often be achieved surgically in both favorable-
gectomy depending on the surgical findings. and poor-prognosis patients, the irrevers-
a b
c d
.. Fig. 23.5 a The distal end of the fallopian tube is salpinx is everted and eversion is maintained with mul-
stabilized with the grasper and dilute vasopressin is tiple circumferential sutures to the serosa. d Patent tube
injected for hemostasis. b The obstructed distal end is as end result of neosalpingostomy. (Reproduced with
opened sharply or with electrosurgery or laser energy permission from Falcone and Hurd [86])
and the fimbriated end is examined closely. c The endo-
524 M. Lee et al.
ible damage caused by pelvic infection to the theoretically limit the success of subsequent
23 endosalpinx may account for compromised ART cycles.
tubal function after surgery. Despite the clear advantages to removing
a hydrosalpinx before IVF, this population of
patients is also at a higher surgical risk due
23.12 Hydrosalpinx and IVF to history of pelvic infection and/or adhe-
sive disease. Thus, there has been a push for
The harmful effect of hydrosalpinx on IVF development of alternative minimally inva-
outcomes has been well documented [40–45]. sive methods of treating hydrosalpinx such
This observation may be explained by toxic as aspiration and sclerotherapy. The evidence
effects of the hydrosalpinx fluid on the embryo, surrounding ultrasound-guided aspiration is
flushing of the embryo from the endometrium currently conflicting [56–59]. Sclerotherapy is
by hydrosalpinx fluid, or impaired endome- performed by instillation of ethanol to con-
trial receptivity. A meta-analysis of over 5500 tract, sclerose, and decrease secretory function
women showed that the implantation and of the tube, but studies have shown no differ-
delivery rate per transfer is halved and the ence in clinical pregnancy or miscarriage rates
miscarriage rate is increased in women with when compared to salpingectomy [60, 61].
untreated hydrosalpinx undergoing IVF [46].
Several prospective randomized trials have
demonstrated that hydrosalpinges treated with Case Vignette
salpingectomy prior to IVF result in restora-
tion of comparable pregnancy rates to con- The aforementioned patient undergoes lap-
trols [47–49]. This finding has been replicated aroscopic bilateral neosalpingostomies for
even in patients with unilateral salpingec- mild hydrosalpinges with distal tubal occlu-
tomy for unilateral hydrosalpinx [50]. A large sion discovered on HSG. She conceives
hydrosalpinx visualized by ultrasound should spontaneously 3 months after surgery. She
be removed prior to IVF, as these appear to be presents to her obstetrician with a positive
associated with the poorest outcomes [46, 47, home pregnancy test and light vaginal
51]. An area of greater controversy is whether bleeding. Her last menstrual period was
less pronounced hydrosalpinges (such as those 5 weeks prior. An ultrasound shows a thick-
identified by HSG or on laparoscopy) should ened endometrium without evidence of a
also be removed in this circumstance. gestational sac, and her quantitative hGC is
The gold standard for treatment of hydrosal- 2500 mU/mL. There are no adnexal masses.
pinx prior to IVF is laparoscopic salpingectomy;
however, other techniques such as proximal
tubal ligation or occlusion, ultrasound-guided 23.13 Ectopic Pregnancy
drainage, or salpingostomy have been suggested.
Salpingectomy prior to IVF should be per- Women with a history of tubal adhesions
formed laparoscopically, taking care to remain are at an increased risk of ectopic pregnancy.
close to the tube to preserve the ovarian blood Ectopic pregnancy is defined by the abnor-
supply and maintain ovarian reserve. PTO has mal implantation of an embryo outside of
been demonstrated to be an effective alternative the endometrial cavity. These pregnancies
to salpingectomy in cases where salpingectomy represent approximately 1.55–2% of pregnan-
is technically difficult or surgery is contraindi- cies and most frequently affect the fallopian
cated [49, 52]. Pregnancy rates following tubal tube (>90%), although they can uncommonly
occlusion appear comparable to treatment with involve sites such as the abdomen, ovary, cer-
salpingectomy [53]. Most recently, several small vix, or cesarean scar [62]. Further, within the
case series have demonstrated the effective- tube itself, ectopic pregnancies have a predi-
ness of using tubal inserts to hysteroscopically lection for the ampullary portion of the tube
occlude hydrosalpinges [54, 55]; however, per- where fertilization occurs (70%); an addi-
sistent coils within the endometrial cavity may tional 10% occur in the isthmus, 10% in the
525 23
fimbria, and 2% in the uterine cornu or inter-
stitium [63]. Although rates of ectopic preg- 55 Infertility
nancy in the USA appear to have peaked and 55 Cigarette smoking
plateaued in the 1990s [64], the true incidence 55 Increasing age
is difficult to estimate because these pregnan- 55 More than one lifetime sexual partner
cies are increasingly managed as outpatients 55 Abdominal or pelvic surgery
and therefore may not be included in hospi- 55 Sexually transmitted diseases (gonor-
tal databases. It does appear that enhanced rhea and/or chlamydia)
awareness and improved detection methods 55 Intrauterine device use
have resulted in more favorable outcomes. 55 No clear association
Nevertheless, ectopic pregnancies remain the 55 Oral contraceptive use
leading cause of maternal deaths in the first 55 Prior spontaneous miscarriage
trimester [65] and must be recognized and 55 Prior elective termination of pregnancy
managed promptly. Failure to do so can result 55 Cesarean section
in fallopian tube rupture, intraperitoneal
aReproduced
hemorrhage, shock, and even death. with permission from Falcone
Abnormal implantations are thought to and Hurd [87]
result mainly from inflammation or block-
age within the tubal lumen. As with infertil-
Of special consideration is the relationship
ity, most tubal damage that precedes ectopic
between ART and extrauterine pregnancies.
pregnancy is caused by infection with N. gon-
The ectopic risk is increased in patients under-
orrhoeae or C. trachomatis. As many as half
going treatments ranging from ovulation
of women with ectopic pregnancies will have
induction to IVF, perhaps due to preexist-
no identifiable risk factors [66]. Known risk
ing tubal pathology or the effects of supra-
factors for ectopic pregnancy include infec-
physiologic hormonal levels on tubal motility.
tion, prior ectopic pregnancy, and prior tubal
Ectopic risk after oocyte retrieval and embryo
surgery. Although IUD use does not increase
transfer is 4.5%, significantly higher than
the overall risk of ectopic pregnancy, a posi-
what is observed in the general population
tive pregnancy test in an IUD user warrants
[69]. The incidence of heterotopic pregnancy
suspicion for ectopic, as the location of the
(i.e., simultaneous intrauterine and extra-
gestation is most likely extrauterine [66]. A
uterine pregnancies) is similarly increased in
complete list of maternal risk factors is shown
ART patients. In contrast to the classic rate of
in 7 Box 23.5. It has also been theorized that
1:30,000 pregnancies or even more recent rates
chromosomally abnormal embryos may have
of 1:4000 pregnancies, heterotopic pregnan-
a higher rate of inappropriate implantation.
cies in ART patients are estimated to occur as
However, more recent studies with larger
frequently as 1:100 pregnancies [70, 71].
patient numbers are not consistent with ear-
lier case reports showing high percentages of
abnormal karyotypes from ectopic pregnan-
cies [67, 68]. 23.14 Presentation and Diagnosis
Over the past few decades, increased reports

of ectopic pregnancy are likely due to earlier
Box 23.5 Risk Factors for Ectopic Preg- and better methods of detection. Most diag-
nancya noses are made based on abnormally rising
55 Strong associations levels of beta-hCG or characteristic ultraso-
55 Tubal surgery nographic findings. In recent years, the devel-
55 Pelvic inflammatory disease opment of the radioimmunoassay for hCG
55 Prior ectopic pregnancy quantification and the introduction of the
55 Weaker associations specific antiserum to the beta subunit of hCG
have improved the clinician’s ability to moni-
526 M. Lee et al.
tor the rise and fall of this hormone in early should be visualized, if present, by transvagi-
23 pregnancy [72]. Similarly, ultrasound technol- nal ultrasound [76]. The discriminatory zone
ogy has progressed to allow higher-resolution varies by institution but is generally between
transvaginal images assisted by Doppler flow 1500 and 2500 mIU/mL. Care must be taken
to evaluate the adnexa and endometrium. to differentiate a “pseudosac” (endometrial
Although diagnostic methods have recently cavity distended by bleeding from decidual-
improved, the typical presentation of ectopic ized endometrium) from a true gestational sac.
pregnancy outside of the ART setting has In the presence of multiple gestation, as may
remained extremely consistent over time. Pain be suspected after ART, the discriminatory
(99%) and vaginal bleeding (56%) are the hall- zone may not be valid; twins and higher-order
marks of confirmed ectopic pregnancies [73]. multiples may have beta-hCG levels above the
Pain is thought to result from tubal distention cutoff value before ultrasound detection is
and/or peritoneal irritation from hemoperito- possible [77].
neum. However, the sensitivity and specificity In cases where the beta-hCG is lower than
of these clinical indicators is low, and clini- the discriminatory zone, serial beta-hCG
cians should be aware that these complaints measurements will be helpful. Although older
may be intermittent or absent. An important gynecologic dogma suggested that beta-hCG
observation is that neither presenting com- levels should rise by 66% in 2 days, newer data
plaints nor beta-hCG levels correlate well with indicate that beta-hCG rise in viable gesta-
risk of tubal rupture. Studies have shown that tions may be considerably slower than previ-
low (<100 IU/L) or even decreasing beta-hCG ously reported [78]. According to these data,
levels can still be associated with ruptured an increase in beta-hCG of less than 53% in
ectopic pregnancy [74, 75]. 48 h confirms an abnormal early pregnancy
The physical exam for ectopic pregnancy with 99% specificity. Adhering to this model
should begin with vital signs; the combina- can minimize the risk of intervening during
tion of hypotension and tachycardia signifies a potentially viable pregnancy. Serum pro-
acute blood loss and the need for prompt sur- gesterone levels have limited utility in ecto-
gical intervention and fluid resuscitation. The pic pregnancy due to the common scenario
abdominal exam may reveal signs of perito- of an equivocal progesterone level as well as
neal irritation (e.g., rebound or guarding) or the long turnaround time for the test at many
tenderness to palpation. A normal physical centers [79]. When an abnormally rising hCG
exam cannot be used to exclude ectopic preg- is documented and the distinction cannot be
nancy. The speculum exam should document made between failing intrauterine pregnancy
the presence of blood or products of concep- and ectopic pregnancy, uterine cavity sam-
tion from the cervical os. The adnexa should pling to look for the presence or absence of
be gently palpated on bimanual exam; exces- chorionic villi may be required.
sive pressure can increase the risk of tubal
rupture.
Although suspicion for ruptured ectopic 23.15 Medical Management
may necessitate a rapid bedside transabdomi- of Ectopic Pregnancy
nal ultrasound to verify hemoperitoneum,
most ART patients and nonurgent non-ART Methotrexate (MTX) is an antimetabolite that
patients can be investigated further with stan- has been used for decades in the treatment of
dard transvaginal ultrasound techniques and ectopic pregnancy and gestational trophoblas-
beta-hCG levels. An algorithm for diagnosing tic diseases. MTX acts as a folic acid antagonist
ectopic pregnancies based on ultrasound and that inhibits cellular DNA and RNA synthesis.
laboratory findings is outlined in . Fig. 23.6. MTX arrests mitosis in rapidly dividing tissues
A key concept in the evaluation of ectopic such as trophoblast, bone marrow, and oro-
pregnancies is the “discriminatory zone.” This gastric/intestinal mucosa. Side effects such as
cutoff is defined as the beta-hCG level above gastrointestinal symptoms (nausea, vomiting,
which a single intrauterine gestational sac indigestion, abdominal pain, or stomatitis), as
527 23
Early Pregnancy with Pain/Bleeding
Expectant IUP Ultrasound Ectopic pregnancy Treat EP

management
Abnormal IUP Non-Diagnostic
D&C vs. Medical Management w/

misoprostil
β-hCG
>discriminatory <discriminatory No
zone (no IUP) zone treatment
abnl rise normal

D&C or fall Serial β-hCG fall
no chorionic chorionic normal

villi villi rise
Treat EP (MTX vs. Ultrasound when

Surgery) β-hCG>
discrimin. zone
(back to top)
.. Fig. 23.6 Diagnostic algorithm flowchart. (Reproduced with permission from Falcone and Hurd [87]; adapted
from [78])
well as more unusual severe effects such as gas- Initial treatment with MTX is appropri-
tritis, enteritis, or pneumonitis [76], are uncom- ate for patients with confirmed or highly sus-
mon with regimens used for treating ectopic pected unruptured ectopic pregnancies that
pregnancy. Hepatotoxicity and bone marrow desire conservative management and are reli-
suppression have also been rarely described. A able for follow-up. Absolute medical contrain-
baseline complete blood count and liver func- dications to MTX therapy are listed in 7 Box
tion testing should be obtained prior to MTX 23.6. Relative contraindications for MTX are
treatment. More commonly, abdominal pain the subject of some debate; however, many
and cramping after MTX administration is clinicians would restrict MTX treatment to
often reported 2–7 days after the injection and patients with adnexal masses <3.5 cm, no
typically represents tubal distention or abor- fetal cardiac activity, and beta-hCG beneath a
tion of necrotic trophoblastic tissue. Without predetermined limit [80]. Although prior hCG
signs of tubal rupture or acute bleeding by thresholds were in the 5000–15,000 mIU/mL
laboratory or ultrasonographic criteria, these range, a recent systematic review has reported
symptoms can be managed expectantly with a significant and substantial increase in failure
reassurance for the patient. rates (14.3% vs. 3.7%) with single-dose MTX
528 M. Lee et al.
when the hCG level exceeds 5000 mIU/mL overall success for treatment with MTX was
23 [81]. A multidose approach or surgical treat- high (89%). MTX therapy can be safely pur-
ment may be preferable in this scenario. sued in appropriately selected patients; two-
dose or fixed multiple-dose regimens should
be considered in more advanced gestations or
Box 23.6 Absolute Contraindications to when MTX therapy is pursued in the setting
Methotrexate Therapya of relative contraindications. All regimens
55 Breastfeeding must be followed until beta-hCG levels are <5
55 Overt or laboratory evidence of immu- mIU/mL to ensure complete resolution of the
nodeficiency trophoblastic tissue.
55 Alcoholism, alcoholic liver disease, or
other chronic liver disease
55 Preexisting blood dyscrasias (bone mar- 23.16 Surgical Management
row hypoplasia, leukopenia, thrombo- of Ectopic Pregnancy
cytopenia, significant anemia)
55 Known sensitivity to methotrexate Ectopic pregnancies can be treated with
55 Active pulmonary disease either chemotherapeutic agents or surgery.
55 Peptic ulcer disease Both strategies have high success rates and
55 Hepatic, renal, or hematological dys- maintain the potential for future pregnan-
function cies. Indications for surgical management of
ectopic pregnancy are listed in 7 Box 23.7.
aReproduced from Falcone and Hurd [87]; The traditional surgical approach for ecto-
adapted from [85] pic pregnancy was exploratory laparotomy
with salpingectomy. Today, laparoscopy with
tubal preservation (i.e., salpingostomy) is usu-
Several regimens have been outlined for the ally possible. Exploratory laparotomy is still
treatment of ectopic pregnancy with intra- used when patients are unstable following
muscular MTX. Protocols for the single-dose, tubal rupture, when the laparoscopy would
two-dose, and fixed multi-dose MTX regi- be complex (significant adhesions, extratubal
mens as outlined by the American Congress gestation) or contraindicated, or when clinical
of Obstetricians and Gynecologists are shown proficiency in laparoscopy is lacking.
in . Table 23.1 [76]. Under the single-dose
and two-dose regimens, MTX is administered
at a dose of 50 mg/m2 based on body surface Box 23.7 Indications for Surgical Man-
area, which is calculated as follows: agement of Ectopic Pregnancy
55 Hemodynamic instability
  Height ( cm ) × Weight ( kg )  
1/ 2
55 Signs of tubal rupture
BSA m 2 ( ) =   55 Simultaneous intrauterine pregnancy
  3600  
55 Unable to adhere to follow-up plan
A fixed multi-dose protocol adds “rescue” 55 Contraindications to MTX (see 7 Box
with leucovorin (i.e., folinic acid). For all pro- 23.6)
tocols, a beta-hCG decrease of less than 15% 55 NB: Surgery may also be considered
between days 4 and 7 represents treatment with ectopic size >3.5 cm, presence of
failure and the need for additional manage- fetal cardiac activity, or elevated beta-
ment [76]. Although the single-dose regimen hCG due to higher risk of MTX failure.
is the least complicated and costly and mini-
mizes side effects, a meta-analysis of multiple
case series has shown that the fixed multiple- Laparoscopic salpingectomy can be accom-
dose regimen is five times more effective than plished with either a combined coagulation-
a single-dose regimen [82]. It should be noted cutting device or by sequential use of bipolar
that, regardless of treatment regimen, the cautery and laparoscopic scissors. Care should
529 23
.. Table 23.1 Methotrexate protocols for ectopic pregnancya
Treatment day Laboratory tests Intervention
Pretreatment β-hCG, CBC with Rule out SAB

differential, LFTs,
RhoGAM if Rh-negative
creatinine, type, and
screen
Single-dose protocol
1 β-hCG MTX 50 mg/m2 IM
4 β-hCG
7 β-hCG MTX 50 mg/m2 IM if β-hCG <15% decrease day 4–7
Two-dose protocol
Pretreatment β-hCG, CBC with Rule out SAB
differential, LFTs,
RhoGAM if Rh-negative
creatinine, type, and
screen
7 β-hCG MTX 50 mg/m2 IM if <15% decline day 4–7. If >15% stop

treatment and start surveillance
11 β-hCG MTX 50 mg/m2 IM if <15% decline day 7–11. If >15%
consider surgical treatment
Multi-dose protocol
1 β-hCG MTX 1.0 mg/kg
2 LEU 0.1 mg/kg

3 β-hCG MTX 1.0 mg/kg if <15% decline day 1–3. If >15% stop
4 LEU 0.1 mg/kg
6 LEU 0.1 mg/kg
8 LEU 0.1 mg/kg
aAdapted from [26]

Surveillance every 7 days (until β-hCG <5 mIU/mL)
β(beta)-hCG β(beta)-human chorionic gonadotropin, CBC complete blood count, LFTs liver function tests,
MTX methotrexate, SAB spontaneous abortion
530 M. Lee et al.
be taken to stay close to the tube to avoid 23.17 Expectant Management

23 compromising the ovarian blood supply. The
more conservative approach via linear salpin- Increased monitoring and early pregnancy
gostomy involves an incision on the anti-mes- detection now prompt the clinician to inter-
enteric surface of the tube using the unipolar vene when ectopic pregnancy is suspected.
needle or scissors, laser, or ultrasonic scalpel. However, prior to sensitive hCG assays and
Prior to that, dilute vasopressin is injected high-resolution ultrasonography, it is likely
in the mesosalpinx beneath the ectopic to that many early tubal pregnancies resolved
improve hemostasis and to minimize tubal spontaneously without adverse outcomes.
damage from excessive cauterization. After With close and careful follow-up, patients
tubal incision, the trophoblastic tissue is then with low and decreasing beta-hCG levels may
either gently teased or irrigated from the tube, be appropriate for expectant management,
taking into consideration that the majority of but these patients must be counseled and
tissue is usually located on the more proximal accept the risk of tubal rupture and its associ-
aspect of the incision. Failure to remove all tro- ated morbidities. In one prospective observa-
phoblastic tissue can lead to persistent ectopic tional study of over 100 women, spontaneous
pregnancy or post-ectopic tubal obstruction; resolution rates were 88% when the first hCG
a Cochrane review concluded that persis- level was <200 IU/L [84].
tent ectopic rates after salpingostomy can be
reduced when coupled with a prophylactic
single injection of MTX [83]. 23.18 Review Questions
When choosing between salpingostomy and
salpingectomy, the most conservative approach ??1. The most common cause of tubal dis-
possible (i.e., salpingostomy) is advised in ease is
patients wishing to preserve their fertility. A. Ectopic pregnancy
However, in cases complicated by severe tubal B. Pelvic inflammatory disease
damage, adhesions, rupture, large ectopic size C. Endometriosis/adhesions
(>5 cm), or bleeding from the incision site, a D. Surgery/trauma to fallopian tubes
salpingectomy may be the only feasible strat-
egy. Additional factors such as previous ectopic ??2. Which of the following is incorrect?
in the same tube, prior tubal reanastomosis or A. Tubal reanastomosis when com-
other tubal surgery, or undesired future fertility pared with IVF offers a one-time,
are also important when determining a surgical minimally invasive treatment with
approach. In a multi-study review, linear salpin- high success rates.
gostomy was associated with a 15% recurrent B. Studies have shown higher cumula-
ectopic rate and 60% successful postoperative tive pregnancy rates after tubal
pregnancy rate [72]. The risk of persistent ecto- reanastomosis when compared to
pic pregnancy with tube-sparing surgery was IVF in women < 37 years old.
3–20%. For salpingectomy, this same review C. Most pregnancies occur within the
cited a recurrence risk of 10% and a subsequent first 6 months after tubal reanasto-
pregnancy rate of 38%. When possible, tubal mosis.
conservation is recommended because it may D. Successful tubal anastomosis is not
increase future fecundity; however, patients correlated with method of prior
must be carefully followed owing to the concern tubal sterilization.
for persistent ectopic, recurrent ectopic, and
post-ectopic tubal obstruction. Serial beta-hCG ??3. True or False: Tubal disease is an inde-
levels should be performed weekly until they pendent risk factor of ectopic and het-
reach non-detectable values to ensure resolution erotopic pregnancies with ART.
of the ectopic pregnancy after salpingostomy. A. True
531 23
23.19 Answers 12. Soules MR, Mack LA. Imaging of the reproduc-
tive tract in infertile women: hysterosalpingography,
ultrasonography, and magnetic resonance imaging.
vv1. B. Pelvic inflammatory disease In: Keye WR, Chang RJ, Rebar RW, Soules MR,
editors. Infertility evaluation and treatment. Phila-
vv 2. D. This statement is incorrect “Successful delphia: WB Saunders; 1995. p. 300–29.
tubal anastomosis is not correlated with 13. Ubeda B, Paraira M, Alert E, Abuin RA. Hystero-
salpingography: spectrum of normal variants and
method of prior tubal sterilization”.
nonpathologic findings. AJR Am J Roentgenol.
2001;177(1):131–5.
vv3. A. True 14. Preutthipan S, Linasmita V. A prospective compara-
tive study between hysterosalpingography and hys-
teroscopy in the detection of intrauterine pathology
in patients with infertility. J Obstet Gynaecol Res.
References 2003;29(1):33–7.
15. Evers JL, Land JA, Mol BW. Evidence-based medi-
1. Cates W, Farley TM, Rowe PJ. Worldwide pat- cine for diagnostic questions. Semin Reprod Med.
terns of infertility: is Africa different? Lancet. 2003;21(1):9–15.
1985;2(8455):596–8. 16. Mol BW, Collins JA, Burrows EA, van der Veen F,
2. Hull MG, Glazener CM, Kelly NJ, Conway DI, Bossuyt PM. Comparison of hysterosalpingogra-
Foster PA, Hinton RA, et al. Population study of phy and laparoscopy in predicting fertility outcome.
causes, treatment, and outcome of infertility. Br Hum Reprod. 1999;14(5):1237–42.
Med J (Clin Res Ed). 1985;291(6510):1693–7. 17. Dessole S, Meloni GB, Capobianco G, Manzoni
3. Bhattacharya S, Porter M, Amalraj E, Templeton MA, Ambrosini G, Canalis GC. A second hystero-
A, Hamilton M, Lee AJ, et al. The epidemiology salpingography reduces the use of selective tech-
of infertility in the North East of Scotland. Hum nique for treatment of a proximal tubal obstruction.
Reprod. 2009;24(12):3096–107. Fertil Steril. 2000;73(5):1037–9.
4. Available at http://www.cdc.gov/std/stats10/trends. 18. Lorino CO, Prough SG, Aksel S, Abuzeid M, Alex-
htm. ander SE, Wiebe RH. Pain relief in hysterosalpin-
5. Westrom L, Joesoef R, Reynolds G, Hagdu A, gography. A comparison of analgesics. J Reprod
Thompson SE. Pelvic inflammatory disease and Med. 1990;35(5):533–6.
fertility. A cohort study of 1,844 women with lapa- 19. Peters AA, Witte EH, Damen AC, Holm JP,
roscopically verified disease and 657 control women Drogendijk AC, van de Velde EA, et al. Pain relief
with normal laparoscopic results. Sex Transm Dis. during and following outpatient curettage and hys-
1992;19(4):185–92. terosalpingography: a double blind study to com-
6. Brunham RC, Maclean IW, Binns B, Peeling pare the efficacy and safety of tramadol versus
RW. Chlamydia trachomatis: its role in tubal infer- naproxen. Cobra Research Group. Eur J Obstet
tility. J Infect Dis. 1985;152(6):1275–82. Gynecol Reprod Biol. 1996;66(1):51–6.
7. Wiesenfeld HC, Hillier SL, Meyn LA, Amorte- 20. Owens OM, Schiff I, Kaul AF, Cramer DC, Burt
gui AJ, Sweet RL. Subclinical pelvic inflam- RA. Reduction of pain following hysterosalpin-
matory disease and infertility. Obstet Gynecol. gogram by prior analgesic administration. Fertil
2012;120(1):37–43. Steril. 1985;43(1):146–8.
8. Westrom L. Effect of pelvic inflammatory disease 21. Wang R, Watson A, Johnson N, Cheung K, Fitzger-
on fertility. Venereology. 1995;8(4):219–22. ald C, Mol BWJ, Mohiyiddeen L. Tubal flushing for
9. Trent M, Bass D, Ness RB, Haggerty C. Recur- subfertility. Cochrane Database Syst Rev. 2020(10):
rent PID, subsequent STI, and reproductive health CD003718.
outcomes: findings from the PID evaluation and 22. Hurd WW, Wyckoff ET, Reynolds DB, Amesse
clinical health (PEACH) study. Sex Transm Dis. LS, Gruber JS, Horowitz GM. Patient rotation
2011;38(9):879–81. and resolution of unilateral cornual obstruction
10. Sellors JW, Mahony JB, Chernesky MA, Rath during hysterosalpingography. Obstet Gynecol.
DJ. Tubal factor infertility: an association with 2003;101(6):1275–8.
prior chlamydial infection and asymptomatic sal- 23. Honore GM, Holden AE, Schenken RS. Patho-
pingitis. Fertil Steril. 1988;49(3):451–7. physiology and management of proximal tubal
11. Hillis SD, Owens LM, Marchbanks PA, Amster- blockage. Fertil Steril. 1999;71(5):785–95.
dam LF, Mac Kenzie WR. Recurrent chlamydial 24. Pinto AB, Hovsepian DM, Wattanakumtornkul
infections increase the risks of hospitalization S, Pilgram TK. Pregnancy outcomes after fallo-
for ectopic pregnancy and pelvic inflammatory pian tube recanalization: oil-based versus water-
disease. Am J Obstet Gynecol. 1997;176(1 Pt 1): soluble contrast agents. J Vasc Interv Radiol.
103–7. 2003;14(1):69–74.
532 M. Lee et al.
25. Thurmond AS. Selective salpingography and fal- 41. Nackley AC, Muasher SJ. The significance of
23 lopian tube recanalization. AJR Am J Roentgenol.
1991;156(1):33–8.
hydrosalpinx in in vitro fertilization. Fertil Steril.
1998;69(3):373–84.
26. Peterson HB. Sterilization. Obstet Gynecol. 2008; 42. Audebert A, Pouly JL, Bonifacie B, Chadi YC. Lap-
111:189–203. aroscopic surgery for distal tubal occlusions: lessons
27. Hillis SD, Marchbanks PA, Tylor LR, Peterson learned from a historical series of 434 cases. Fertil
HB. Poststerilization regret: findings from the Steril. 2014;102:1203–8.
United States collaborative review of sterilization. 43. Zeyneloglu HB, Arici A, Olive DL. Adverse
Obstet Gynecol. 1999;93(6):889–95. effects of hydrosalpinx on pregnancy rates after
28. Yoon TK, Sung HR, Kang HG, Cha SH, Lee CN, in vitro fertilization-embryo transfer. Fertil Steril.
Cha KY. Laparoscopic tubal anastomosis: fertil- 1998;70(3):492–9.
ity outcome in 202 cases. Fertil Steril. 1999;72(6): 44. Andersen AN, Yue Z, Meng FJ, Petersen K. Low
1121–6. implantation rate after in-vitro fertilization in
29. Boeckxstaens A, Devroey P, Collins J, Tournaye patients with hydrosalpinges diagnosed by ultraso-
H. Getting pregnant after tubal sterilization: surgical nography. Hum Reprod. 1994;9(10):1935–8.
reversal or IVF? Hum Reprod. 2007;22(10):2660–4. 45. Strandell A, Lindhard A. Why does hydrosalpinx
30. Kim JD, Kim KS, Doo JK, Rhyeu CH. A report reduce fertility? The importance of hydrosalpinx
on 387 cases of microsurgical tubal reversals. Fertil fluid. Hum Reprod. 2002;17(5):1141–5.
Steril. 1997;68(5):875–80. 46. Camus E, Poncelet C, Goffinet F, Wainer B, Merlet
31. Cha SH, Lee MH, Kim JH, Lee CN, Yoon TK, Cha F, Nisand I, et al. Pregnancy rates after in-vitro fertil-
KY. Fertility outcome after tubal anastomosis by ization in cases of tubal infertility with and without
laparoscopy and laparotomy. J Am Assoc Gynecol hydrosalpinx: a meta-analysis of published compar-
Laparosc. 2001;8(3):348–52. ative studies. Hum Reprod. 1999;14(5):1243–9.
32. Gordts S, Campo R, Puttemans P, Gordts S. Clini- 47. Strandell A, Lindhard A, Waldenstrom U, Thor-
cal factors determining pregnancy outcome after burn J, Janson PO, Hamberger L. Hydrosalpinx and
microsurgical tubal reanastomosis. Fertil Steril. IVF outcome: a prospective, randomized multicen-
2009;92(4):1198–202. tre trial in Scandinavia on salpingectomy prior to
33. Trimbos-Kemper TC. Reversal of sterilization in IVF. Hum Reprod. 1999;14(11):2762–9.
women over 40 years of age: a multicenter survey in 48. Dechaud H, Daures JP, Arnal F, Humeau C, Hedon
the Netherlands. Fertil Steril. 1990;53(3):575–7. B. Does previous salpingectomy improve implanta-
34. Petrucco OM, Silber SJ, Chamberlain SL, Warnes tion and pregnancy rates in patients with severe
GM, Davies M. Live birth following day surgery tubal factor infertility who are undergoing in vitro
reversal of female sterilisation in women older than fertilization? A pilot prospective randomized study.
40 years: a realistic option in Australia? Med J Aust. Fertil Steril. 1998;69(6):1020–5.
2007;187(5):271–3. 49. Kontoravdis A, Makrakis E, Pantos K, Botsis D,
35. Dubuisson JB, Chapron C, Nos C, Morice P, Deligeoroglou E, Creatsas G. Proximal tubal occlu-
Aubriot FX, Garnier P. Sterilization reversal: fertil- sion and salpingectomy result in similar improve-
ity results. Hum Reprod. 1995;10(5):1145–51. ment in in vitro fertilization outcome in patients
36. Dharia Patel SP, Steinkampf MP, Whitten SJ, with hydrosalpinx. Fertil Steril. 2006;86(6):1642–9.
Malizia BA. Robotic tubal anastomosis: surgi- 50. Shelton KE, Butler L, Toner JP, Oehninger S,
cal technique and cost effectiveness. Fertil Steril. Muasher SJ. Salpingectomy improves the pregnancy
2008;90(4):1175–9. rate in in-vitro fertilization patients with hydrosal-
37. Rodgers AK, Goldberg JM, Hammel JP, Fal- pinx. Hum Reprod. 1996;11(3):523–5.
cone T. Tubal anastomosis by robotic compared 51. de Wit W, Gowrising CJ, Kuik DJ, Lens JW, Schats
with outpatient minilaparotomy. Obstet Gynecol. R. Only hydrosalpinges visible on ultrasound are
2007;109(6):1375–80. associated with reduced implantation and preg-
38. Berger GS, Thorp JM Jr, Weaver MA. Effectiveness nancy rates after in-vitro fertilization. Hum Reprod.
of bilateral tubotubal anastomosis in a large outpa- 1998;13(6):1696–701.
tient population. Hum Reprod. 2016;31:1120–5. 52. Johnson N, van Voorst S, Sowter MC, Strandell A,
39. Tulandi T, Collins JA, Burrows E, Jarrell JF, Mol BW. Tubal surgery before IVF. Hum Reprod
McInnes RA, Wrixon W, et al. Treatment- Update. 2011;17(1):3.
dependent and treatment-independent pregnancy 53. Surrey ES, Schoolcraft WB. Laparoscopic manage-
among women with periadnexal adhesions. Am J ment of hydrosalpinges before in vitro fertilization-
Obstet Gynecol. 1990;162:354–7. embryo transfer: salpingectomy versus proximal
40. The American Fertility Society. The American fer- tubal occlusion. Fertil Steril. 2001;75(3):612–7.
tility society classifications of adnexal adhesions, 54. Mijatovic V, Veersema S, Emanuel MH, Schats R,
distal tubal occlusion, tubal occlusion second- Hompes PG. Essure hysteroscopic tubal occlusion
ary to tubal ligation, tubal pregnancies, Mullerian device for the treatment of hydrosalpinx prior to
anomalies and intrauterine adhesions. Fertil Steril. in vitro fertilization-embryo transfer in patients
1988;49(6):944–55.
533 23
with a contraindication for laparoscopy. Fertil 68. Goddijn M, van der Veen F, Schuring-Blom GH,
Steril. 2010;93(4):1338–42. Ankum WM, Leschot NJ. Cytogenetic char-
55. Darwish AM, El Saman AM. Is there a role for hys- acteristics of ectopic pregnancy. Hum Reprod.
teroscopic tubal occlusion of functionless hydrosal- 1996;11(12):2769–71.
pinges prior to IVF/ICSI in modern practice? Acta 69. Maymon R, Shulman A. Controversies and prob-
Obstet Gynecol Scand. 2007;86(12):1484–9. lems in the current management of tubal pregnancy.
56. Sowter MC, Akande VA, Williams JA, Hull MG. Is Hum Reprod Update. 1996;2(6):541–51.
the outcome of in-vitro fertilization and embryo 70. DeVoe RW, Pratt JH. Simultaneous intrauterine
transfer treatment improved by spontaneous or and extrauterine pregnancy. Am J Obstet Gynecol.
surgical drainage of a hydrosalpinx? Hum Reprod. 1948;56(6):1119–26.
1997;12:2147–50. 71. Goldman GA, Fisch B, Ovadia J, Tadir Y. Hetero-
57. Van Voorhis BJ, Sparks AE, Syrop CH, Stovall topic pregnancy after assisted reproductive technol-
DW. Ultrasound-guided aspiration of hydrosal- ogies. Obstet Gynecol Surv. 1992;47(4):217–21.
pinges is associated with improved pregnancy and 72. Yao M, Tulandi T. Current status of surgical and
implantation rates after in-vitro fertilization cycles. nonsurgical management of ectopic pregnancy. Fer-
Hum Reprod. 1998;13:736–9. til Steril. 1997;67(3):421–33.
58. Hammadieh N, Coomarasamy A, Ola B, Papaio- 73. Alsuleiman SA, Grimes EM. Ectopic pregnancy:
annou S, Afnan M, Sharif K. Ultrasound-guided a review of 147 cases. J Reprod Med. 1982;27(2):
hydrosalpinx aspiration during oocyte collec- 101–6.
tion improves pregnancy outcome in IVF: a ran- 74. Saxon D, Falcone T, Mascha EJ, Marino T, Yao M,
domized controlled trial. Hum Reprod. 2008;23: Tulandi T. A study of ruptured tubal ectopic preg-
1113–7. nancy. Obstet Gynecol. 1997;90(1):46–9.
59. Zhou Y, Jiang H, Zhang WX, Ni F, Wang XM, Song 75. Tulandi T, Hemmings R, Khalifa F. Rupture of
XM. Ultrasound-guided aspiration of hydrosalpinx ectopic pregnancy in women with low and declining
occurring during controlled ovarian hyperstimula- serum beta-human chorionic gonadotropin concen-
tion could improve clinical outcome of in vitro fer- trations. Fertil Steril. 1991;56(4):786–7.
tilization-embryo transfer. J Obstet Gynaecol Res. 76. American College of Obstetricians and Gynecolo-
2016;42:960–5. gists. ACOG Practice Bulletin No. 94: medical man-
60. Song XM, Jiang H, Zhang WX, Zhou Y, Ni F, agement of ectopic pregnancy. Obstet Gynecol.
Wang XM. Ultrasound sclerotherapy pretreatment 2008;111(6):1479–85.
could obtain a similar effect to surgical intervention 77. Goldstein SR, Snyder JR, Watson C, Danon
on improving the outcomes of in vitro fertilization M. Very early pregnancy detection with endovagi-
for patients with hydrosalpinx. J Obstet Gynaecol nal ultrasound. Obstet Gynecol. 1988;72(2):200–4.
Res. 2017;43:122–7. 78. Barnhart KT, Sammel MD, Rinaudo PF, Zhou L,
61. Cohen A, Almog B, Tulandi T. Hydrosalpinx Hummel AC, Guo W. Symptomatic patients with
sclerotherapy before in vitro fertilization: systematic an early viable intrauterine pregnancy: hCG curves
review and meta-analysis. J Minim Invasive Gyne- redefined. Obstet Gynecol. 2004;104(1):50–5.
col. 2018;25:600–7. 79. Buckley RG, King KJ, Disney JD, Riffenburgh
62. Barnhart KT. Clinical practice. Ectopic pregnancy. RH, Gorman JD, Klausen JH. Serum progester-
N Engl J Med. 2009;361(4):379–87. one testing to predict ectopic pregnancy in symp-
63. Bouyer J, Coste J, Fernandez H, Pouly JL, Job- tomatic first-trimester patients. Ann Emerg Med.
Spira N. Sites of ectopic pregnancy: a 10 year 2000;36(2):95–100.
population-based study of 1800 cases. Hum Reprod. 80. American College of Obstetricians and Gynecolo-
2002;17(12):3224–30. gists. ACOG practice bulletin. Medical management
64. Van Den Eeden SK, Shan J, Bruce C, Glasser of tubal pregnancy. Number 3, December 1998.
M. Ectopic pregnancy rate and treatment utiliza- Clinical management guidelines for obstetrician-
tion in a large managed care organization. Obstet gynecologists. Int J Gynaecol Obstet. 1999;65(1):
Gynecol. 2005;105(5 Pt 1):1052–7. 97–103.
65. Centers for Disease Control and Prevention (CDC). 81. Menon S, Colins J, Barnhart KT. Establishing a
Ectopic pregnancy—United States, 1990–1992. human chorionic gonadotropin cutoff to guide
MMWR Morb Mortal Wkly Rep. 1995;44(3): methotrexate treatment of ectopic pregnancy: a sys-
46–8. tematic review. Fertil Steril. 2007;87(3):481–4.
66. Della-Giustina D, Denny M. Ectopic pregnancy. 82. Barnhart KT, Gosman G, Ashby R, Sammel M. The
Emerg Med Clin North Am. 2003;21(3):565–84. medical management of ectopic pregnancy: a meta-
67. Coste J, Fernandez H, Joye N, Benifla J, Girard analysis comparing “single dose” and “multidose”
S, Marpeau L, et al. Role of chromosome abnor- regimens. Obstet Gynecol. 2003;101(4):778–84.
malities in ectopic pregnancy. Fertil Steril. 83. Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum
2000;74(6):1259–60. WM, van der Veen F. Interventions for tubal
534 M. Lee et al.
ectopic pregnancy. Cochrane Database Syst Rev. ACOG Practice Bulletin 3. Washington, D.C.:
23 84.
2007;1(1):CD000324.
Korhonen J, Stenman UH, Ylostalo P. Serum 86.
ACOG; 1998.
Al-Fadhli R, Tulandi T. In: Hurd WW, Falcone T,
human chorionic gonadotropin dynamics during editors. Clinical reproductive medicine and surgery.
spontaneous resolution of ectopic pregnancy. Fertil St. Louis: Mosby/Elsevier; 2007.
Steril. 1994;61(4):632–6. 87. Seeber B, Barnhart K. In: Falcone T, Hurd WW,
85. American College of Obstetricians and Gynecolo- editors. Clinical reproductive medicine and surgery.
gists. Medical management of tubal pregnancy. St. Louis: Mosby/Elsevier; 2007.
535 24
Endometriosis
Dan I. Lebovic and Tommaso Falcone
Contents
24.2 Prevalence of Endometriosis – 537
24.3 Diagnosis of Endometriosis – 537
24.4 Classification of Endometriosis – 539
24.5 Associated Disease Processes – 539
24.6 Anatomic Sites of Endometriosis – 539
24.7 Ovarian Endometriosis – 540
24.8 Deep Endometriosis – 540
24.9 Extrapelvic Endometriosis – 541
24.10 Predisposing Factors for Endometriosis – 541
24.12 Mechanism of Infertility – 542
24.13 Mechanism of Pain – 543
24.14 reatment of Endometriosis in the Infertile

T
Couple – 543
24.16 In Vitro Fertilization – 543
24.17 Endometriomas – 544

https://doi.org/10.1007/978-3-030-99596-6_24
24.18 Treatment of Patients with Chronic
Pelvic Pain – 544
24.18.1 edical Management for Pain – 544
M
24.18.2 Progestins – 544
24.18.4 Gonadotropin-Releasing Hormone Antagonist – 546
24.18.5 Aromatase Inhibitors – 546
24.18.6 Surgical Management for Pain – 546
24.18.7 Neurectomy – 547
24.18.8 Hysterectomy – 547
24.18.9 Posthysterectomy Recurrence – 547
24.18.10 Retrocervical Septum Endometriosis – 547
24.19 anagement of Endometriosis on Extragenital

M
Organs – 547
24.19.1 astrointestinal Endometriosis – 547
G
24.19.2 Respiratory System – 548
24.19.3 Genitourinary System – 548
24.19.4 Sciatic Nerve Involvement – 548
24.21 Answers – 549
References – 549
Endometriosis
537 24
pathophysiology of endometriosis—still
Key Points inconclusive. We then continue the theoretical
55 38.3% of women with an isolated endo- mindset by explaining the mechanisms for
metrioma will experience pelvic pain, endometriosis-associated subfertility and
whereas those with both an endometri- pain. At this point, treatment options are
oma and peritoneal implants will expe- explored starting with the infertile couple and
rience pain 85.4% of the time. then pelvic pain—both medical and surgical
55 Sensory nerve fibers are found more fre- management. Finally, options are provided
quently in the functional layer of the for dealing with extragenital endometriosis.
endometrium in women with endome-
triosis. Moreover, changes in the central
pain system may contribute to the Case Vignette
chronic pelvic pain.
55 The absolute benefit to fertility in per- A 27-year-old woman presents with a 1 year
forming surgery for minimal or mild history of infertility. She has a history of
endometriosis is a number needed to dysmenorrheal and dyspareunia. An ultra-
treat of 12. It should be noted that this sound reveals a 5 cm ovarian cyst compati-
is not including those undergoing sur- ble with an endometrioma. Semen analysis
gery for presumed endometriosis who is normal.
end up having a normal pelvis.
55 Surgery to remove endometriomas has
shown a deleterious effect on ovarian 24.2 Prevalence of Endometriosis
reserve as judged by anti-Müllerian
hormone levels. Endometriosis affects nearly 10% of
reproductive-age women between the ages of
12 and 80 years, with the average age at diag-
nosis around 28 years. Several conditions are
24.1 Introduction associated with higher rates of disease: for
instance, up to 50% of those with subfertility
Endometriosis is an incorrigible disease that is or chronic pelvic pain are found to have endo-
responsible for a multitude of hospital admis- metriosis and nearly 70% of adolescents with
sions and operative procedures [1]. When nonresponsive pelvic pain end up showing
endometrial tissue is found outside the endo- endometriotic lesions at the time of surgery.
metrial lining, this is called endometriosis. The incidence of ovarian cystic endometriosis
There is debate as to whether or not symp- (endometriomas) increases with age [2], but
tomatology must be present to meet the defi- its incidence and progression seem to stabilize
nition of endometriosis. This disease is in patients who are older than 35 years. Based
typically a chronic, progressive disorder, with on a study that involved repetitive laparos-
pelvic pain and infertility as the hallmark copy in baboons, we know that endometriosis
symptoms. Owing to the recognition of more appears spontaneously and that new lesions
subtle forms of endometriosis and the more seem to appear and disappear spontaneously
liberal use of diagnostic laparoscopy, the [3]. Thus, endometriotic lesions in humans
prevalence has been increasing. This chapter most likely are in continuous evolution as
has been organized to lead the reader initially well [4].
through the prevalence, diagnosis, and classi-
fication scheme before exploring the varied
anatomic sites of endometriotic lesions. 24.3 Diagnosis of Endometriosis
Predisposing factors are then delineated as a
means to expedite a diagnosis in those more The definitive diagnosis of endometriosis can
prone to having the disease. This then leads only be made surgically. The classic symptoms
into a review of the myriad theories as to the are dysmenorrhea, noncyclic pelvic pain,
538 D. I. Lebovic and T. Falcone
yspareunia, and infertility. Specific present-

d
ing physical signs indicative of advanced
endometriosis are listed in 7 Box 24.1.
24 Physical examination during menstruation is
more sensitive in the detection of pelvic dis-
ease. There is no laboratory test that can iden-
tify patients with endometriosis with a high
degree of sensitivity and specificity. The
search for biomarkers of this disease is robust
[5], although further studies are required
before clinical use can be recommended.
Currently, there is no reliable biochemical
.. Fig. 24.1 Typical black and white lesions of the pel-
marker to diagnose or stage endometriosis. vic peritoneum with dense fibrosis and retraction
stromal fibroblasts and epithelial cells from

Box 24.1 Signs and Symptoms of
Endometriosis lesions outside the endometrial cavity and
Signs uterine musculature. These lesions are histol-
Adnexal mass ogy independent from menstrual cycle-related
Adnexal tenderness changes [6]. The various typical lesions of
Uterine tenderness endometrios are referred to as clear, white,
55 Fixed retroversion red, polypoid, flame-like, powder-burn,
55 Lateral cervical displacement brown, blue-black, brown, or yellow lesions
Cul-de-sac (. Fig. 24.1). Defects in the peritoneum or
55 Tenderness peritoneal windows may contain these lesions.
55 Nodularity The American Society for Reproductive
55 Mass Medicine (ASRM) scoring system for endo-
Uterosacral ligament metriosis is widely used clinically but has sig-
55 Tenderness nificant intra- and interobserver variation
55 Nodularity (between 38% and 52%) [7].
Vaginal lesions The positive predictive value of lapa-
Cervical lesions roscopic visualization of endometriosis is
Symptoms considered to be approximately 50%. Classic
Reproductive tract red or black lesions have a visual accuracy
55 Infertility between 90% and 100%. White lesions are
55 Dysmenorrhea associated with endometriosis less often.
55 Dyspareunia with associated anor The main pathologies that can be confused
gasmia with endometriosis are endosalpingiosis,
55 Noncyclic pelvic pain fibrosis, mesothelial hyperplasia, carbon
Gastrointestinal deposits from previous surgery, and malig-
55 Diarrhea and/or constipation nancy. Hemangiomas, adrenal rests, and
55 Tenesmus splenosis canal can rarely be confused with
55 Abdominal cramps endometriosis. For this reason, diagnostic
55 Cyclic rectal bleeding laparoscopy should be accompanied with
Urinary biopsy for lesions that are not clearly endo-
Low-backpain metriosis. In fact, nearly 40% of women
undergoing laparoscopy for chronic pelvic
pain are found to have occult microscopic
endometriosis when clinically negative
The microscopic definition of endometriosis appearing peritoneum is biopsied [8].
implies histologically confirmed endometrial
Endometriosis
539 24
Ovarian endometriosis, as opposed to is poor, and future improvement in the clas-
nonovarian disease, can be detected pre- sification is both warranted and likely.
operatively with a high degree of accuracy
using ultrasonography. There may be a role
for magnetic resonance imaging (MRI) in the 24.5 Associated Disease Processes
identification of deeply infiltrating lesions
that involve the cul-de-sac or lesions in Surveys of endometriosis patients report
uncommon locations such as the sciatic nerve. increased incidence of atopic disease and
Diagnostic tests for patients with gastrointes- other autoimmune phenomena such as thy-
tinal symptoms such as colonoscopy or bar- roid disease, fibromyalgia, and chronic fatigue
ium enema radiography are typically normal syndrome. Endometriosis is associated with
or may occasionally show stricture. Patients increased incidence of non-Hodgkin’s lym-
with significant urinary symptoms should phoma, dysplastic nevi, and melanoma.
have a urologic evaluation to rule out intersti- Ovarian cancer (endometrioid and clear cell)
tial cystitis or potentially endometriosis of the is higher, although the overall life time risk is
bladder wall [8]. still quite low: 1.5% compared to 1% in the
The more common differential diagnoses general population.
of patients with chronic pain and potential
endometriosis are adhesions, chronic pelvic
inflammatory disease, interstitial cystitis, 24.6 Anatomic Sites
irritable bowel syndrome, and musculoskele- of Endometriosis
tal problems such as myofascial pain or
neuralgias. Endometriosis is most commonly found in the
posterior pelvis compartment [10]. The fol-
lowing are the most common locations, in
descending order: ovaries, cul-de-sac, broad
24.4 Classification ligament, and utero sacral ligaments. The left
of Endometriosis hemipelvis is the most common location—64%
compared to the right hemipelvis. More endo-
The classification of endometriosis has been metriosis is found on the left as opposed to the
an evolving process. In 1978, the American right ovary, possibly because the sigmoid
Fertility Society (AFS, now called the colon alters intraperitoneal fluid movement.
American Society for Reproductive Medicine) The bowel is the most common extra geni-
classified four stages (stages I–IV) and used an tal location of endometriosis. Bowel loca-
arbitrarily weighted points core that included tions, in decreasing order of frequency, are the
assessment of the extent of endometriosis in sigmoid colon (>65% of cases), rectum, ter-
two dimensions and the presence and extent minalileum, appendix, and the cecum. Most
of adhesions in the peritoneum, ovaries, and bowel lesions are superficial and limited to the
tubes. It also took into account whether the serosa. Occasionally, transmural involvement
endometriosis was unilateral or bilateral. of the bowel occurs, which may cause cyclic
The size of the endometrioma was consid- diarrhea, rectal bleeding, abdominal disten-
ered along with the presence of filmy vs. sion, and, rarely, bowel obstruction. The uri-
dense adhesions. In 1985 and again in 1996 nary tract is involved in only 1% of cases, and
(R-AFS), further revisions were made to the it most often affects the bladder (84%).
original AFS classification [9] (. Fig. 24.2). Symptoms for vesical endometriosis are simi-
An endometrioma measuring greater than 3 lar to those associated with recurrent cystitis.
cm in diameter signifies at least stage III dis- Endometriosis of the urinary tract should be
ease. Despite the improvements, the correla- suspected if cyclical urinary symptoms such
tion between the stage of endometriosis and as surgency, frequency, and suprapubic pain
the likelihood of pregnancy or degree of pain with or without hematuria occur.
STAGE I (MINIMAL) STAGE II (MILD) STAGE III (MODERATE)
24
PERITONEUM PERITONEUM PERITONEUM

Superficial endo – 1–3cm –2 Deep endo – > 3cm –6 Deep endo – > 3cm –6
R OVARY R OVARY CULDESAC

Superficial endo – < 1cm –1 Superficial endo – < 1cm –1 Partial obliteration –4
Filmy adhesions – < 1 –1 Filmy adhesions – < 1 –1
TOTAL POINTS 3 4 3 L OVARY
L OVARY Deep endo – 1–3cm –16
Superficial endo – < 1cm –1 TOTAL POINTS 26
TOTAL POINTS 9
STAGE III (MODERATE) STAGE IV (SEVERE) STAGE IV (SEVERE)
PERITONEUM PERITONEUM PERITONEUM

Superficial endo – >3cm –4 Superficial endo – >3cm –4 Deep endo – >3cm –6
R TUBE L OVARY CULDESAC

Filmy adhesions – < 1 –1 Deep endo – 1–3cm –32** Complete obliteration –40
3 Dense adhesions – < 1 –8**
3 R OVARY
R OVARY
Filmy adhesions – < 1 –1 L TUBE Deep endo – 1–3cm–16
3 Dense adhesions – < 1 –8** Dense adhesions – < 1
3 –4
L TUBE TOTAL POINTS 52 3
Dense adhesions – < 1 –16* L TUBE
3 Dense adhesions – > 2 –16
L OVARY 3
Deep endo – < 1cm –4 L OVARY
Dense adhesions – < 1 –4 *Point assignment changed to 16 Deep endo – 1–3cm –16
TOTAL POINTS 3 30 **Point assignment doubled Dense adhesions – > 2 –16
TOTAL POINTS 3 114
.. Fig. 24.2 ASRM revised classification of endometriosis
24.7 Ovarian Endometriosis pain [11]). Only a small percentage of patients

with peritoneal implants will eventually
Ovarian endometriosis or endometriomas develop an endometrioma. Endometriomas
increase with age and are generally associated can be uniloculated or multiloculated. They
with a more advanced stage of the disease [2]. are more commonly localized in the left ovary,
This form of endometriosis can be diagnosed as with peritoneal implants, likely due to the
with a high level of accuracy by serial natural peritoneal fluid flow subsequent to
ultrasounds. They may be confused with a menstrual regurgitation.
hemorrhagic corpus luteum, which will disap-
pear over the course of a few months. These
ovarian forms of endometriosis of 10 have 24.8 Deep Endometriosis
associated peritoneal implants (77% of the
time and 85.4% of these women experienced Invasion of endometriotic cells deeper than
pelvic pain whereas only 38.3% of those 5 mm has been associated with increased
with an isolated endometrioma experienced pain [12]. A recto vaginal exam during the
Endometriosis
541 24
menstrual period in the office setting or a (PCBs), might also play a role in the predispo-
thorough exam under anesthesia prior to lap- sition to endometriosis.
aroscopy may alert the surgeon to the pres- Data from the Nurses’ Health Study II
ence of these types of lesions. In a study suggests that specific dietary fat consumption
looking at 93 women with deep in filtrating may influence the risk of developing endome-
peritoneal endometriosis, 61% had concomi- triosis—long-chain omega-3 fatty acids were
tant superficial implants and 51% had endo- protective, whereas trans-unsaturated fats led
metriomas. Deep nodules were the only form to a greater risk.
of the disease in just 7% of the women.
24.11 Pathophysiology
24.9 Extrapelvic Endometriosis
Managing endometriosis receives the lion
Cutaneous endometriosis has been reported share of attention, although investigation into
in abdominal scars following cesarean sec- the genesis of the disease does not lag far
tions, hysterectomy, appendectomy, and lapa- behind. In fact, it is likely that only with the
roscopy. Rare lung cases of endometriosis discovery of the true pathogenesis of endome-
leading to cyclical hemoptysis or even catame- triosis will more efficacious therapy emerge as
nial pneumothorax have been reported and well as preventative measures for younger
imply that hematogenous and/or lymphatic women. The three different endometriosis
dissemination of endometrial cells is possible. entities—endometriomas, implants, and ret-
This mechanism can also explain the possible rocervical septum disease—could develop
spread to rare locations, such as the brain, along distinct routes, but overlapping
liver, pancreas, kidney, vertebra, and bones. mechanisms are probably at play for at least
some of these. The disease has multitudinous
theories for pathogenesis, yet only a handful
24.10 Predisposing Factors continue to be proffered as valid: (1) retro-
for Endometriosis grade menstruation (Sampson’s theory), (2)
metaplastic transformation (Meyer’s theory),
Endometriosis is mainly present during the (3) lymphatic or hematogenous embolization
reproductive years (average age of 28) and (Halban’s theory), (4) tissue relocation (i.e.,
usually regresses during menopause, suggest- iatrogenic surgical displacement of endome-
ing that the development and growth of endo- trium during laparoscopy or cesarean sec-
metriosis is estrogen dependent. Accordingly, tion), and (5) immune dysregulation leading
the Nurses’ Health Study prospectively to deficient clearance of ectopic endometrial
assessed predisposing factors for endometrio- tissue.
sis and observed an association with early age Over the years, each theory has received
of menarche, shorter length of menstrual indirect corroboration. Retrograde men-
cycles during late adolescence, and nulliparity. struum from the fallopian tubes into the pel-
Furthermore, women with low estrogen levels vis and beyond has been supported by
and low bodymass index, who use alcohol, identifying menstrual tissue refluxing from
who are infertile smokers, and who exercise the fallopian tubes during surgery and the
intensely appear to be at decreased risk [13]. identification of fresh endometrial lesions
Heredity is an important predisposing fac- during menstrual phase laparoscopy. In addi-
tor for endometriosis since the prevalence is tion, the baboon model of endometriosis is, in
increased seven fold among first-degree rela- effect, iatrogenic retrograde menses in vari-
tives. In monozygotic twins, the prevalence ably leading to the development of scattered
increased 15-fold. Exposure to pollutants, lesions [14]. Lastly, a greater frequency of
especially endocrine-disrupting compounds lesions in the right subphrenic region and left
such as dioxins or polychlorinated biphenyls hemipelvis/ovary supports retrograde menses,
since these locations follow the natural ten- adherence/invasion, angiogenesis, and nerve
dency of intra-abdominal peritoneal flow and fiber innervation [19].
obstruction via the falciform ligament.
24 Unclear, however, is why endometriosis is not
24.12 Mechanism of Infertility
found in all women, given the ubiquitous
nature of retrograde menstruation.
Metaplasia of the coelomic epithelium Even though there is a purported association
seems equitable given that both peritoneal between infertility and endometriosis, the
and endometrial tissues emanate from coelo- mechanism of this association remains com-
mic cells. Zheng et al. have shown histologic, plex and is not completely understood [20]. A
morphologic evidence of transitioning ovar- population-based cohort study using record
ian surface epithelium into endometriotic linkage comparing 5375 women with surgi-
cells, corroborating a metaplastic process [15]. cally confirmed endometriosis with outcomes
A corollary to this postulate is that of the in 8710 women without endometriosis
embryo genetic theory or Müllerianosis: mis- revealed an increased risk of miscarriage [21].
placed endometrial tissue during the embryo- The following factors may explain a dimin-
logic period of organogenesis. Signorile et al. ished fecundity:
demonstrated the presence of ectopic endo- 55 Anatomical changes. Endometriosis, when
metrium in 9% of 101 human female fetuses moderate or severe, will often lead to peri-
[16]. With endogenous estradiol stimulation tubal or periovarian adhesions, thus com-
later in life, this tissue could grow and thus promising tubal motility and ovum
present as ectopic implants. Theoretically, capture.
deep retrocervical septum lesions could derive 55 Immunological factors. The peritoneal
from such abnormal embryogenesis. fluid of women with endometriosis has an
Newer, exciting pathophysiology theories abnormal level of cytokines, prostaglan-
borrow from the traditional theories and, dins, growth factors, and inflammatory
most significantly, build upon these premises cells, which are likely to participate in the
in order to better grasp the true etiology. For etiology and/or sustenance of endometrial
instance, stem cells originating from the bone implants. These alterations negatively
marrow (Meyer’s theory) have been found to affect sperm motility, oocyte maturation,
populate eutopic endometrium (Halban’s the- fertilization, embryo survival, and tubal
ory) that may then be shed (Sampson’s theory) function.
into the peritoneal cavity. Vercellini et al. pro- 55 Effect on embryo development and implan-
vided another concept for the development of tation. Patients with stage I and II endome-
endometriomas when they described how a triosis have high levels of anti-endometrial
hemorrhagic corpus luteum may progress to antibodies, which may reduce implanta-
an endometrioma [17]. If this were truly an tion. IL-1 and IL-6 are elevated in the
endometrioma, then retrograde menses peritoneal fluid of patients with endome-
(Sampson’s theory) would be a prerequisite to triosis and are embryotoxic. Expression of
seed the cyst contents with endometrial cells. HOXA10 and HOXA11 genes, which are
Underlying virtually all of these theories is usually upregulated during the secretory
the molecular underpinnings of the disease phase of the menstrual cycle, is not upregu-
and, in particular, the inherent immune dys- lated inpatients with endometriosis. These
function that could at once promote and sus- genes regulate the expression of α(alpha)
tain endometriosis [18]. The aberrant immune vβ(beta)3 integrin, which plays a crucial
factors found in women affected with endo- role in the embryo’s ability to attach to the
metriosis could explain why some develop the endometrium. A decrease in α v β3 and
disease while others do not. The chronic l-selectin expression has been reported in
inflammatory milieu can impair normal clear- patients with endometriosis, which might
ance of endometrial tissue and encourage explain the decrease in implantation.
Endometriosis
543 24
24.13 Mechanism of Pain 24.15 Surgical Treatment
Pain associated with endometriosis is quite Surgical treatment of minimal or mild (stage
complex. Pain associated with advanced dis- I-II) endometriosis improves the spontaneous
ease can be caused by extensive adhesions, pregnancy rate; however, the absolute benefit
ovarian cysts, or deeply infiltrating endome- is small. A meta-analysis of the two random-
triosis. Expression of nerve growth factor is ized clinical trials investigating this question
associated with endometriosis pain. Sensory showed a mild improvement with a number
nerve fibers have been found more frequently needed to treat (NNT)—that is, the number
in the functional layer of the endometrium of of persons that would need to be treated sur-
women with endometriosis than those unaf- gically to achieve an extra pregnancy—of 12
fected by the disease. Finally, discrete changes (95%CI,7,49).
in the central pain system (i.e., regional gray Postoperative suppressive medical therapy
matter volume) may contribute to chronic after surgical treatment does not improve fer-
pain in women with endometriosis [22]. tility. The only value of medical suppressive
Even patients with early-stage disease (few therapy (i.e., GnRHa) may be before in vitro
scattered implants) can experience severe fertilization (IVF) [23]. In these cases, the use
pain. This pain can be explained in part by the of GnRHa for 3–6 months prior to IVF
increase in prostaglandins. In contrast to the increases the clinical pregnancy rate by a fac-
normal endometrium (referred to as eutopic tor of 4 (OR 4.28, 95% CI, 2,9.15). There are
endometrium), ectopic endometrium (endo- few studies along these lines with significant
metriosis) is the site of at least two molecular design heterogeneity giving one pause as to its
aberrations that result in the accumulation of validity. Moreover, it is not clear for the
increasing quantities of estradiol and prosta- moment if a specific disease severity may have
glandin E2 (PGE2). With the first aberration, a better response to such suppressive therapy.
activation of the gene that encodes aromatase If the patient does not wish surgical ther-
increases, leading to increased aromatase apy, then the next step is either IV for treat-
activity in endometriotic tissue. This activa- ment with superovulation and intrauterine
tion is stimulated by PGE2, which is the most insemination (IUI) followed by gonadotro-
potent inducer of aromatase activity in the pins and IUI. There is insufficient evidence to
endometriotic stromal cells. The second recommend surgery prior to IVF.
important molecular aberration in endometri- In advanced disease, surgical management
otic tissue is the increased stimulation of improves fertility. However, this surgery is
COX-2 by estradiol, which leads to increased complex and requires meticulous dissection.
production of PGE2. This establishes a circu- If an initial surgery for advanced disease fails,
lar event leading to accumulation of PGE2 in subsequent surgery is less successful than IVF
the endometriotic tissue. in establishing a pregnancy and should be
reserved for patients who require manage-
ment of pain.
24.14 Treatment of Endometriosis
in the Infertile Couple
24.16 In Vitro Fertilization
It is estimated that in an infertile couple with
stage I or II endometriosis, the monthly fecun- In a retrospective cohort study, the diagnosis
dity rate is 3% per cycle. Medical suppressive of endometriosis (without endometriomas)
therapy with an oral contraceptive agent or was associated with similar IVF pregnancy
gonadotropin-releasing hormone agonist rates [24] compared with tubal factor infertil-
(GnRHa) does not improve the pregnancy ity. IVF offers the best fecundity rate for those
rate prior to trying non-assisted reproductive with endometriosis. Endometriosis patients
technology. undergoing IVF had no greater aneuploidy
rate compared with age-matched women sonable to offer patients oocyte vitrification
without endometriosis [25]. Moreover, simi- as a means to preserve their future fertility
lar implantation rates were observed when and allow them to take suppressive hormonal
24 transferring euploid embryos in women with therapy in the interim [32].
endometriosis compared with controls sug- Interestingly, in a retrospective chart
gesting a normalized endometrium with review, the higher the rate of endometrioma
ovarian suppression from estradiol and intra- recurrence, the greater the antral follicle count
muscular progesterone [26], Admittedly, cost in the affected ovary. This may be a conse-
and fewer supernumerary embryos maybe a quence of less ovarian trauma at the time of
limiting factor. cystectomy [33]. Simple drainage of an endo-
Initial studies proposed using prolonged metrioma has been shown to be ineffective.
GnRH agonists prior to IVF in endometrio-
sis patients (especially those with more
advanced disease), and yet most of these 24.18 Treatment of Patients
studies were of low quality, and subsequent with Chronic Pelvic Pain
randomized trials have not substantiated any
improved outcome [27, 28 29]. The same can 24.18.1 Medical Management
be concluded from using extended GnRH
agonists prior to frozen embryo transfers.
for Pain
Several classes of drugs have traditionally

been used to manage pain associated with
24.17 Endometriomas endometriosis (. Table 24.1). Progestins or
combined oral contraceptives and nonsteroi-
Endometriomas larger than 4 cm should be dal anti-inflammatory drugs are used as first-
removed to confirm they are benign. In a line therapy for chronic pain associated with
randomized trial, excision of the endometri- endometriosis. In a prospective, randomized
oma was associated with less recurrence and controlled trial comparing combined oral
higher spontaneous fertility rates than fen- contraceptives with GnRHa, both treatment
estration and bipolar coagulation [30]. IVF arms led to similar pain relief [34].
outcomes have been reported to be similar in
patients with and without endometriomas.
However, the number oocytes, fertilization 24.18.2 Progestins
rates, and the number of embryos obtained
were decreased in women with endometrio- Subcutaneous medroxyprogesterone acetate
mas compared with those without endome- (Depo-subQprovera104, Pfizer, New York,
triomas. The preponderance of evidence NY, USA)administered every 12–14weeks
suggests that in symptomatic women, one can subcutaneously was approved by the US Food
safely remove endometriomas without com- and Drug Administration (FDA) for the treat-
promising ovarian function or the success of ment of endometriosis-related pelvic pain. The
assisted reproduction. Accumulating studies bone loss seems to be less pronounced than
reflect a detrimental impact from surgery on with the use of GnRHa without add- back
ovarian reserve as assessed by anti-Müllerian therapy. However, there are no data yet with
hormone levels [31]. Accidental puncture of the prolonged use of Depo-subQ, and the rec-
an endometrioma during oocyte retrieval ommendation is not to use the drug for more
may cause infection or contamination of fol- than 2 years unless other methods are unac-
licular fluid. Histologic confirmation of the ceptable. Note that the rate of abnormal vagi-
benign nature of a large endometrioma may nal bleeding while on Depo-subQ was 17%.
be prudent. Given the negative effect on ovar- There are several other progestins that
ian reserve by endometriosis, it is not unrea- have been used for the treatment of
Endometriosis
545 24
.. Table 24.1 Drugs used for the treatment of endometriosisa
Class Drug Dosage
Androgen Danazolb 100–400 mg PO twice a day

100 mg per vagina daily
Aromatase inhibitor Anastrozolec 1 mg PO daily
Letrozolec 2.5 mg PO daily
Estrogen–progestin Monophasic estrogen/ Low ethinylestradiol dose continuously
combinations progestinb
Gonadotropin-releasing Goserelinb, c 3.6 mg SC monthly (10.8 mg IM every
hormone agonist 3 months)
Leuprolide depotb, c 3.75 mg IM monthly (11.75 mg IM every
3 months)
Nafarelinb, c 200 μg intra nasally twice a day
Gonadotropin-releasing Elagolixb 150 mg PO daily or 200 mg PO twice daily
hormone antagonist
Cetrorelix 3 mg SC weekly
Progestin Depo-subQ provera 104b 104 mg/0.65 mLSC every 3 months
Dienogest 2 mg PO dailyd
Etonogestrel-releasing implant 1 for 3 years
Levonorgestrel-releasing IUS 1 for 5 years
Medroxyprogesterone acetate 30 mg PO daily for 6 months, followed by
100 mg IM every 2 weeks × 2 months, then
200 mg IM monthly × 4 months
Norethindrone acetateb 5 mg PO daily
SC subcutaneously, IM intramuscularly, IUS intrauterinesystem

aAdapted from [4]
bFDA approved for endometriosis
cWith add-back therapy, that is, norethindrone acetate 5 mg daily + vitamin D 800 IU daily + calcium 1.25 g daily
dDienogest is a 19-nortestosterone derivative that is approved in the European Union for the treatment of
endometriosis. It is not available in the United States as a separate drug. It is only available in the oral contra-
ceptive Natazia (Bayer Pharmaceuticals, Montville, NJ, USA) (estradiolvalerate/dienogest), which is a newer
four-phasic pack that contains dienogest.
endometriosis-associated pelvic pain. The seems to be merit in reverting to NETA if oral

FDA also approved norethindrone acetate contraceptives alone are ineffective at reliev-
(NETA) 5 mg daily with a GnRHa. Through ing pain [35]. The levonorgestrel intrauterine
NETA’s estrogenic activity, there is a beneficial system has been successfully used for symp-
effect on both bone mineral density and vaso- tomatic endometriosis. Trials have demon-
motor symptoms; 5 mg of NETA is equiva- strated pain relief and decreased menstrual
lent to 20–30 μg of oral ethinylestradiol. There blood loss.
24.18.3 Gonadotropin-Releasing over 6 months, but we do not recommend its

Hormone Agonists use as empiric therapy [36]. There are two
doses of elagolix, 150 mg once daily (diminu-
24 GnRH agonists can be given via an intramus- tion in dysmenorrhea and nonmenstrual pel-
cular (leuprolide acetate), subcutaneous (gos- vic pain) and 200 mg twice daily (significant
erelin), or nasal (nafarelin) route. After an decrease in dyspareunia as well as dysmenor-
initial increase in gonadotropins during the rhea and nonmenstrual pelvic pain). There
first 10 days, there is a decrease in pituitary are several drawbacks to advocating elagolix
secretion secondary to GnRH receptor down- as a first-line therapeutic [37]. Since there is a
regulation. These drugs are typically given for dose-dependent decrease in bone mineral den-
an initial 6-month course. The majority of sity after six months of treatment, add-back
patients (75–80%) in clinical trials responded. therapies should be prescribed if one is using
However, many patients will have recurrence the higher elagolix dose. Since estrogen-
of pain within five months. A main concern is containing oral contraceptives can reduce the
the progressive loss in bone mineral density. efficacy of elagolix, and ovulation is not suf-
Menstrual periods return between 2 and ficiently inhibited with low elagolix doses,
3 months after the last monthly injection, but women should use a nonhormonal method of
recovery of bone mineral density takes more contraception during treatment. How elagolix
time. compares with currently used progestogens
Add-back therapy with estrogens or pro- and low-dose hormonal contraceptives is yet
gestins was introduced as a way to reduce the to be determined and should factor into a
hypoestrogenic side effects of GnRHa, espe- stepped-care approach to these patients, espe-
cially the loss in bone mineral density, but also cially given the much higher cost of elagolix.
vasomotor symptoms and atrophic vaginal
mucosa. Other symptoms such as insomnia,
mood disorders, and cognitive dysfunction 24.18.5 Aromatase Inhibitors
may occur. The mean decrease in bone min-
eral density after 1 year of GnRH a treatment Aromatase inhibitors have been successfully
without add-back is between 3% and 7%. used in a limited number of cases of persistent
Add-back therapy has been proposed for disease after hysterectomy and bilateral
both short-term (less than 6 months) and oophorectomy, as well as inpatients with
long-term use (more than 6 months). Many intact pelvic organs. The putative mechanism
studies have shown that the efficacy is not is by suppression of locally produced estro-
reduced. Norethindrone (5 mg orally daily) is gens from aromatase activity expressed by the
the most commonly used add-back regimen. endometriotic cells. Typically, an aromatase
Low-dose estrogen (conjugated equine estro- inhibitor such as letrozole 2.5 mg or anastro-
gen 0.625 mg) can also be added to the noreth- zole 1 mg daily is given with NETA (5 mg
indrone without loss of benefit in symptom daily) to prevent ovarian cyst formation and a
control. Higher doses of estrogen (i.e., possible decrease in bone mineral density.
combined oral contraceptives) are associated
with diminished efficacy in relieving pain
symptoms. 24.18.6 Surgical Management
for Pain
24.18.4 Gonadotropin-Releasing Two prospective randomized controlled stud-
Hormone Antagonist ies have clearly shown that surgical therapy is
superior to no treatment for relief of pain
Elagolix is an oral, nonpeptide gonadotropin- from endometriosis [38]. One randomized
releasing hormone antagonist used for mod- controlled trial with only 16 women did not
erate to severe endometriosis-related pain
Endometriosis
547 24
show a statistically significant difference in oophorectomy in women less than 40 years of
pain relief [39]. age [44, 45].
Several observations can be surmised from
these studies: (1) surgery is more effective than
simple diagnostic laparoscopy in the treat- 24.18.9 Posthysterectomy
ment of pain associated with endometriosis; Recurrence
(2) there is a significant placebo effect associ-
ated with surgery, especially early on Endometriosis can recur in 5–10% of patients
(3 months), that persists in approximately after hysterectomy and bilateral salpingo-
20% of patients; (3) between 20 and 40% of oophorectomy. The role of hormone replace-
patients will not respond to surgery and will ment therapy after surgical castration is
continue to experience pain and (4) surgery is controversial. There is a possibility of symp-
least effective for early-stage disease. tom or disease recurrence (3.5%). However,
It is unclear if excision of endometriosis is there is the real possibility of severe vasomo-
superior to simple ablation by cautery or laser tor symptoms and osteoporosis. Hormone
[40]. Postoperative treatment with hormonal replacement therapy is not contraindicated,
suppressive therapy can delay recurrence of and the risks and benefits should be discussed
disease and associated symptoms [41]. with the patient.
24.18.7 Neurectomy 24.18.10 Retrocervical Septum

Endometriosis
Interruption of the cervical and uterine sen-
sory nerves by transaction of the utero sacral The management of retrocervical septum
ligaments, an uterosacral nerve ablation, has endometriosis is extremely difficult and usu-
been shown not to have any long-term benefit ally involves the recto sigmoid. Patients usu-
[42]. A presacral neurectomy has been shown ally have severe symptoms that may involve
to be beneficial in patients with chronic pelvic the gastrointestinal tract such as constipa-
pain and endometriosis when performed with tion, diarrhea, and painful bowel movements.
surgical treatment of the endometriosis However, some patients with retrocervi-
lesions [43]. The procedure is associated with cal endometriosis are asymptomatic. These
greater relief of midline pain rather than lat- patients do not need treatment.
eral pain. The success of the procedure is
dependent on excision of the superior hypo-
gastric plexus (presacral nerve) before exten- 24.19 Management of
sive branching has occurred. The most
common postsurgical complications that have
Endometriosis on
limited its use are constipation and urinary Extragenital Organs
urgency.
24.19.1 Gastrointestinal
Endometriosis
24.18.8 Hysterectomy
Although gastrointestinal symptoms are quite
Hysterectomy with or without bilateral common in women with endometriosis, the
salpingo-oophorectomy can be considered in overall incidence of bowel involvement is
patients whose disease fails to respond to con- reported to be around 5%. Endometriosis of
servative management and who do not desire the gastrointestinal system typically involves
future fertility. Most studies have shown sig- the rectum or recto sigmoid. Recurrence of
nificant pain relief from definitive surgery. disease after hysterectomy and oophorectomy
Caution should be used in recommending more commonly involves the bowel. Excision
of disease or intestinal resection can be
a b
24
.. Fig. 24.3 a This figures how fibrotic-type endome- by the liver. b Hemorrhagic-type endometriosis lesions
trios is involving the right hemidiaphragm. The lesions of the right hemidiaphragm
are seen above the liver. Most of the lesions are obscured
erformed by laparotomy or by laparoscopy.

p 24.19.3 Genitourinary System
Rectovaginal fistula and abscess formation
are the most serious complications reported. Endometriosis often involves the peritoneum
over the ureter. However, direct ureter involve-
ment is uncommon and has been reported in
24.19.2 Respiratory System less than 1% of patients; it is predominantly
left-sided (63%) when this is observed.
Diaphragmatic endometriosis can be a symp- Ureteral involvement can be the result of
tomatic and noted incidentally at diagnos- extrinsic compression from extensive endome-
tic laparoscopy (. Fig. 24.3). Symptomatic triosis that surrounds the ureter with signifi-
patients often report right-sided chest pain cant fibrosis. The majority of the patients
or shoulder pain in association with men- have significant involvement of the retrocervi-
struation that occasionally radiates into the cal septum with nodules that are often greater
neck or arm and dyspnea. Asymptomatic than 3 cm. Preoperative imaging studies such
diaphragmatic lesions do not need treatment. as MRI with contrast should be used to evalu-
Electrosurgery, laser, or surgical excision ate the renal system preoperatively in patients
should be performed carefully because the with retrocervical disease. Medical therapy
thickness of the diaphragm ranges between 1 has been used successfully in a limited number
and 5 mm. of patients. Most cases of ureteral endome-
Thoracic endometriosis most commonly triosis can be treated with excision of the peri-
presents as a right-sided catamenial pneumo- ureteral fibrosis and active lesions without
thorax but the canal can be manifested by ureter resection. Complications such as ure-
hemothorax, hemoptysis, or pulmonary nod- teral fistulae (5% incidence) can occur with
ules. The typical symptoms are chest pain and extensive ureterolysis in women with deeply
dyspnea. Approximately 30% of these women infiltrating disease.
have pelvic endometriosis at the time of surgi-
cal management of the thoracic disease. A
chest CT scan may demonstrate pulmonary or 24.19.4 Sciatic Nerve Involvement
pleural nodules, especially if performed dur-
ing a menstrual period. Chemical pleurodesis Patients with endometriosis of the sciatic
is associated with a lower recurrence rate of nerve can present with hip pain, which is usu-
catamenial pneumothorax than hormonal ally localized to the buttock. The pain radi-
treatment. However, initial treatment with ates down to the back of the leg, and numbness
hormonal therapy is indicated. occurs in areas innervated by the sciatic nerve.
Endometriosis
549 24
The symptoms typically occur in association References
with a menstrual period but then extend in to
other times of the cycle. Progressive leg and 1. Simoens S, Dunselman G, Dirksen C, Hummelshoj
foot muscle weakness with electromyogram L, Bokor A, Brandes I, et al. The burden of endo-
metriosis: costs and quality of life of women with
studies showing denervation can be demon-
endometriosis and treated in referral centres. Hum
strated. MRI typically shows a lesion infiltrat- Reprod. 2012;27(5):1292–9.
ing the sciatic nerve. CT-guided biopsy can be 2. Koninckx PR, Mueleman C, Demeyere S, Lesaffre
used to confirm the diagnosis. Two-thirds of E, Cornillie FJ. Suggestive evidence that pelvic
cases are localized to the right-side. Most endometriosis is a progressive disease, whereas
deeply infiltrating endometriosis is associated with
cases have pelvic endometriosis associated
pelvic pain. Fertil Steril. 1991;55(4):759–65.
with this disease. Treatment with a GnRHa 3. Harirchian P, Gashaw I, Lipskind ST, Braundmeier
and add-back therapy have been shown to AG, Hastings JM, Olson MR, et al. Lesion kinetics
reverse the neurologic abnormalities. in an on-human primate model of endometriosis.
Hum Reprod. 2012;27(8):2341–51.
4. Falcone T, Lebovic DI. Clinical management of
endometriosis. Obstet Gynecol. 2011;118(3):
24.20 Review Questions 691–705.
5. Fassbender A, Waelkens E, Verbeeck N, Kyama
??1. What is the positive predictive value of CM, Bokor A, Vodolazkaia A, et al. Proteomics
laparoscopic visualization of endome- analysis of plasma for early diagnosis of endome-
triosis. Obstet Gynecol. 2012;119(2Pt1):276–85.
triosis?
6. Colgrave EM, Bittinger S, Healey M, Dior UP, Rog-
A. 10% ers PAW, Keast JR, Girling JE, Holdsworth-Carson
B. 30% SJ. Superficial peritoneal endometriotic lesions are
C. 50% histologically diverse and rarely demonstrate men-
D. 80% strual cycle synchronicity with matched eutopic
endometrium. Hum Reprod. 2020;35(12):2701–14.
7. Revised American fertility society classification of
??2.
Which of the following is associated endometriosis. Fertil Steril. 1985;43:1–2.
with a lower risk of developing endo- 8. Gubbels AL, Li R, Kreher D, Mehandru N, Castel-
metriosis? lanos M, Desai NA, Hibner M. Prevalence of occult
A. Long-chain omega-3 fatty acids microscopic endometriosis in clinically negative
peritoneum during laparoscopy for chronic pelvic
B. Exposure to dioxins
pain. Int J Gynaecol Obstet. 2020;151(2):260–6.
C. Elevated body mass index 9. Canis M, Donnez JG, Guzick DS, Halme JK, Rock
D. Trans-unsaturated fats JA, Schenken RS, Vernon MW. Revised American
society for reproductive medicine classification of
??3. Endometriosis can recur in what percent endometriosis: 1996. Fertil Steril. 1997;67(5):
817–21.
of patients undergoing hysterectomy
10. Scioscia M, Bruni F, Ceccaroni M, Steinkasserer M,
and bilateral salpingo-oophorectomy? Stepniewska A, Minelli L. Distribution of endome-
A. <3% triotic lesions in endometriosis stage IV supports
B. 5–10% the menstrual reflux theory and requires specific
C. 30% preoperative assessment and therapy. Acta Obstet
Gynecol Scand. 2011;90(2):136–9.
D. 40%
11. Khan KN, Kitajima M, Fujishita A, Hiraki K, Mat-
sumoto A, Nakashima M, Masuzaki H. Pelvic pain
in women with ovarian endometrioma is mostly
24.21 Answers associated with coexisting peritoneal lesions. Hum
Reprod. 2013;28(1):109–18.
12. Koninckx PR, Martin DC. Deep endometriosis: a
vv1. C consequence of infiltration or retraction or possibly
adenomyosis externa? Fertil Steril. 1992;58(5):
vv2. A 924–8.
13. Missmer SA, Hankinson SE, Spiegelman D, Barb-
ieri RL, Marshall LM, Hunter DJ. Incidence of
vv3. B
laparoscopically confirmed endometriosis by demo-
graphic, anthropometric, and lifestyle factors. Am J adjuvant medical treatment of peritoneal endome-
Epidemiol. 2004;160(8):784–96. triosis on the outcome of IVF. Hum Reprod.
14. D’Hooghe TM, Bambra CS, Raeymaekers BM, 2016;31(9):2017–23.
DeJonge I, Lauweryns JM, Koninckx PR. Intra pel- 28. Rodríguez-Tárrega E, Monzo AM, Quiroga R,
24 vic injection of menstrual endometrium causes Polo-Sánchez P, Fernández-Colom P, Monterde-
endometriosis in baboons (Papio cynocephalus and Estrada M, Novella-Maestre E, Pellicer A. Effect of
Papioanubis). Am J Obstet Gynecol. GnRH agonist before IVF on outcomes in infertile
1995;173(1):125–34. endometriosis patients: a randomized controlled
15. Zheng W, Li N, Wang J, Ulukus EC, Ulukus M, trial. Reprod Biomed Online. 2020;41(4):653–62.
Arici A, et al. Initial endometriosis showing 29. Georgiou EX, Melo P, Baker PE, Sallam HN,
direct morphologic evidence of metaplasia in the Arici A, Garcia-Velasco JA, Abou-Setta AM,
pathogenesis of ovarian endometriosis. Int J Gyne- Becker C, Granne IE. Long-term GnRH agonist
col Pathol. 2005;24(2):164–72. therapy before in vitro fertilisation (IVF) for
16. Signorile PG, Baldi F, Bussani R, Viceconte R, Bul- improving fertility outcomes in women with endo-
zomi P, D’Armiento M, et al. Embryologic origin of metriosis. Cochrane Database Syst Rev.
endometriosis: analysis of 101 human female 2019;2019(11):CD013240.
fetuses. J Cell Physiol. 2012;227(4):1653–6. 30. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E,
17. Vercellini P, Somigliana E, Vigano P, Abbiati A, Bolis P. Randomized clinical trial of two laparo-
Barbara G, Fedele L. ‘Blood on the tracks’ from scopic treatments of endometriomas: cystectomy
corpora lutea to endometriomas. BJOG. 2009; versus drainage and coagulation. Fertil Steril.
116(3):366–71. 1998;70:1176–80.
18. Lebovic DI, Mueller MD, Taylor RN. Immuno biol- 31. Shah DK, Mejia RB, Lebovic DI. Effect of surgery
ogy of endometriosis. Fertil Steril. 2001;75(1):1–10. for endometrioma on ovarian function. J Minim
19. Asante A, Taylor RN. Endometriosis: the role of Invasive Gynecol. 2014;21(2):203–9.
neuroangiogenesis. Annu Rev Physiol. 2011;73: 32. Pluchino N, Roman H. Oocyte vitrification offers
63–82. more space for a tailored surgical management of
20. The Practice Committee of the American Society endometriosis. Reprod Biomed Online.
for Reproductive Medicine. Endometriosis and 2020;41(5):753–5.
infertility: a committee opinion. Fertil Steril. 33. Somigliana E, Benaglia L, Vercellini P, Paffoni A,
2012;98(3):591–8. Ragni G, Fedele L. Recurrent endometrioma and
21. Saraswat L, Ayansina DT, Cooper KG, Bhattacha- ovarian reserve: biological connection or surgical
rya S, Miligkos D, Horne AW, Bhattacharya S. Preg- paradox? Am J Obstet Gynecol. 2011;204(6):529.
nancy outcomes in women with endometriosis: a e1–5.
national record linkage study. BJOG. 34. Guzick DS, Huang LS, Broadman BA, Nealon M,
2017;124(3):444–52. Hornstein MD. Randomized trial of leuprolide ver-
22. As-Sanie S, Harris RE, Napadow V, Kim J, Neshe- sus continuous oral contraceptives in the treatment
wat G, Kairys A, Williams D, Clauw DJ, Schmidt- of endometriosis-associated pelvic pain. Fertil
Wilcke T. Changes in regional gray matter volume in Steril. 2011;95(5):1568–73.
women with chronic pelvic pain: a voxel-based mor- 35. Vercellini P, Ottolini F, Frattaruolo MP, Buggio L,
phometry study. Pain. 2012;153(5):1006–14. Roberto A, Somigliana E. Is shifting to a progestin
23. Sallam HN, Garcia-Velasco JA, Dias S, Arici worthwhile when estrogen-progestins are ineffica-
A. Long-term pituitary down-regulation before cious for endometriosis-associated pain? Reprod
in vitro fertilization (IVF) for women with endome- Sci. 2018;25(5):674–82.
triosis. Cochrane Database Syst Rev. 2006;1: 36. Taylor HS, Giudice LC, Lessey BA, et al. Treatment
CD004635. of endometriosis-associated pain with elagolix, an
24. Opoien HK, Fedorcsak P, Omland AK, Abyholm T, oral GnRH antagonist. N Engl J Med. 2017;377:
Bjercke S, Ertzeid G, et al. Invitro fertilization is a 28–40.
successful treatment in endometriosis-associated 37. Vercellini P, Viganò P, Barbara G, Buggio L,
infertility. Fertil Steril. 2012;97(4):912–8. Somigliana E. ‘Luigi Mangiagalli’ Endometriosis
25. Juneau C, Kraus E, Werner M, Franasiak J, Morin Study Group. Elagolix for endometriosis: all that
S, Patounakis G, Molinaro T, de Ziegler D, Scott glitters is not gold. Hum Reprod. 2019;34(2):
RT. Patients with endometriosis have aneuploidy 193–9.
rates equivalent to their age-matched peers in the 38. Sutton C, Ewen S, White law N, Haines P. Prospec-
in vitro fertilization population. Fertil Steril. tive, randomized, double-blind, controlled trial of
2017;108(2):284–8. laser laparoscopy in the treatment of pelvic pain
26. Bishop LA, Gunn J, Jahandideh S, Devine K, associated with minimal, mild. and moderate endo-
Decherney AH, Hill MJ. Endometriosis does not metriosis.FertilSteril. 1994;62:696–700.
impact live-birth rates in frozen embryo transfers of 39. Jarrell J, Mohindra R, Ross S, Taenzer P, Brant
euploid blastocysts. Fertil Steril. 2020;21:S0015–282. R. Laparoscopy and reported pain among patients
27. Decleer W, Osmanagaoglu K, Verschueren K, Com- with endometriosis. J Obstet Gynaecol Can.
haire F, Devroey P. RCT to evaluate the influence of 2005;27(5):477–85.
Endometriosis
551 24
40. Burks C, Lee M, DeSarno M, Findley J, Flyckt tomy in women with severe dysmenorrhea caused by
R. Excision versus ablation for management of min- endometriosis who were treated with laparoscopic
imal to mild endometriosis: a systematic review and conservative surgery: a 1-year prospective random-
meta-analysis. J Minim Invasive Gynecol. ized double-blind controlled trial. AmJObstetGyne-
2020;10:S1553–4650. col. 2003;189(1):5–10.
41. Zakhari A, Delpero E, McKeown S, Tomlinson G, 44. Shakiba K, Bena JF, McGill KM, Minger J, Falcone
Bougie O, Murji A. Endometriosis recurrence fol- T. Surgical treatment of endometriosis: a7-year fol-
lowing post-operative hormonal suppression: a sys- low-up on the requirement for further surgery.
tematic review and meta-analysis. Hum Reprod Obstet Gynecol. 2008;111(6):1285–92.
Update. 2021;27(1):96–107. 45. Sandström A, Bixo M, Johansson M, Bäckström T,
42. Proctor ML, Latthe PM, Farquhar CM, Khan KS, Turkmen S. Effect of hysterectomy on pain in
Johnson NP. Surgical interruption of pelvic nerve women with endometriosis: a population-based reg-
pathways for primary and secondary dysmenor- istry study. BJOG. 2020;127(13):1628–35.
rhoea. Cochrane Database Syst Rev.2005;(4):
CD001896.
43. Zullo F, Palomba S, Zupi E, Russo T, Morelli M,
Cappiello F, et al. Effectiveness of presacral neurec-
553 25
Contraception:
Evidence-Based Practice
Guidelines and
Recommendations
Ashley Brant, Rachel Shin, and Pelin Batur
Contents

25.1.1 Contraceptive Use in the United States – 554
25.2 Contraceptive Methods – 555

25.2.1 ermanent Methods – 555
P
25.2.2 Long-Acting Reversible Methods – 556
25.2.3 Short-Acting Reversible Methods – 558
25.2.4 Barrier Contraceptives – 561
25.2.5 Behavioral Methods – 563
25.2.6 Emergency Contraception – 563
25.3 Medical Considerations – 564

25.3.1 ormonal Contraceptives – 564
H
25.3.2 IUDs – 566
25.4 Counseling Patients About Contraceptives – 567
25.5 Questions – 567
25.6 Answers – 568
References – 569

https://doi.org/10.1007/978-3-030-99596-6_25
554 A. Brant et al.
nomic benefits, access to contraception is con-

Key Points sidered a basic human right [2].
55 Long-acting reversal contraceptives Traditional contraceptive methods have
provide high effectiveness with a single been used for centuries and include tech-
intervention and do not require any niques such as withdrawal, barriers, and fer-
user action after insertion. tility awareness. These methods are of low
25 55 Noncontraceptive benefits of combined efficacy and are predominately controlled by
hormonal contraceptives are plentiful, men. The second half of the twentieth cen-
including improved cycle regularity, tury led to the development of “modern con-
reduced menstrual bleeding, and treat- traceptives” including oral contraceptives,
ment of dysmenorrhea and endometri- implants, intrauterine devices, injectables,
osis-related pain. patches, and vaginal rings. This represented a
55 Risk of thromboembolism with hor- shift to female-controlled and highly effective
monal contraception is lower than the methods. The development of modern contra-
risk during pregnancy and in the post- ceptives was a major achievement in women’s
partum period. sexual and reproductive health.
55 Vasectomy is the least invasive method Of the 1.11 billion women of reproduc-
of sterilization and should always be tive age worldwide with a need for family
included in the discussion of permanent planning, approximately 75% use a modern
birth control methods. method of contraception [3]. However, there
55 The lack of estrogen in progestin-only is great geographic variability in access and
contraceptives makes them attractive use of modern contraceptives. About 15%
options for those with contraindica- of women worldwide have an unmet need for
tions to estrogen, such as patients at contraception, with the highest rates of unmet
high risk of venous thromboembolism need in low- and low-middle income countries
and recently postpartum women. [3]. Research and development of novel con-
55 Comprehensive sex education during traceptive methods is ongoing.
formative years is crucial, as nearly half
of never married male and female teen-
agers between the ages of 15 and 19 Case Vignette
have already had sexual intercourse.
55 Access to emergency contraception is A 37-year-old G3P3003 cisgender female
crucial, especially in cases of method would like to discuss her contraceptive
failure or sexual assault. options. She is sexually active with a sperm-
producing partner and does not want any
more children. She has chronic hyperten-
sion and a family history of breast cancer.
25.1 Introduction She asks about the efficacy, safety, and side
effects of hormonal contraceptives.
The ability to control if and when to become
pregnant and have children is inextricably tied
to the well-being of women, their families, 25.1.1 Contraceptive Use
and their communities. Use of highly effec- in the United States
tive contraceptives is associated with reduced
unintended pregnancy and abortion rates, Almost all US women will use contraception
reduced maternal mortality, and improved at some point in their lifetime. Two-thirds of
child health outcomes. Contraceptive use women are currently using some form of con-
and delayed childbearing is also associated traception [4]. Among women who currently
with greater educational achievement, work- use contraception, 38% rely on sterilization
force participation, and economic stability for (29% female, 9% male), and the remainder
women [1]. Given these health and socioeco- rely on reversible methods [4]. The most com-
Contraception: Evidence-Based Practice Guidelines and Recommendations
555 25
monly used method of reversible contracep- cator and a ring is released onto the tubal
tion is the pill, which is currently used by loop to cause constriction and tubal necrosis.
19% of contraceptive users [4]. Popularity of Ten-year failure rates for the silicone plastic
long-acting reversible contraceptive methods band application are 17.7 pregnancies per
(LARC), which includes intrauterine devices 1000 procedures [8]. Laparoscopic steriliza-
and implants, has increased in the last 15 tion using electrocoagulation can be achieved
years. From 2015 to 2017, 10% of women in with monopolar and bipolar energy. Bipolar
the United States used a LARC method [5]. is typically used because risk of unintentional
Less than 10% of women rely on condoms thermal injury is lower with bipolar energy.
alone, but many women use more than one Complete desiccation through bipolar cau-
method concurrently. Despite widespread use tery should be achieved by coagulating three
of contraceptives in the United States, 45% of or more sites of the fallopian tube [9]. Once
all pregnancies are unintended [6]. The major- full desiccation is achieved, 10-year pregnancy
ity of unintended pregnancies are a result of rates are 8.3 per 1000 women for procedures
contraceptive nonuse or inconsistent use. using bipolar coagulation [8]. Laparoscopic
partial bilateral salpingectomy is achieved
by elevating a 2-3 cm segment of fallopian
tube, securing suture around the base of the
25.2 Contraceptive Methods loop, and excising the loop of fallopian tube.
Hysteroscopic tubal occlusion involves
25.2.1 Permanent Methods placing coils into the fallopian tubes
under hysteroscopic visualization using a
25.2.1.1 Female Sterilization transcervical approach. The coils cause an
Women who request female sterilization inflammatory response that leads to fibro-
desire a permanent method of contraception. sis and eventual occlusion of the tubes. This
Although it is safe, effective, and lasts a repro- method, known as the Essure®, was volun-
ductive lifetime, it is sometimes discouraged tarily discontinued in the United States by the
based on age and parity [7]. The historic con- manufacturer in 2018 [7].
text of reproductive coercion and risk of deci- The postpartum period is convenient for
sional regret must be carefully balanced with tubal ligation in women who desire steriliza-
reproductive agency. There are three com- tion because it can be performed in conjunc-
mon sterilization procedures: (1) laparoscopic tion with cesarean delivery or within the first
tubal interruption or salpingectomy, (2) hys- 24–48 hours after delivery. A small infra- or
teroscopic tubal occlusion, and (3) postpar- supraumbilical mini-laparotomy can be made
tum tubal interruption or salpingectomy. to easily access the tubes adjacent to the
Laparoscopic tubal interruption can be enlarged postpartum uterus. Partial bilateral
achieved using clips, rings, electrocoagula- salpingectomy is most common, but com-
tion, or partial salpingectomy. The clips are plete salpingectomy may also be performed
silicone-lined titanium clips that are placed [9]. This method is the most effective form of
around the fallopian tube approximately 2 cm female sterilization, with 10-year failure rates
from the uterine cornua. They cause immedi- of 1.2 per 1000 procedures [8].
ate occlusion by crushing the fallopian tube, Laparoscopic bilateral complete salpingec-
with eventual tubal necrosis. Laparoscopic tomy has become more popular over time due
spring clip applications have the highest prob- to the benefit of ovarian cancer risk reduction.
ability of failure for tubal interruption, with In women with BRCA1 and BRCA2 muta-
ten-year failure rates of 36.5 pregnancies per tions, salpingectomy is expected to reduce the
1,000 procedures [8]. The ring is a silicone risk of ovarian cancer by 80% [10]. In cases
plastic (silastic) band. Using a special lapa- where opportunistic laparoscopic salpingec-
roscopic applicator, a 2–3 cm segment of the tomy is performed, operating time may only
fallopian tube is drawn up inside the appli- be increased by 10 minutes [7].
556 A. Brant et al.
25.2.1.2 Male Sterilization

.. Table 25.1 Contraceptive effectiveness:
Vasectomy is the least invasive method of percentage of women experiencing unintended
sterilization and should always be included pregnancy during first year of typical use in the
in the discussion of permanent birth control United States [28]
methods. It avoids risk of pelvic organ injury
or risk of ectopic pregnancy and can be per- Method Percentage
25 formed in an outpatient setting through a Contraceptive implant 0.05
small scrotal incision with local anesthesia. It
is highly effective, with a failure rate of 0.15% Male sterilization (vasectomy) 0.15
in the first year (. Table 25.1) [11]. This is Hormonal IUD 0.2
comparable to failure rates of long-acting Female sterilization 0.5
reversible contraceptives (LARC) available
for women. Since residual sperm remain in Nonhormonal IUD 0.8
the vas deferens beyond the occlusion point, DMPA 6
vasectomy is not immediately effective and Contraceptive pills, patch, or ring 9
interim backup contraception should be used
for 3 months and until azoospermia can be Diaphragm 12
confirmed by semen analysis. Patients should Cervical cap 16
also refrain from ejaculation 1 week after the Male condoms 18
procedure. Risk of pregnancy after vasec-
tomy is approximately 1 in 2000 for men who Female condoms 21
have confirmed azoospermia or rare nonmo- Withdrawal 22
tile sperm postprocedure [12]. A review con- Fertility awareness method (FAM) 24
ducted by the American Urologic Association
in 2012 reported that vasectomy is not a risk Spermicides 28
factor for prostate cancer, testicular cancer, No method 85
coronary heart disease, stroke, hypertension,
or dementia, and that such conditions do not
need to be discussed in pre-vasectomy coun- the hormonal levonorgestrel-releasing IUD
seling [12]. (LNG-IUD) and the nonhormonal copper-
bearing IUD (Cu-IUD). There are four LNG-
IUDs in the United States and one Cu-IUD
25.2.2 Long-Acting Reversible (Paragard®). The four LNG-IUDs are the
Methods Mirena® (LNG-52 mg), Liletta® (LNG-52
mg), Kyleena® (LNG-19.5 mg), and Skyla®
Long-acting reversible contraceptive (LARC) (LNG-13.5 mg). Most studies show rapid
methods include the intrauterine device return to fertility after IUD discontinuation,
(IUD) and the contraceptive arm implant. with most nulliparous and parous women
They provide high contraceptive effectiveness able to achieve pregnancy within a period of
with a single intervention and do not require 12 months after removal of the hormonal or
any user action after insertion. Since the user nonhormonal IUD [13].
cannot alter the method’s efficacy, the typical IUDs can be placed immediately post-
use effectiveness is similar to the perfect use partum, preferably within 10 minutes after
effectiveness. placental delivery or postabortion. While
immediate postplacental IUDs have expulsion
25.2.2.1 Intrauterine Devices rates ranging from 10% to almost 30% for
Intrauterine devices (IUDs) in the United early placement (between 10 minutes and 4
States are flexible T-shaped devices that are weeks postpartum), the benefit of placing an
inserted into the uterus by a trained clini- IUD immediately or soon after delivery may
cian. The two types of IUDs available include outweigh the risks of short interval pregnan-
557 25
cies in women who experience significant cal hyperplasia or early-grade endometrial
healthcare access barriers [14]. Reasons to cancer [20].
avoid IUD placement include anatomical con-
cerns or active symptomatic infection, such as onhormonal IUDs (Copper-Bearing
N
pelvic inflammatory disease or an active sexu- IUDs)
ally transmitted infection [15]. The Cu-IUD works primarily by creating
an inhospitable environment to spermatozoa,
ormonal IUDs (Levonorgestrel-
H thus impairing fertilization. It is highly effec-
Releasing IUDs) tive, with a failure rate of 0.8 per 100 women
Hormonal IUDs contain levonorgestrel in at 1 year (. Table 25.1) [17]. Paragard® is the
the stem and work primarily by (1) thick- only Cu-IUD approved for use in the United
ening the cervical mucus and (2) impairing States. It is effective for at least 12 years,
sperm migration through the endometrium. although it is only FDA-approved for 10
They may impair ovulation to some degree in years. It is also a highly effective form of emer-
the first year after placement, but most cycles gency contraception if inserted up to 5 days
become ovulatory thereafter [13]. Hormonal after unprotected intercourse. The Cu-IUD is
IUDs work locally, as levonorgestrel levels in more likely to be associated with heavier men-
the endometrium are a thousand-fold higher strual bleeding and cramping compared to the
than in the serum [16]. The LNG-52 mg LNG-IUD [17]. Outside the United States,
IUDs (Mirena® and Liletta®) are FDA- Cu-IUDs come in a variety of copper surface
approved for 7 years. The LNG-19.5 mg areas and frame shapes (including frameless),
(Kyleena®) and LNG-13.5 mg (Skyla®) are and they are the most commonly used IUDs
FDA approved for 5 and 3 years, respec- worldwide.
tively. Hormonal IUDs are highly effective
contraception with failure rates similar to 25.2.2.2 Contraceptive Implants
perfect use, at 0.2 and 0.3 pregnancies per The contraceptive implant (Nexplanon®)
100 women at 1 year (. Table 25.1) [17]. is an etonogestrel-releasing device that is
Emerging evidence suggests the LNG-52 mg inserted subdermally in the upper arm. The
IUD is effective for emergency contraception contraceptive implant consists of a radi-
if inserted up to 5 days after unprotected opaque rod-shaped implant containing 68 mg
intercourse [18]. of etonogestrel (ENG), a potent progestin,
Hormonal IUDs may cause irregular spot- that is pre-loaded in a device applicator. It
ting, especially during the first 3–6 months of is FDA-approved for up to 3 years, although
use, although bleeding patterns should stabi- studies show it may continue to be highly effec-
lize with time. Approximately 20% of women tive for up to 5 years. The ENG implant lacks
using a LNG-52 mg IUD will experience estrogen. The contraceptive implant works
amenorrhea within the first year of use, with primarily by suppressing ovulation, thicken-
upwards of 50% experiencing amenorrhea ing the cervical mucus, and altering the endo-
or oligomenorrhea within the first 2 years metrial lining. It is the most effective method
of use [19]. Although not all patients like of reversible contraception, with a failure rate
being amenorrheic, it may be a favorable side of 0.05% annually. The ENG implant leads to
effect for those who wish to suppress menses. thinning of the endometrial lining, which can
Noncontraceptive benefits of the hormonal change menstrual bleeding patterns and cause
IUD include treatment of abnormal uterine amenorrhea, frequent, or prolonged bleeding.
bleeding (AUB), dysmenorrhea, pelvic pain, Amenorrhea and irregular bleeding patterns
endometriosis, and endometrial hyperpla- are most common. Such irregular bleeding
sia [17]. It is therefore increasingly used as can affect a patient’s quality of life and may
an effective tool to manage AUB. Hormonal be a reason for early discontinuation of the
IUDs have also been shown to be effective in implant. The ENG implant may be placed in
the conservative treatment of complex atypi- the immediate postpartum period and is com-
558 A. Brant et al.
patible with breastfeeding. Noncontraceptive during estrogen-deficient states may reduce

benefits of the ENG implant include improve- fracture risk.
ments in dysmenorrhea, pelvic pain, and
endometriosis-associated pain [21]. Combination Oral Contraceptive Pills
The development of the combined oral con-
traceptive pill (COC) is often regarded as
25 25.2.3 Short-Acting Reversible one of the most important public health
Methods achievements in the twentieth century, and
COCs have been used by women worldwide
25.2.3.1 Combined Hormonal since 1960 [23]. Oral contraceptive formula-
Contraceptives tions vary widely by hormone type, dosage,
Combined hormonal contraceptives (CHCs) and hormone-free duration, although they
contain both estrogen and progestin and are typically contain ethinylestradiol (EE) and a
delivered as a pill, transdermal patch, or vagi- progestin. Most available pills contain 20–35
nal ring. The safety and side effect profiles of mcg of EE, but some formulations contain as
the pill are similar to that of non-oral formu- little as 10 mcg EE. Reduced doses of EE are
lations. suspected to confer a decreased risk of venous
Combined hormonal contraceptives thromboembolism compared to higher doses
prevent pregnancy through inhibition of of COCs, but low-dose formulations may
ovulation, thickening of the cervical mucus be associated with higher rates of irregular
which impairs sperm transport through the bleeding. There are more than a dozen dif-
female genital tract, and altering the endo- ferent progestins in COCs. Theoretically,
metrial lining. Noncontraceptive benefits progestins derived from testosterone, such
of CHCs are plentiful, including improved as norethindrone or levonorgestrel, were
cycle regularity, reduced menstrual bleed- thought to have more androgenic side effects
ing, and treatment of dysmenorrhea and such as acne and excess hair growth. The
endometriosis-related pain. While light newer progestins derived from progesterone
spotting may occur in the first 3–6 months and spironolactone, such as drospirenone,
of CHC use, CHCs are often used to cor- were designed to bind more selectively to pro-
rect menstrual irregularities and help make gesterone receptors and minimize estrogenic,
menstruation more predictable. Since CHCs androgenic, and glucocorticoid side effects
increase sex hormone binding globulin and [23]. However for most women, there are no
decrease androgen levels, they can also significant clinical differences between the
reduce unwanted side effects of androgen various progestins [24, 25]. Traditional pill
excess such as acne and hirsutism. packs have active pills for 21 consecutive days
Continuous use can relieve symptoms of followed by 7 days of nonhormonal pills; the
premenstrual syndrome (PMS) and premen- sudden decrease in progestin during the hor-
strual dysphoric disorder (PMDD). In some mone-free week leads to withdrawal bleeding.
cases, use of continuous CHC can reduce or Extended or continuous COC regimens refer
eliminate the hormonal fluctuations which to regimens that eliminate the hormone-free
contribute to menstrual migraine head- interval, allowing patients to plan withdrawal
aches. Since CHCs prevent ovulation, their bleeding on a more flexible schedule or elimi-
use reduces rates of functional ovarian cysts nate it entirely.
and can also prevent benign breast disease Disadvantages of COCs include once
such as fibrocystic changes, cysts, or fibro- daily dosing and lack of privacy with pill-
adenomas. Furthermore, CHC use has been taking. Side effects such as breast tenderness,
associated with increased bone mineral den- nausea, headache, bloating, mood changes,
sity in women of later reproductive years if and irregular bleeding may occur. Most of
used for a lengthy period of time (>10 years) these symptoms will improve within a few
[22]. It has been proposed that CHC use months of pill initiation. Rare, adverse effects
559 25
of COCs include venous thromboembolism Important considerations for patch use
(VTE) and hypertension. Despite a 2-3-fold include increased serum estrogen levels
relative risk of VTE in COC users com- compared to COCs, which may translate to
pared to nonusers, the absolute risk remains increased risk of VTE and cardiovascular
low [23]. Among COC users, the risk of events. Women using the 150 mcg norelge-
VTE is 3–9/10,000 woman-years, compared stromin and 35 mcg EE TDS (Xulane®) were
to 1–5/10,000 woman-years among nonus- found to have 60% higher serum estrogen lev-
ers [26]. The risk of VTE in pregnancy is els compared to those using conventional pills
5–20/10,000 woman-years and the risk in the [29]. In addition, Xulane® is only approved
postpartum period is 40–65/10,000 woman- for patients with a BMI <30 kg/m2, as it may
years [27]. Scenarios in which the risks of be less effective in those who weigh 198 lbs (90
COC outweigh the benefits include cigarette kg) or more.
smoking in older women (>15 cigarettes/day A newer TDS was developed in 2020, con-
in women 35 years or older), multiple risk taining a slightly lower dose of EE (30 mcg)
factors for arterial cardiovascular disease, and 120 mcg levonorgestrel (Twirla®). It is
uncontrolled hypertension (blood pressure similarly FDA approved for women with a
>160/100), and migraines with aura. Typi- BMI <30 kg/m2 and has the same dosing regi-
cal use failure rates are 9% compared to 0.3% men of once weekly application for 3 weeks
with perfect use (. Table 25.1) [28]. followed by a patch-free week [11].
ransdermal Contraceptive Delivery

T Vaginal Ring
Systems The contraceptive vaginal ring (CVR) is a
The transdermal contraceptive system (TDS) monthly combined contraceptive that does
is a combined contraceptive method deliv- not rely on daily adherence and results in
ered via a once weekly patch. The primary stable circulating hormone levels. The first
mechanism of action is similar to combined approved CVR in the United States releases
oral contraceptives (COCs). The 150 mcg 120 mcg etonogestrel (ENG) and 15 mcg EE
norelgestromin and 35 mcg EE transdermal per day (NuvaRing®). It is placed inside the
system (Xulane® formally Ortho Evra) is vagina by the user and remains there for 21
applied weekly for a total of 3 weeks. The days and is followed by a 7-day hormone-free
fourth week is a patch-free week in which interval. During the 3 weeks it is in place, it
withdrawal bleeding occurs, although it can can be removed for up to 3 hours at a time.
be used continuously without a break like A new ring is used each month. To use it in a
any CHC method. After the patch applica- continuous fashion, it can be replaced every
tion, there is an abrupt rise in circulating hor- 3–4 weeks without a ring-free week. A second
mones that achieves relatively constant serum CVR (Annovera®) was FDA approved in
levels. Due to its transdermal application, the 2018 and releases 150 mcg segesterone acetate
TDS avoids the first-pass metabolism of oral (SA) and 13 mcg EE per day. It is used for 21
medications that occurs in the gastrointesti- days and removed for 7 days. The same ring
nal (GI) tract and liver. Therefore, it can be can be used cyclically for 13 cycles. It should
used in cases of GI absorption issues such not be removed for more than 2 hours, oth-
as those with a history of malabsorptive bar- erwise backup contraception should be used.
iatric surgery or active Crohn’s disease [29]. The ENG/EE CVR (NuvaRing®) system is
Patch adhesion should be checked daily, as a flexible, transparent ring made of ethinyl
it must be completely adhered to the skin to vinyl acetate that is 54 mm across in diameter
work properly. Disadvantages of the con- and 4 mm in cross-section, whereas the SA/
traceptive patch include lack of privacy, as EE ring (Annovera®) is 56 mm in diameter
patches may be noticeable. Skin irritation at and 8.4 mm in cross-section but is made of a
the site of placement can occur. soft, sponge-like silicone elastomer. The CVR
560 A. Brant et al.
can be compressed for manual placement into are methods that can be considered for long-
the vagina in any orientation. It does not need term menstrual suppression.
to be professionally fitted or in any particular
position, but should be in direct contact with Progestin-Only Pills
the vaginal mucosa. Progestin-only pills (POPs) are often referred to
Side effects are similar to other CHCs, as “mini-pills.” All POPs prevent pregnancy by
25 with the exception of vaginal complaints such thinning the endometrial lining, thickening the
as vaginitis and leukorrhea, which are more cervical mucus, and reducing ciliary motion in
common among ring users [30]. The bleeding the fallopian tube. In the United States, active
profile with the ENG/EE is highly predictable. ingredients of POPs include drospirenone or
When used cyclically, withdrawal bleeding norethindrone. Norethindrone suppresses ovu-
often occurs within 2–3 days of ring removal lation in approximately 50% of cycles, whereas
and may continue past the 7-day ring-free drospirenone suppresses ovulation in most
period. Extended off-label regimens that have cycles [31]. Norethindrone progestin-only pills
no hormone-free period often have fewer total do not affect breast milk supply or result in
bleeding days but more days of irregular spot- negative health outcomes in infants and are
ting. To date, there are no published clinical commonly used by postpartum and breastfeed-
trials on the efficacy of the 13 mcg SA/EE ing women [32]. However, the disadvantage is
CVR when used continuously. that norethindrone has a relatively short half-
Advantages to using CVRs include a once- life and needs to be taken within a three-hour
monthly regimen that is discrete and offers window daily to maximize efficacy. Typical
user control. Disadvantages include risk of use failure rate is 9% annually (. Table 25.1).
expulsion. Women should be counseled that There is less data available on the typical user
in such cases, it should be rinsed in water and effectiveness and breast-feeding safety of the
replaced within 2 or 3 hours, depending on drospirenone POP. After pill discontinuation,
the CVR being used. The contraindications to there is prompt return of fertility.
CVR use are the same as that of other com- While there are very few absolute contrain-
bined hormonal contraceptives. dications to POPs, current breast cancer is
an absolute contraindication [15]. Cases in
25.2.3.2 Progestin-Only which the risks generally outweigh the ben-
Contraceptives efits of using POPs include persons with
The lack of estrogen in progestin-only con- malabsorptive bariatric surgical procedures,
traceptives makes them attractive contracep- systemic lupus erythematosus with positive or
tive options for those with contraindications unknown antiphospholipid antibodies, past
to estrogen-containing contraceptives, such breast cancer (with no disease in the last 5
as patients at high risk of venous throm- years), and severe cirrhosis or hepatocellular
boembolism and recently postpartum adenoma [15]. Despite these risks, it is also
women. Potential noncontraceptive ben- important to consider that the risks of unin-
efits of progestin-only contraceptives include tended pregnancy are typically much greater
improvement in dysmenorrhea, improvement than the risks of contraceptives.
of chronic pelvic pain related to endometrio-
sis, and protection from endometrial cancer. Injectable Contraceptives
Progestin-only contraceptive users often have Depo medroxyprogesterone acetate (DMPA,
higher rates of abnormal bleeding patterns Depo-Provera®) is an injectable progestin-
compared to CHC users. However, these only contraceptive that has been used world-
unpredictable bleeding patterns often sub- wide. The primary mechanism of action
side with time, and progestin-only methods of DMPA is ovulation suppression, but it
can provide highly effective contraception. also thickens the cervical mucus and causes
Hormonal IUDs are progestin-only contra- atrophic changes to the endometrium. It is
ceptives which were previously discussed. a popular contraceptive due to its efficacy,
Injectable contraceptives and hormonal IUDs simple re-injection schedule of every 12
561 25
weeks, and discreet usage. DMPA is available the benefits include past breast cancer with
in two different forms that differ by route of no evidence of disease for 5 years, severe cir-
administration: 150 mg administered intra- rhosis, history of vascular disease, diabetes for
muscularly (Depo-Provera®), which is typi- more than 20 years, those with multiple risk
cally administered in healthcare offices, or factors for cardiovascular disease, or diabetes
104 mg self-administered subcutaneously with microvascular complications such as the
(Depo-SubQ®). In the United States, Depo- presence of vascular, nephropathy, neuropa-
SubQ® is not widely available due to cost and thy, or retinal disease [15].
lack of generic formulation [33]. However, In 2004, the FDA issued a “black box warn-
self-administration may expand contracep- ing” to DMPA labeling to address its asso-
tive access and reduce rates of unintended ciation with decreased bone mineral density
pregnancies among women who discontinue (BMD). However, this warning was not evi-
intramuscular DMPA due to difficulty return- dence-based, and professional organizations
ing for repeat injections [34]. DMPA is highly such as the CDC and ACOG do not recom-
effective. With typical use, unintended preg- mend limiting usage to a specific duration [15].
nancy occurs in 6 out of 100 women who use Cross-sectional studies have demonstrated
this method for 1 year; efficacy is highest in that fracture risk in former adult DMPA users
those who complete all four injections within is similar to that of nonusers, indicating that
the year (. Table 25.1) [28]. While DMPA the decreased BMD associated with DMPA is
injections should be given every 12 weeks, likely reversible. However, the risks of BMD
injections can be given up to 15 weeks from loss may be greater in certain populations.
the last injection without requiring backup For example, adolescents are in their peak
contraception [35]. Patients who desire a years of BMD attainment, and perimeno-
quarterly contraceptive regimen or need pausal women may lack the time needed to
short-term contraception (i.e., following male regain BMD prior to menopause. The risks of
partner vasectomy) may benefit from DMPA. decreased BMD should be balanced against
DMPA has also been shown to decrease the risks of unplanned pregnancy. Patients
the number of sickle cell crises in women with concerned about BMD changes who seek
sickle cell disease and increases the seizure a contraceptive method with similar conve-
threshold in those with epilepsy [33]. While nience may consider LARC methods such as
DMPA reduces overall bleeding days and has the IUD or the implant.
a high rate of amenorrhea with continued use,
irregular bleeding is common after initiation.
Counseling on DMPA use should include 25.2.4 Barrier Contraceptives
potential delayed return to fertility after dis-
continuation, with the median delay of con- 25.2.4.1 Condoms
ception being 9 months after the last injection Condoms act as physical barriers that prevent
[36]. Side effects include weight gain in some semen from entering the vagina, reducing
individuals (approximately 2.2 kg on average). both risk of pregnancy and sexually trans-
There are few contraindications to DMPA mitted infections (STI) by covering mucosal
use, and it can safely be used in breastfeed- surfaces. They do not fully cover nonmucosal
ing and postpartum patients. Absolute con- surfaces, so some STIs may still be transmit-
traindications to DMPA use include current ted. Condoms can be used with or without
breast cancer. Relative contraindications to vaginal spermicide.
DMPA use are not identical to those of other External condoms are commonly referred
progestin-only methods. The high-dose and to as male condoms and are one of the most
metabolic activity of DMPA may adversely popular contraceptive methods. External con-
affect cardiovascular health through the doms are most commonly made from latex,
reduction of high-density lipoprotein and although plastic and lambskin condoms are
increase in insulin resistance. Relative contra- options for those with latex allergies. External
indications in which the risks likely outweigh condoms have a reservoir at the tip for ejacu-
562 A. Brant et al.
late. Latex condoms should not be used with along the outer rim and within the concave
oil-based lubricants as they can cause damage side which abuts the cervix. The anterior rim
to the latex condom. Advantages to exter- fits behind the pubic bone and the posterior
nal condoms include prevention against STI rim fits in the posterior fornix. The ring of the
transmission and ubiquitous nature without diaphragm is flexible and is meant to form a
need for prescription. Disadvantages include seal between the diaphragm and the vaginal
25 disruption of coital spontaneity, need for wall. Traditional diaphragms must be fitted
withdrawal immediately after ejaculation, and come in different sizes ranging from 50
reliance on partner cooperation, and need to 105 mm in diameter. The size may need
for synthetic condoms (like polyurethane) to be changed if there is a significant change
in cases of latex allergy. Typical use failure in weight or parity [37]. There is a one-size-
rates for external condoms are 18% annually fits-most diaphragm (Caya®) that is made of
(. Table 25.1). silicone and is designed to fit women who nor-
One brand of internal, or female, con- mally wear size 65–80 mm diaphragms. Once
dom is available in the United States (FC2 placed, a diaphragm should be worn for at least
Female Condom®). The female condom is 6 hours after intercourse and no more than 24
also called the “single-use internal condom” hours after insertion. The one-size-fits-most
for gender inclusivity, as it is FDA approved diaphragm should not be used in the first 6
for both vaginal and anal intercourse. Internal weeks postpartum. Between uses, it needs only
condoms are made of polyurethane and syn- to be cleaned with soap and water. The failure
thetic latex, which is safe for those with latex rate is 12% for typical use (. Table 25.1) [28].
allergies. The larger outer ring sits outside the
introitus and partially covers the vulva, while 25.2.4.3 Cervical Cap
the smaller, inner ring sits at the top of the Like the diaphragm, the cervical cap fits over
vaginal vault. The inner ring may be removed the cervix and acts as a physical barrier to the
for use during anal sex. The outer ring must uterus with a reservoir for spermicide. It is a
be stabilized during intercourse. Spermicides reusable silicone rubber cap (FemCap®) and
may be used in conjunction with internal is available in three sizes (22, 26, and 30 mm).
condoms. An external condom should not be It does not require custom fitting but is sized
used at the same time as an internal condom based on birth history. It is the only cervical
because friction can cause breakage. It may be cap currently available in the United States.
inserted up to 8 hours prior to intercourse and Similar to the one-size-fits-most diaphragm,
should be removed and discarded immediately the cervical cap should remain inserted for at
after intercourse. Advantages of the internal least 6 hours after intercourse to prevent sperm
condom include availability over the counter, penetration during removal and should remain
protection from STIs, compatibility with latex in place for no more than 24 hours. The cap has
allergies, and female control. Disadvantages a strap on the convex surface for easy removal.
include difficulty with correct use and higher
cost compared to external condoms. Typical 25.2.4.4 Spermicides
use failure rates are as high as 21% annually Vaginal spermicides work by destroying sperm
(. Table 25.1). and preventing them from entering the uterus.
Spermicides work best when used in conjunc-
25.2.4.2 Diaphragm tion with barrier methods. When used alone,
Diaphragms have been around for over a typical-use failure rates are as high as 28%
century, and they are one of the oldest con- annually (. Table 25.1). The only spermicide
traceptive methods available. The diaphragm available in the United States is nonoxynol-9,
is a user-controlled method of contraception which is a surfactant that immobilizes sperm
that must be used in conjunction with a sper- and disrupts plasma membranes. Spermicides
micide. It is a shallow, dome-shaped device are available in different formulations, such as
that is placed in the vagina and covers the gels, creams, sponges, foams, films, and sup-
cervix. Prior to insertion, spermicide is placed positories. Spermicides may increase viral
563 25
shedding by disrupting the cervical mucosa 25.2.5.3 Fertility Awareness
and are contraindicated in patients who are at Methods
high risk for HIV acquisition [15]. The Fertility Awareness Methods (FAM),
In 2020, the FDA approved a hormone- also called Natural Family Planning (NFP),
free birth control gel containing lactic acid, require users to identify the most fertile days
citric acid, and potassium bitartrate (Phexxi®). of their menstrual cycle by using physiologic
It acidifies the vaginal pH and impairs sperm data and avoiding fertilization on those days
motility. Similar to spermicides, it is used beforeby refraining from vaginal sex, using barrier
sex and works for up to 1 hour after insertion. contraception, or practicing withdrawal. FAM
is comprised of several different methods.
Partners may learn to track signs and symp-
25.2.5 Behavioral Methods
toms such as cycle length (Calendar Rhythm
Method or Standard Days Method), basal
25.2.5.1 Abstinence
body temperature (Basal Body Temperature
Abstinence refers to the avoidance of penile- Method), cervical fluid (Two-Day Method or
vaginal penetrative intercourse. Although Billings Technique), a combination of these
abstinence with perfect use is theoretically techniques (symptothermal method), and/or
100% effective, in practice abstinence often urinary hormones to track their fertile win-
fails to protect individuals from unwanted dow. FAMs are a nonhormonal method of
pregnancy and sexually transmitted infec- contraception and can be used in conjunc-
tions (STIs). Rates of failure can be as high as tion with barrier methods. However, FAM
not using any method of contraception at all. requires partner cooperation and adherence.
In 2011–2013, 44% of never married female Patients with underlying reproductive condi-
teenagers and 47% of never married male tions or irregular menstrual cycles may have
teenagers aged 15–19 had sexual intercourse difficulty identifying and interpreting their
at least once [38]. Initiation of intercourse in physiologic signs and symptoms [40]. Typical
the adolescent years carries considerable risk use failure rates vary widely and are as high as
of pregnancy and STIs. While individuals 25% annually.
may abstain from penile-vaginal intercourse,
those engaging in oral, anal, and nonpenetra-
tive sexual activity are still at risk of STIs. 25.2.6 Emergency Contraception
Therefore, comprehensive sexual education
during formative years is crucial. Emergency contraception (EC) refers to meth-
ods of pregnancy prevention that prevent
25.2.5.2 Withdrawal pregnancy after intercourse has occurred.
The withdrawal method, also known as coitus Despite the number of effective contraceptive
interruptus, refers to removal of the penis from methods available, EC remains an important
the vagina prior to ejaculation. It is one of the back-up method of contraception. EC may
oldest methods of contraception worldwide. be used in cases of sexual intercourse without
This form of contraception is particularly contraception, suspected contraceptive fail-
prevalent among younger women, as 31% of ure, or incidents of rape. In the United States,
females between the ages of 15–24 reported there are four major EC options available: the
using this method [39]. Obvious advantages copper-bearing IUD, ulipristal acetate which
include freedom from medications or devices, is a selective progesterone receptor modula-
and preservation of pre-coital spontaneity. tor (SPRM), progestin-only levonorgestrel
Even with perfect use at every act, pregnancy (LNG) pills, and combination oral contracep-
is still possible since pre-ejaculatory fluid con- tives (COCs). All methods can be used up to
tains sperm. Thus, the probability of preg- 5 days after intercourse. Oral EC pills do not
nancy in the first year of use is approximately cause abortion or harm a pregnancy that has
22% (. Table 25.1) [28]. already been established.
564 A. Brant et al.
The copper-bearing IUD is the most 25.3 Medical Considerations

effective method of EC and is the most well-
studied IUD for emergency contraceptive use. The Center for Disease Control has devel-
It has a failure rate of 0.09% and can be used oped comprehensive guidelines on the use of
as ongoing contraception [41]. However, it contraceptives in the United States. The US
requires a healthcare encounter within a nar- Medical Eligibility Criteria for Contraceptives
25 row timeframe which often limits access to it Use (MEC) and Selected Practice
as a form of EC. In 2021, a study showed that Recommendations (SPR) provide guidance
the LNG-52 mg IUD was not inferior to the on the use of contraceptives in specific medi-
copper-bearing IUD in preventing pregnancy cal scenarios as well as recommendations
when used as EC [18]. regarding patient evaluation prior to initiating
Oral forms of EC include ulipristal acetate contraceptive methods (. Table 25.2) [45].
30 mg (Ella®), levonorgestrel 1.5 mg as a single The World Health Organization also main-
dose, and levonorgestrel 1.5 mg administered tains medical eligibility criteria for contracep-
as two separate 0.75 mg doses. Both ulipris- tive initiation and continuation worldwide.
tal acetate and levonorgestrel work by delay- An important caveat to the MEC interpreta-
ing or inhibiting ovulation. Ulipristal acetate tion is that MEC category determinations are
is FDA approved for up to 120 hours after based on the risks of a method compared to
unprotected intercourse and is more effective the contraceptive benefit of that method. In
than levonorgestrel, with a failure rate of less patients for whom there are significant non-
than 1.3% per cycle [42]. It is only available contraceptive benefits, the risk-benefit ratio
by prescription in the United States, which may be different. Elicitation of a thorough
may delay treatment. Levonorgestrel is FDA patient medical and social history is neces-
approved for use up to 72 hours after sex but sary prior to initiating contraception in order
may still have some efficacy up to 120 hours to identify medical and personal factors that
after sex. When used within 120 hours of inter- may influence the selection of a contraceptive
course, it has a failure rate of 2.2%, with lower method. This chapter will review some of the
pregnancy rates in the 0–72 hour timeframe. most common medical conditions that influ-
Levonorgestrel is also less effective in obese ence the choice of a contraceptive method.
women [43]. Levonorgestrel EC is available Please refer to the MEC and SPR for up-to-
over-the-counter in the United States, making date information regarding contraindications
it the most accessible form of EC. However, and special considerations for specific con-
since ulipristal acetate is twice as effective as traceptive methods and medical conditions
the over-the-counter options, advance provi- (. Table 25.2).
sion of ulipristal pills may be considered for
those at highest risk of levonorgestrel failure,
such as women who are overweight or obese 25.3.1 Hormonal Contraceptives
[44]. Ulipristal acetate and levonorgestrel do
not protect against pregnancy that may occur Exogenous contraceptive-dose estrogen
from subsequent acts of sex within the same induces hepatic enzymatic pathways which
menstrual cycle and women should be coun- affect the production of thrombotic factors,
seled on the importance of abstinence or ultimately resulting in a pro-coagulant state
effective contraception after taking EC. [46]. Though the absolute risks of arterial and
Lastly, COCs can be used as EC (Yuzpe venous thromboembolism (VTE) in young
regimen). Specific regimens depend on the women are low, an increased relative risk
formulation of the COC. However, the Yuzpe has been demonstrated in users of estrogen-
regimen is less effective and less well-tolerated containing contraceptives [46]. Estrogen-
than other methods of EC. It may be consid- containing contraceptives should be avoided
ered in cases where access to EC is poor. in patients at high risk of stroke, myocardial
565 25
.. Table 25.2 Excerpts from CDC summary chart of US Medical Eligibility Criteria
Condition Subcondition Cu LNG Implant DMPA POP CHC

IUD IUD
Breast disease Benign disease 1 1 1 1 1 1

Family history of cancer 1 1 1 1 1 1
Current breast cancer 1 4 4 4 4 4
Past breast cancer, no 1 3 3 3 3 3
evidence of disease in last
5 years
Deep venous History of DVT/PE, not 1 2 2 2 2 4
thrombosis (DVT), on anticoagulation 3
Pulmonary embolus High recurrence risk
(PE) Low recurrence risk
Acute DVT/PE 2 2 2 2 2 4
DVT/PE, on anticoagula- 2 2 2 2 2 4
tion ≥3 months 3
High recurrence risk
Low recurrence risk
Headaches Migraine without aura 1 1 1 1 1 2
Migraine with aura 1 1 1 1 1 4
Hypertension Adequately controlled 1 1 1 2 1 3
Systolic 140–159 or 1 1 1 3 1 3
diastolic 90–99
Systolic ≥160 or diastolic 1 2 2 3 2 4
≥100 or presence of
vascular disease
Sexually transmitted Current purulent 4 4 1 1 1 1

infection (STI) cervicitis, chlamydia, or 2 2
gonorrhea infection
Initiation of contracep-
tive method
Continuation of
contraceptive method
Vaginitis 2 2 1 1 1 1
Smoking Age <35 1 1 1 1 1 2
Age ≥35, <15 cigarettes 1 1 1 1 1 3
per day
Age ≥35, ≥15 cigarettes 1 1 1 1 1 4

per day
1: No restriction
2: Advantages generally outweigh theoretical or proven risks
3: Theoretical or proven risks usually outweigh benefits
4: Unacceptable health risk
566 A. Brant et al.
infarction, venous thromboembolism, and current or recent breast cancer, especially in

peripheral arterial disease. Examples of such those with positive estrogen or progesterone-
medical conditions include being less than 21 receptor status [47].
days postpartum, severe decompensated liver Contraceptive hormones are metabolized
cirrhosis or liver cancer, uncontrolled hyper- by the cytochrome P450 system of the liver.
tension (>160/100), acute VTE and history of Concurrent use of medications that induce
25 VTE with high risk for recurrence, major sur- the cytochrome P450 system may affect ste-
gery with prolonged immobilization, diabetes roid hormone metabolism, making hormonal
with end-organ or vascular complications, contraceptives less effective and increasing
migraine headaches with aura, thrombogenic the risk of abnormal bleeding. Examples of
hematologic conditions, ischemic and valvu- these medications include rifamycin antibiot-
lar heart disease, lupus with antiphospholipid ics and anticonvulsant medications such as
antibodies, stroke, and smoking over age 35 carbamazepine, phenytoin, and topiramate
(15 or more cigarettes per day) (. Table 25.2) [47]. Nonrifamycin antibiotics do not impair
[47]. Over time, the dose of estrogen in con- contraceptive efficacy significantly, though
traceptive pills has been reduced in an attempt concerns have been raised about a higher
to lessen the risk of adverse events. Pregnancy risk of unintended pregnancy among anti-
is also a risk factor for development of both microbial medication users in observational
arterial thromboembolic events and VTE. studies [51, 52]. Emerging evidence on interac-
Thus, the risks of estrogen-containing con- tions between antiretroviral medications and
traceptives should be considered in the con- contraceptive hormones suggests that some
text of an individual’s risk of pregnancy and protease inhibitors may decrease contracep-
the other contraceptive methods which are tive hormone serum levels, but the impact on
available. The risks of VTE are greater dur- contraceptive efficacy remains unclear [53].
ing pregnancy and the postpartum period Additionally, hormonal contraceptives may
compared to the risks of VTE while using affect the metabolism of lamotrigine, impair-
estrogen-containing contraceptives. ing its efficacy when used as anticonvulsant
The link between hormonal contracep- monotherapy [47]. Non-oral contraceptive
tives and breast cancer remains controversial. methods avoid first-pass hepatic metabolism
Some studies have suggested that CHCs and and are preferred when there is concern about
progestin-only contraceptives increase the risk hepatic metabolism or medication interac-
of breast cancer in current and recent users. In tions.
one study, the risk appeared to increase with
longer duration of use but decrease after dis-
continuation of hormonal contraception [48]. 25.3.2 IUDs
However, the association with breast cancer
has not been replicated in many studies assess- There are few contraindications to the use of
ing the lower dose hormonal contraceptives in IUDs. While pregnancy should be ruled out
use since the 1980s [49]. Furthermore, CHC prior to initiating most contraceptive meth-
use is associated with decreased lifetime risk ods, this is especially important prior to IUD
of ovarian, endometrial, colorectal, and total insertion. The CDC provides guidance on
cancers (45 fewer cancers per 100,000 woman- “how to be reasonably certain a woman is
years of use among ever-users of CHC) [50]. not pregnant” [45] which includes having no
The presence of risk factors for breast can- symptoms of pregnancy and at least one of
cer, such as family history of breast cancer or the following:
BRCA gene positivity, are not contraindica- 55 Is ≤7 days after the start of normal menses
tions to hormonal contraceptive use but may 55 Has not had sexual intercourse since the
be taken into consideration when choosing a start of last normal menses
contraceptive method. Use of hormonal con- 55 Has been correctly and consistently using
traception is not recommended in women with a reliable method of contraception
567 25
55 Is ≤7 days after spontaneous or induced utilizes shared decision-making is associated
abortion with increased contraceptive method satisfac-
55 Is within 4 weeks postpartum tion [56].
55 Is fully or nearly fully breastfeeding, amen- Information on efficacy, risks, benefits,
orrheic, and <6 months postpartum and side effects should be presented in a way
that allows the patient to make an informed
Anatomic abnormalities that distort the decision. Real-world, rather than perfect-
intrauterine cavity can affect both the safety use, efficacy rates should be reviewed. In
and efficacy of IUDs; they are not recom- the absence of contraception, the aver-
mended in women with Müllerian anomalies age sexually active woman has an 80–90%
or fibroids that significantly distort the uterine chance of becoming pregnant in a year [57].
cavity. IUDs should not be inserted in women Noncontraceptive benefits and side effects of
with acute infections such as cervicitis, pelvic specific methods should be discussed. The
inflammatory disease or intra-uterine infec- risks of contraception use should be weighed
tion, or current cervical cancer [47]. However, against the risks of unplanned pregnancy.
past history of infection is not a contraindi- Prevention of STIs should also be discussed,
cation. Rates of pelvic infections are not sig- especially when a nonbarrier method is cho-
nificantly increased with modern-day IUDs sen. Routine follow- up after contraceptive
beyond the first month after insertion. initiation is not necessary, but may be helpful
for some patients.
25.4 ounseling Patients About

C
Contraceptives 25.5 Questions
Contraceptive and reproductive counseling ??1.

How do combined hormonal contra-
should be patient-centered and utilize shared ceptives prevent pregnancy? Select all
decision-making. Patient centered care is that apply.
defined by the Institute of Medicine as “care A. Inhibiting ovulation
that is respectful of and responsive to indi- B. Creating an inhospitable environ-
vidual patient preferences, needs, values, and ment for sperm
ensuring that patient values guide all clini- C. Thickening the cervical mucus to
cal decisions” [54]. Contraceptive counsel- prevent sperm transport
ing includes three phases: needs assessment, D. Altering the endometrial lining
decision-making support, method choice, and
follow-up [55]. The needs assessment phase ??2. A 21-year-old G1P0 female presents to
includes understanding the patient’s reproduc- your office to discuss starting a method
tive goals, prior experiences with pregnancy of contraception. She is primarily
and sexually transmitted infection (STI) pre- interested in starting a combination
vention, and preferences regarding contra- oral contraceptive. She smokes half
ception. Decision-making support refers to a pack of cigarettes a day, has a body
providing nonbiased, evidence-based infor- mass index of 34 kg/m2, and has a past
mation on individual contraceptive methods. medical history of migraines without
Decision-making support should be tailored to aura and sickle cell disease. According
the patient’s contraceptive needs, preferences, to the US Medical Eligibility Criteria
and medical and social history. Method choice (MEC) for Contraceptive Use, which
and follow-up involves confirming the patient’s best describes the safety profile of the
selection of a contraceptive method, docu- combination hormonal oral contracep-
menting informed consent when a procedure tive in this patient?
is necessary, reviewing how to use the method A. No restriction (method can be used)
correctly, and reviewing a plan for follow-up. B. Advantages generally outweigh
High-quality patient-centered counseling that theoretical or proven risks
568 A. Brant et al.
C. Theoretical or proven risks usually outweigh the theoretical or proven

outweigh the advantages risks. The described patient has no
D. Unacceptable health risk (method contraindications for combination oral
not to be used) contraceptive use. All her risk factors
fall into a risk category of 2, including
??3. A 42-year-old woman presents to your the smoking, obesity, migraines with-
25 office hoping to start a method of out aura, and sickle cell disease. Even
contraception and seeks your opinion though the use of an estrogen-contain-
on which method would be the safest. ing contraceptive is not prohibited,
Which of the options below would pre- this patient should be counseled on the
clude starting a method of combined importance of weight loss and smoking
hormonal contraception? Select all that cessation to minimize the risk of future
apply. arterial and venous thromboembolism.
A. History of cervical cancer
B. Uncontrolled hypertension vv3. Answer: B, C, D
(>160/100) Estrogen-containing contracep-
C. History of diabetes with nephropa- tives should be avoided in patients at
thy and retinopathy high risk of stroke, myocardial infarc-
D. <21 days postpartum tion, venous thromboembolism, and
peripheral arterial disease, as exog-
??4. What are some of the noncontraceptive enous contraceptive dose estrogen
benefits of combined hormonal contra- affects the production of thrombotic
ception? Select all that apply. factors and can result in a procoagu-
A. Decrease risk of endometrial and lant state. A patient with history of
ovarian cancer answer choices B, C, or D would have
B. Regulate and reduce menstrual increased relative risk of arterial and
bleeding and dysmenorrhea venous thromboembolism. A per-
C. Treatment of ovarian cysts sonal history of cervical pathology,
D. Improve acne including cancer, ectropion, or cervi-
cal intraepithelial neoplasia would not
preclude the use of a combination oral
25.6 Answers contraceptive. The lack of estrogen in
progestin-only contraceptives makes
vv1. Answer: A, C, D them an attractive option for those
Combined hormonal contracep- with contraindications to estrogen-
tives prevent pregnancy by inhibit- containing contraceptives.
ing ovulation, thickening the cervical
mucus to prevent spermatozoa trans- vv4. Answer: A, B, D
port, and by altering the endometrial Combined hormonal contracep-
lining. Answer choice B describes the tion has been shown to decrease the
primary mechanism of action of the risk of endometrial and ovarian can-
nonhormonal IUD (copper- bearing cer. It has also been shown to reduce
IUD), which works by creating an menstrual bleeding, treat dysmenor-
inhospitable environment for sperm rhea, reduce premenstrual dysphoric
and impairing fertilization. disorder symptoms, and improve acne.
Though combined hormonal contra-
vv2. Answer: B ception can help prevent production
According to the US MEC for of new ovarian cysts, it has not been
Contraceptive Use, the combination shown to be beneficial in ovarian cyst
oral contraceptive is Category 2. In treatment.
other words, the advantages generally
569 25
References 15. Report MW. U. S. medical eligibility criteria for
contraceptive use. 2016;65:2016.
16. Bahamondes L, Fernandes A, Monteiro I,
1. Sonfield A, Hasstedt K, Kavanaugh ML, Anderson
Bahamondes MV. Long-acting reversible contra-
R. The social and economic benefits of women’s
ceptive (LARCs) methods. Best Pract Res Clin
ability to determine whether and when to have
Obstet Gynaecol. 2020;66:28–40.
children [Internet]. 2013 [cited 2021 Jan 31].
17. Adeyemi-Fowode OA, Bercaw-Pratt
Available from: www.guttmacher.org.
JL. Intrauterine devices: effective contraception
2. Policy statement 20153: Universal Access to
with noncontraceptive benefits for adolescents. J
Contraception [Internet]. 2015 [cited 2021 Jan 31].
Pediatr Adolesc Gynecol. 2019;32(5):S2–6.
Available from: https://www.apha.org/policies-
18. Turok DK, Gero A, Simmons RG, Kaiser JE,
and-a dvocacy/public-h ealth-p olicy-s tatements/
Stoddard GJ, Sexsmith CD, et al. Levonorgestrel
policy-d atabase/2015/12/17/09/14/universal-
vs. copper intrauterine devices for emergency con-
access-to-contraception.
traception. N Engl J Med. 2021;384(4):335–44.
3. Kantorová V, Wheldon MC, Ueffing P, Dasgupta
19. Allen R, Villavicencio J. Unscheduled bleeding and
ANZ. Estimating progress towards meeting wom-
contraceptive choice: increasing satisfaction and
en’s contraceptive needs in 185 countries: a
continuation rates. Open Access J Contracept.
Bayesian hierarchical modelling study. PLoS Med
2016;7:43.
[Internet]. 2020 Feb 18 [cited 2021 May
20. Westin SN, Fellman B, Sun CC, Broaddus RR,
21];17(2):e1003026. Available from: https://doi.
Woodall ML, Pal N, et al. Prospective phase II
org/10.1371/journal.pmed.1003026.
trial of levonorgestrel intrauterine device: nonsur-
4. Contraceptive use in the United States [Internet].
gical approach for complex atypical hyperplasia
Guttmacher Institute. 2020. Available from:
and early-stage endometrial cancer. In: American
h t t p s : / / w w w.g u t t m a c h e r.o r g / f a c t -s h e e t /
journal of obstetrics and gynecology. Mosby Inc;
contraceptive-use-united-states.
2021. p. 191.e1–191.e15.
5. Daniels K, Abma JC. Current contraceptive status
21. Bahamondes L, Valeria Bahamondes M, Shulman
among women age 15–49: United States, 2015–
LP. Non-contraceptive benefits of hormonal and
2017 [Internet]. Hyattsville; 2018 Dec [cited 2021
intrauterine reversible contraceptive methods.
Feb 7]. Available from: https://www.cdc.gov/nchs/
Hum Reprod Update [Internet]. 2015 [cited 2017
data/databriefs/db327_tables-508.pdf#3.
Jan 13];21(5):640–51. Available from: http://www.
6. Finer LB, Zolna MR. Declines in unintended preg-
ncbi.nlm.nih.gov/pubmed/26037216.
nancy in the United States, 2008–2011. Obstet
22. Hartard M, Bottermann P, Bartenstein P, Jeschke
Gynecol Surv. 2016;71(7):408–9.
D, Schwaiger M. Effects on bone mineral density
7. Stuart GS, Ramesh SS. Interval female steriliza-
of low-dosed oral contraceptives compared to and
tion. Obstet Gynecol. 2018;131(1):117–24.
combined with physical activity. Contraception.
8. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor
1997;55(2):87–90. https://doi.org/10.1016/s0010-
LR, Trussell J, et al. The risk of pregnancy after
7824(96)00277-6. PMID: 9071517.
tubal sterilization: findings from the U.S. collab-
23. Dragoman MV. The combined oral contraceptive
orative review of sterilization. Am J Obstet
pill: recent developments, risks and benefits. Best
Gynecol. 1996;174(4):1161–70.
Pract Res Clin Obstet Gynaecol. 2014;28(6):
9. Moss C, Isley MM. Sterilization. A review and
825–34.
update. Obstet Gynecol Clin N Am.
24. Creinin MD, Jensen JT. Oral contraceptive genera-
2015;42(4):713–24.
tions – time to stop using a marketing myth to
10. Hartmann LC, Lindor NM. The role of risk-
define nomenclature. Contraception. 2020;102(3):
reducing surgery in hereditary breast and ovarian
143–4.
cancer. N Engl J Med. 2016;374(5):454–68.
25. Arowojolu AO, Gallo MF, Lopez LM, Grimes
11. Shih G, Turok DK, Parker WJ. Vasectomy: the
DA. Combined oral contraceptive pills for treat-
other (better) form of sterilization. Contraception.
ment of acne. In: Cochrane database of systematic
2011;83(4):310–5.
reviews. John Wiley & Sons, Ltd; 2012.
12. Sharlip ID, Belker AM, Honig S, Labrecque M,
26. FDA Drug Safety Communication: Updated
Marmar JL, Ross LS, et al. Vasectomy: AUA
information about the risk of blood clots in women
guideline. J Urol. 2012;188(6 Suppl):2482–91.
taking birth control pills containing drospirenone |
13. Dinehart E, Lathi RB, Aghajanova
FDA.
L. Levonorgestrel IUD: is there a long-lasting
27. Risk of venous thromboembolism among users of
effect on return to fertility? J Assist Reprod Genet.
drospirenone-containing oral contraceptive pills |
2020;37(1):45–52.
ACOG.
14. Jatlaoui TC, Whiteman MK, Jeng G, Tepper NK,
28. Trussell J. Contraceptive failure in the United
Berry-Bibee E, Jamieson DJ, et al. Intrauterine
States. Contraception. 2011;83(5):397–404.
device expulsion after postpartum placement: a
29. Nelson AL. Transdermal contraception methods:
systematic review and meta-analysis. Obstet
today’s patches and new options on the horizon.
Gynecol. 2018;132(4):895–905.
Expert Opin Pharmacother. 2015;16(6):863–73.
570 A. Brant et al.
30. Madden T, Blumenthal P. Contraceptive vaginal 7. Available from: http://linkinghub.elsevier.com/

ring. Clin Obstet Gynecol. 2007;50(4):878–85. retrieve/pii/S0010782411000618.
31. Duijkers IJM, Heger-Mahn D, Drouin D, Colli E, 44. Glasier AF, Cameron ST, Fine PM, Logan SJ,
Skouby S. Maintenance of ovulation inhibition Casale W, Van Horn J, et al. Ulipristal acetate ver-
with a new progestogen-only pill containing dro- sus levonorgestrel for emergency contraception: a
spirenone after scheduled 24-h delays in pill intake. randomised non-inferiority trial and meta-
Contraception [Internet]. 2016 Apr 1 [cited 2021 analysis. Lancet. 2010;375(9714):555–62.
25 May 26];93(4):303–9. Available from: https:// 45. Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB,
pubmed.ncbi.nlm.nih.gov/26708301/. Horton LG, Jamieson DJ, et al. U.S. selected prac-
32. Phillips SJ, Tepper NK, Kapp N, Nanda K, tice recommendations for contraceptive use, 2016.
Temmerman M, Curtis KM. Progestogen-only MMWR Recomm Rep [Internet]. 2016 Jul 29
contraceptive use among breastfeeding women: a [cited 2018 Jan 9];65(4):1–66. Available from:
systematic review. Contraception. 2016;94(3):226– h t t p : / / w w w.c d c .g ov / m m w r / vo l u m e s / 6 5 / r r /
52. rr6504a1.htm.
33. Schivone G, Dorflinger L, Halpern V. Injectable 46. Sitruk-Ware R. Hormonal contraception and
contraception: updates and innovation. Curr Opin thrombosis [Internet]. Fertil Steril. 2016 [cited
Obstet Gynecol. 2016;28(6):504–9. 2021 Apr 17];106:1289–94. Available from: https://
34. Upadhyay UD, Zlidar VM, Foster DG. Interest in doi.org/10.1016/j.fertnstert.2016.08.039. Elsevier
self-administration of subcutaneous depot Inc.
medroxyprogesterone acetate in the United States. 47. Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee
Contraception. 2016;94(4):303–13. E, Horton LG, Zapata LB, et al. U.S. medical eligi-
35. CDC - Injectables - US SPR - Reproductive bility criteria for contraceptive use, 2016. MMWR
Health. Recom Rep. 2016;65(3):1–103.
36. Pardthaisong T, Gray RH, Mcdaniel EB. Return 48. Mørch LS, Skovlund CW, Hannaford PC, Iversen
of fertility after discontinuation of depot medroxy- L, Fielding S, Lidegaard Ø. Contemporary hor-
progesterone acetate and intra-uterine devices in monal contraception and the risk of breast cancer.
northern Thailand. Lancet. 1980;315(8167): N Engl J Med [Internet]. 2017 Dec 7 [cited 2021
509–12. Apr 17];377(23):2228–39. Available from: https://
37. Gallo MF, Grimes DA, Schulz KF. Cervical cap pubmed.ncbi.nlm.nih.gov/29211679/.
versus diaphragm for contraception. Birth. 49. Michels KA, Pfeiffer RM, Brinton LA, Trabert
2003;30(1):64–5. B. Modification of the associations between dura-
38. Martinez GM, Abma JC. Sexual activity, contra- tion of oral contraceptive use and ovarian, endo-
ceptive use, and childbearing of teenagers aged metrial, breast, and colorectal cancers. JAMA
15–19 in the United States key findings data from Oncol [Internet]. 2018 Apr 1 [cited 2021 May
the 2011–2013 National Survey of Family Growth. 24];4(4):516–21. Available from: https://
2015. jamanetwork.com/.
39. Dude AM, Neustadt A, Martins S, Gilliam M. Use 50. Hannaford PC, Selvaraj S, Elliott AM, Angus V,
of withdrawal and unintended pregnancy among Iversen L, Lee AJ. Cancer risk among users of oral
females 15–24 years of age. Obstet Gynecol. contraceptives: cohort data from the Royal College
2013;122(3):595–600. of General Practitioner’s oral contraception study.
40. Simmons RG, Jennings V. Fertility awareness- BMJ [Internet]. 2007 Sep 29 [cited 2017 Jan
based methods of family planning. Baillieres Best 29];335(7621):651. Available from: http://www.
Pract Res Clin Obstet Gynaecol. 2020;66:68–82. ncbi.nlm.nih.gov/pubmed/17855280.
Bailliere Tindall Ltd. 51. Simmons KB, Haddad LB, Nanda K, Curtis
41. Li HWR, Lo SST, Ho PC. Emergency contracep- KM. Drug interactions between non-rifamycin
tion. Best Pract Res Clin Obstet Gynaecol. antibiotics and hormonal contraception: a system-
2014;28(6):835–44. atic review [Internet]. Am J Obstet Gynecol. 2018
42. Glasier AF, Cameron ST, Fine PM, Logan SJS, [cited 2021 Apr 18];218:88–97.e14. Available from:
Casale W, Van Horn J, et al. Ulipristal acetate ver- https://pubmed.n cbi.n lm.n ih.g ov/28694152/.
sus levonorgestrel for emergency contraception: a Mosby Inc.
randomised non-inferiority trial and meta- 52. Aronson JK, Ferner RE. Analysis of reports of
analysis. Lancet (London, England) [Internet]. unintended pregnancies associated with the com-
2010 Feb 13 [cited 2017 Dec 11];375(9714):555–62. bined use of non-enzyme-inducing antibiotics and
Available from: http://linkinghub.elsevier.com/ hormonal contraceptives. BMJ Evid Based Med
retrieve/pii/S0140673610601018. [Internet]. 2020 Jun 1 [cited 2021 May
43. Glasier A, Cameron ST, Blithe D, Scherrer B, 26];26(3):112–3. Available from: https://ebm.bmj.
Mathe H, Levy D, et al. Can we identify women at com/content/26/3/112.
risk of pregnancy despite using emergency contra- 53. CDC - Potential drug interactions: hormonal con-
ception? Data from randomized trials of ulipristal traceptives and antiretroviral drugs - USMEC -
acetate and levonorgestrel. Contraception Reproductive health [Internet]. [cited 2021 Apr
[Internet]. 2011 Oct [cited 2017 Dec 11];84(4):363– 18]. Available from: https://www.cdc.gov/repro-
571 25
ductivehealth/contraception/mmwr/mec/ tive counseling. Contraception [Internet]. 2017
appendixm.html. May 1 [cited 2021 Apr 18];95(5):452–5. Available
54. America I of M (US) C on Q of HC in. Improving from: /pmc/articles/PMC5466847/.
the 21st-century health care system. 2001 [cited 57. Figures and tables to support chances of concep-
2021 Apr 18]. Available from: https://www.ncbi. tion and embryo quality recommendations |
nlm.nih.gov/books/NBK222265/. Fertility problems: assessment and treatment |
55. Holt K, Dehlendorf C, Langer A. Defining quality Guidance | NICE [Internet]. [cited 2021 Apr 18].
in contraceptive counseling to improve measure- Available from: https://www.nice.org.uk/guidance/
ment of individuals’ experiences and enable service cg156/chapter/figures-a nd-t ables-t o-s upport-
delivery improvement [Internet]. Contraception. chances-o f-c onception-a nd-e mbryo-q uality-
2017 [cited 2021 Apr 18];96:133–7. Available from: r e c o m m e n d a t i o n s # t a b l e -1 -c u m u l a t i v e -
https://doi.org/10.1016/j.contraception.2017.06. probability-o f-c onceiving-a -c linical-p regnancy-
0050010-7824/. Elsevier Inc. by-the-number-of-menstrual-cycles.
56. Dehlendorf C, Grumbach K, Schmittdiel JA,
Steinauer J. Shared decision making in contracep-
573 26
Surgical Techniques
for Management
of Anomalies
of the Müllerian Ducts
Marjan Attaran
Contents
26.2 Classification – 576
26.3 Müllerian Agenesis – 577

26.3.1 Clinical Presentation – 577
26.4 Associated Anomalies – 577
26.5 Etiology – 578

26.6.1 I maging – 578
26.6.2 Explaining the Diagnosis to the Patient – 578
26.6.3 Creation of a Neovagina – 579
26.6.4 Vaginal Dilation – 579
26.6.5 Procedure – 579
26.7 Vecchietti Procedure – 580

26.7.1 rocedure – 580
P
26.7.2 Vaginoplasty Techniques – 580
26.7.3 McIndoe Procedure – 580
26.7.4 Peritoneal Graft: Davydov Procedure – 583
26.7.5 Adhesion Barrier Lining – 583
26.7.6 Buccal Mucosa – 584

https://doi.org/10.1007/978-3-030-99596-6_26
26.7.7 T issue Engineering – 584
26.7.8 Muscle and Skin Flap – 584
26.7.9 Bowel Vaginoplasty – 584
26.7.10 Obstructed Rudimentary Uterine Bulbs – 584
26.7.11 Surgical Technique – 585
26.8 Cervical Agenesis – 585

26.10.1 P ain Control – 586
26.10.2 Surgical Approach – 587
26.10.3 Uterine Fusion Defects – 587
26.11 Septate Uterus – 587
26.12 Bicornuate Uterus – 588
26.13 Surgical Technique: Strassman

Metroplasty – 588
26.13.1 Uterus Didelphys – 588
26.14 nicornuate Uterus and Rudimentary

U
Horn – 588
26.14.1 D iagnosis – 589
26.14.2 Management – 590
26.14.3 Surgical Technique: Removal of a
Rudimentary Horn – 590
26.15 Longitudinal Vaginal Septum – 590

26.15.1 T he Nonobstructing Longitudinal Vaginal Septum – 590
26.15.3 The Obstructing Longitudinal Vaginal Septum – 591
26.16 Transverse Vaginal Septum – 593
26.17 Presenting Symptoms – 593

26.17.1 D iagnosis – 593
26.17.3 Surgical Technique: Thin Transverse
Vaginal Septum – 594
26.17.4 Surgical Technique: Thick Transverse Vaginal
Septum – 595
26.18 Z-Plasty Technique – 595
26.20 Answers – 596
References – 596
576 M. Attaran
Case Vignette
Key Points
55 Many Müllerian anomaly diagnoses A 20-year-old woman requests information
overlap. The clinical presentation, imag- about creation of vagina. She is in a stable
ing, and examination must be reviewed relationship and wishes to be sexually
thoughtfully and ideally in conjunction active. She was diagnosed at 16 years of
with a colleague to approach the correct age with absence of a vagina, uterus, and
diagnosis. cervix. On examination, she has Tanner V
26 55 Endometrial suppression is the first pubic hair and breast development. She has
mode of therapy for patients presenting approximately 2 cm depth of vagina.
with obstructed Müllerian anomalies
and pelvic pain.
55 Vaginal dilation is the preferred method 26.2 Classification
of creation of vagina in a patient with
Müllerian agenesis The classification of Müllerian anomalies
helps with both the diagnosis and the com-
parison of outcomes after various modes of
management. However, there is no single
26.1 Introduction classification that encompasses all anomalies
that have been reported in the literature [3–
Malformations of the Müllerian ducts and 5]. Although the direct cause of the majority
the external genitalia can have significant of these anomalies is not known, on the basis
impact on both reproductive potential and of our embryological knowledge, the patho-
sexual function. When a patient presents with genesis of most of these anomalies can be
such an abnormality, it is important to put understood. On the basis of pathophysiol-
significant thought and time into determin- ogy, Müllerian anomalies can be broadly
ing the correct diagnosis and subsequent classified into problems according to the
treatment. developmental mechanism whose failure
The literature reports rates of female con- gave rise to the malformation. Anomalies can
genital anomalies between 0.2% and 0.4% of usually be classified as being related to (1)
the general population [1]. But the prevalence agenesis, (2) vertical fusion defects, or (3) lat-
of female congenital anomalies may be as eral fusion defects [6].
high as 7% when using some of the newer Agenesis of the uterus and vagina is a
diagnostic methods [2]. These rates are much relatively common abnormality. Agenesis of
higher when looking at subgroups of patients other Müllerian structures is extremely rare.
with recurrent pregnancy loss and infertility. Vertical fusion defects are usually the result
However, in many instances, these anomalies of abnormal canalization of the vaginal
are asymptomatic. plate and result in defects such as a trans-
This chapter will begin with a review of verse vaginal septum and imperforate
the diagnostic and presurgical evaluation of hymen. Lateral fusion defects can be sym-
these anomalies. The majority of the chap- metrical or asymmetrical and include sep-
ter will deal with the basic principles of sur- tum of the uterus and vagina, as well as
gical techniques used to correct these unicornuate and bicornuate uteri and related
anomalies. abnormalities.
Surgical Techniques for Management of Anomalies of the Müllerian Ducts
577 26
There are endless variations to Müllerian every 5000 newborn females [11]. Patients typ-
and vaginal anomalies. It is impossible to note ically present during their adolescent years
these variations effectively in any one classifi- with complaint of primary amenorrhea. As a
cation system. Consequently, many investiga- cause of primary amenorrhea, Müllerian
tors are still searching for that elusive agenesis is second only to gonadal dysgenesis
classification system that can not only encom- [12].
pass all the anomalies noted in the vagina, Patients with Müllerian agenesis will pres-
cervix, uterus, and adnexa but also translate ent with normal onset of puberty and appro-
into in-sync comprehension and visualization priate secondary sexual characteristics but
of the defect by other colleagues [7, 8]. apparently delayed menarche. They do not
The most accepted classification of uter- complain of cyclic pelvic pain like patients
ine anomalies was originally published by the with obstructive Müllerian anomalies. The
American Fertility Society in 1988 [9]. It places external genitalia appear completely normal,
uterine anomalies into distinct groups that are with normal pubic hair growth and normal-
numbered, based on anatomic configuration. sized labia minora, which is in contrast to
Vaginal anomalies were not included in this patients with complete androgen-insensitivity
classification. Recently the American Society syndrome. Hymeneal fringes may be evident,
of Medicine (ASRM) released an updated but the vaginal opening is absent. No pelvic
Müllerian anomaly classification (MAC2021) masses suggestive of hematocolpos will be
which maintains the premise of the original evident, which is in contrast to cases of com-
classification but adds three other categories: plete transverse septum.
longitudinal vaginal septum, transverse sep- Since these patients have a 46XX karyo-
tum, and complex anomalies (7 Box 26.1, type, normal ovaries will be present in the pel-
[10]). Its primary goal is to provide effective vis. Ovulation can be documented as a shift in
communication among providers and thereby basal body temperature. These patients’ hor-
improve patient care. monal levels are normal, and their cycle
length, based on hormonal studies, varies
from 30 days to 34 days [13]. In addition, they
may experience the monthly pain (mittel-
Box 26.1 ASRM Müllerian Anomaly
schmerz) that is indicative of ovulation.
Classification 2021 (MAC2021)
55 Müllerian agenesis
55 Cervical agenesis
55 Unicornuate uterus
26.4 Associated Anomalies
55 Uterus didelphys
55 Bicornuate uterus
Müllerian agenesis is associated with renal
55 Septate uterus
and skeletal system anomalies. Renal abnor-
55 Longitudinal vaginal septum
malities are noted in 40% of these patients.
55 Transverse vaginal septum
These include complete agenesis of a kidney
55 Complex anomalies
to malposition of a kidney to changes in renal
structure. Skeletal abnormalities are noted in
12% of patients and include primarily spine
defects followed by limb and rib defects [14].
26.3 Müllerian Agenesis Patients with Müllerian agenesis should
be actively assessed for these associated
26.3.1 Clinical Presentation anomalies.
Hearing difficulties have been reported in
Müllerian agenesis (i.e., Mayer–Rokitansky– patients with Müllerian agenesis [15, 16]. A
Kuster–Hauser syndrome) was first described higher rate of auditory defects has been noted
in 1829. Its incidence is reported to be 1 in in general in patients with Müllerian anoma-
578 M. Attaran
lies compared to those with normal Müllerian

structures [17].
26.5 Etiology
The etiology of Müllerian agenesis remains

unknown. It appears to be influenced by
26 multifactorial inheritance, and rare familial
cases have been reported. It does not appear
to be transmitted in an autosomal-domi-
nant inheritance pattern, since none of the
female offspring of women with Müllerian
agenesis (born via in vitro fertilization and
surrogacy) have shown evidence of vaginal
agenesis [18].
.. Fig. 26.1 Magnetic resonance image of Müllerian

agenesis. Typical findings in the pelvis include normal
26.6 Diagnosis ovaries and fallopian tubes and usually small Müllerian
remnants attached to the proximal portion of the fallo-
26.6.1 Imaging pian tubes that may be solid or have functioning endo-
metrial tissue
The diagnosis of Müllerian agenesis is con-
firmed via imaging techniques. Abdominal
ultrasonography will demonstrate the lack this structure will alert the physician to this
of uterus and existence of ovaries. The pres- possibility.
ence of a midline mass consistent with a
blood collection usually indicates an obstruc-
tive Müllerian anomaly. The distinction 26.6.2 Explaining the Diagnosis
between Müllerian agenesis and obstruction to the Patient
is extremely important since an incorrect
diagnosis can seriously jeopardize appropri- The diagnosis, usually made in early adoles-
ate management. cence, must be explained to the patient with
With the advent of magnetic resonance great sensitivity. At a time when being like
imaging (MRI), laparoscopy is no longer con- her peers is extremely important, knowl-
sidered necessary to make this diagnosis edge of this diagnosis can be psychologi-
(. Fig. 26.1). Typical findings in the pelvis cally devastating. Each patient must be
include normal ovaries and fallopian tubes reassured that her external genitalia appear
and usually small Müllerian remnants normal and that they will be able to have a
attached to the proximal portion of the fallo- normal sex life after the creation of a nor-
pian tubes that may be solid or have function- mally functioning vagina. Although usually
ing endometrial tissue. not voiced, the inability to subsequently bear
Direct communication with the radiolo- children is a major disappointment to teen-
gist about the differential diagnosis prior to agers. Fortunately, with in vitro fertilization
imaging studies is important. On occasion, using a surrogate and more recently via uter-
the unsuspecting radiologist may interpret the ine transplantation, having her own genetic
small uterine remnants as a uterus. Careful child will be an option for many of these
attention to the very small dimensions of young women [19].
579 26
26.6.3 Creation of a Neovagina
The first goal of treatment of Müllerian agen-

esis is the creation of a functional vagina to
allow intercourse. Frank first proposed vagi-
nal dilatation with the use of a dilator as a
means of creating a neovagina in 1938 [20].
However, the surgical techniques of vagino-
plasty remained the preferred methods for
many years. The success of any technique
depends in large part on the emotional matu-
rity of the patient. Pretreatment counseling
and continued support during treatment are .. Fig. 26.2 Examples of vaginal dilators of different
important. sizes. (Reproduced with permission from Falcone and
Hurd [85])
26.6.4 Vaginal Dilation 26.6.5 Procedure
The simplicity and ease of vaginal dilation When the patient expresses a desire to proceed
and its significantly lower complication rate with therapy, she is shown the exact location
than surgical techniques dictate its use as an of her vaginal dimple. The axis of dilator
initial form of therapy for most patients with placement is also demonstrated (. Fig. 26.3).
Müllerian agenesis. The American College of The process is initiated by placement of the
Obstetrics and Gynecology has released a smallest dilator against the dimple. Pressure is
committee opinion that recommends nonsur- kept upon the distal aspect of the dilator by
gical management of Müllerian agenesis as sitting upon a stool while leaning slightly for-
the first mode of treatment [21]. ward. When the dilator fits comfortably, she
Frank’s technique of dilation involves moves to the next size dilator. The patient is
actively placing pressure with the dilators instructed to use this technique a minimum of
against the vaginal dimple (. Fig. 26.2). 20 min a day, two to three times a day. In
Not only the patient is in an awkward posi- motivated patients, a functional vagina can be
tion but the hand applying the pressure can created in as short as 12 weeks.
become tired. In 1981, Ingram proposed the Counseling and psychological support is
concept of passive dilation, where pressure is integral to successful treatment [24–26].
placed upon the dilator by sitting on a bicycle Patients are requested to return to the office
seat [22]. frequently so that the physician can monitor
Roberts reported a success rate of 92% in their progress and provide guidance and an
women who dilated the vagina via the Ingram opportunity to answer questions. Intercourse
technique for 20 min three times a day [23]. may be attempted when the largest dilator fits
The average time of the creation of a func- comfortably.
tional vagina was 11 months. This series dem- Multiple types of graduated dilators, made
onstrated that an initial dimple <0.5 cm was of various materials, are present on the mar-
all that was necessary to achieve adequate ket. None have been found superior to the
dilation. Interestingly, failure of this tech- others. Patients may stop and reinitiate the
nique was not related to the length of vaginal dilation at any time without any negative
dimple but rather more closely associated long-term sequelae. Although most patients
with the patient’s youth. Failure of this tech- appear interested in initiating this therapy the
nique was more common in patients younger summer before college, when they are mature
than 18 years of age. enough and motivated to create the vagina,
580 M. Attaran
the vesicorectal septum into the peritoneal cav-

ity. These sutures have been tied to a dilator oth-
erwise known as a “dummy,” resting on the
perineum. Two curved applicators are placed
through the abdominal wall and guided down
retroperitoneally on the right- and left-side
walls until the needle tip approaches the midline
threads. These threads are then loaded via lapa-
26 roscopic graspers into these applicators and
gently withdrawn through the abdominal wall.
The threads are connected to a traction device
and placed under tension. When the threads are
tightened, the dummy is pulled and within days
a vaginal cavity is created. The duration of
canal formation is about 4.5 days, thus patients
do need to be under analgesia as the dummy is
being pulled into the vesicovaginal space. The
average length of vagina created in such a man-
ner is 9 cm. Patients must continue to use the
.. Fig. 26.3 Schematic drawing of angle of dilator
placement. The patient is viewed in lithotomy position,
dilator after the full vaginal length is developed.
and the axis is directed away from the bladder. (Repro- Brucker et al. have reported on a series of
duced with permission from Falcone and Hurd [85]) 240 patients with a success rate of 98% [31].
Very few operative complications were
the timing of therapy is purely dependent on reported and included bladder hematoma,
the patient’s desires. The median age of start- urethral necrosis, and urinary tract infections.
ing treatment is 17 years. For appropriately
selected motivated patients, the reported suc-
cess rates are as high as 95% [27]. 26.7.2 Vaginoplasty Techniques
The traditional surgical management of vagi-

26.7 Vecchietti Procedure nal agenesis is to create a vaginal space fol-
lowed by placement of a lining to prevent
Giuseppe Vecchietti described this method of stenosis. Multiple tissues and at least one
creating a neovagina in 1965 [28]. Similar to man-made material have been used to line this
vaginal dilatation, this method avoids the use cavity with varying degrees of success in pre-
of a graft. The Vecchietti procedure is a one- venting subsequent stenosis of the neovagina
step procedure in which a neovagina is created (. Table 26.1).
in 7 days by continuous pressure on the vagi-
nal dimple using an acrylic “olive” connected
by retroperitoneal sutures to a spring tension 26.7.3 McIndoe Procedure
device on the lower abdomen. Although the
original description of the Vecchietti proce- The first step of the procedure is obtaining the
dure utilized laparotomy, this technique is split-thickness skin graft. The plastic surgery
currently performed laparoscopically [29, 30]. team typically acquires the skin graft from the
buttock area, a location usually covered by
clothing. The skin graft should be 0.015–
26.7.1 Procedure 0.018-in. thick. Within 2–3 weeks the area
heals with acceptable scarring.
The first step in this procedure is to laparoscop- The skin graft is sutured around the mold
ically observe placement of an applicator bear- with 4–0 absorbable suture (. Fig. 26.4). The
ing suture threads, through the perineum and mold is covered completely because any
581 26
.. Table 26.1 Surgical methods of creating a

neovagina
Dissection of a Split-thickness skin graft

perineal space (McIndoe)
Full-thickness skin graft
Peritoneum (Davydov),
buccal mucosa
Tissue engineering
Muscle and skin flap
Adhesion barriers
Tissue expansion
Bowel vaginoplasty Sigmoid colon
Vulvovaginal pouch Williams vaginoplasty
Traction on Vecchietti
retrohymeneal fovea
.. Fig. 26.5 The initial transverse cut was made on the

fibrous tissue and an initial space developed. (Repro-
duced with permission from Falcone and Hurd [85])
then connected. If the dissection is performed

.. Fig. 26.4 Skin graft is sutured around a mold. (Repro- in this manner, minimal amount of bleeding is
duced with permission from Falcone and Hurd [85]) encountered. Any bleeding sites must be con-
trolled meticulously to avoid lifting of the
uncovered sites, whether due to lack of graft from the newly created vaginal wall and
enough tissue or a gaping hole in the line of subsequent nonadherence and necrosis.
suture, tend to result in the formation of gran- After creation of the vaginal space, the
ulation tissue. Thus, care must be taken to mold covered with the skin graft is placed
obtain sufficient amount of graft for this inside the cavity (. Fig. 26.7). At the introi-
procedure. tus, the skin graft is attached with several sep-
The patient is placed in the dorsolithot- arate 3–0 absorbable stitches. To hold the
omy position. A transverse incision is made in mold in place, several loose, nonreactive
the vaginal vestibule, between the rectum and sutures, such as 2–0 silk, are used to approxi-
urethral openings (. Fig. 26.5). In a patient mate the labia minor in the midline.
who has not had prior surgery or radiation in During the ensuing week, the patient is
the area, areolar tissue is now encountered. maintained on bed rest, broad-spectrum anti-
This tissue is easily dissected with either fin- biotics, a low-residue diet, and an agent to
gers or a Hegar dilator on either side of a decrease bowel motility. She also has an
median raphe (. Fig. 26.6). The dissection is indwelling urinary catheter. Upon return to
continued for at least the length of the mold the operating room in 1 week, the mold is
without entering the peritoneal cavity. By cut- carefully removed. The graft site is carefully
ting the median raphe, the two channels are assessed for any signs of necrosis or underly-
582 M. Attaran
26
.. Fig. 26.6 Placement of Hegar dilator to create space .. Fig. 26.7 The mold with the graft is placed in the
for the graft. The direction of the Hegar dilators is space. Notice that the space to be created must accom-
posterior. (Reproduced with permission from Falcone modate the mold completely. (Reproduced with permis-
and Hurd [85]) sion from Falcone and Hurd [85])
ing hematoma after the vaginal cavity is irri- no study comparing the outcomes of soft vs.
gated with warm saline. Another mold is then rigid molds in this operation. Theoretically,
reinserted and kept in place for the next soft molds decrease the risk of fistula forma-
3 months except during defecation and urination that can result from avascular necrosis. A
tion. Night-time usage of the mold is recom- soft mold can be created by covering a foam
mended for the following 6 months. To prevent rubber block with a condom or as more
contracture of the vagina, the patient is recently described, using surgical sponges
instructed to reinsert the mold during [33]. These soft molds are able to expand and
extended times of sexual inactivity. fit the neovaginal space, thereby providing
Difficulty in dissecting the neovagina and equal pressure throughout the canal.
increased probability of bleeding and fistula An 80% success rate has been reported
formation are encountered in the patient with with this procedure [34]. Since success rates
a prior surgical procedure. Other problems are highest in those patients who have not
that may be encountered include narrow sub- undergone prior vaginoplasty, patients must
pubic arch, strong levators, shorter perineum, be counseled extensively prior to surgery
prior hymenectomy, and congenitally deep regarding the need for prolonged use of the
cul-de-sac. mold. Indeed, part of the presurgical assess-
Both rigid and soft molds have been used ment involves determination of patient matu-
for this procedure. A report on the use of a rity and motivation concerning the use of
rigid mold on 201 patients who underwent the dilators. Lack of compliance with the postop-
McIndoe operation demonstrated a fistula erative use of dilators will lead to contracture
formation rate of less than 1% [32]. There is and diminishment of vaginal length.
583 26
Surgical complications include postopera- This procedure may have several advan-
tive infection and hemorrhage, failure of graft tages compared to the traditional McIndoe.
and formation of granulation tissue, and fis- Contrary to skin grafts that leave visible scar-
tula formation. In general, the incidence of ring at the donor site, there is no outward sign
complications is low: rectal perforation rate of using a graft in the Davydov procedure.
of 1%, graft infection of 4%, and graft-site There appears to be no danger of lack of graft
infection of 5.5% [32]. takes and no problem with hair growth.
Long-term data on the McIndoe proce- In Davydov’s first reported series, sexual
dure, while limited, consistently indicate an intercourse was initiated within several weeks
improvement in quality of life. In a series of of surgery in all but 1 of his 30 patients. On
44 patients who underwent a surgical proce- follow-up, the length of the vagina was noted
dure to create the vagina, 82% achieved a to be 8–11 cm. In a series of 18 patients who
functional satisfactory postoperative result underwent the laparoscopic modification of
[35]. Vaginal length varied from 3.5 cm to this procedure, 85% reported being sexually
15 cm. In another long-term study of women satisfied during an 8–40-month follow-up.
who underwent a McIndoe procedure, 79% of Reported complications include urinary
the patients reported improved quality of life, retention, bladder and ureter injury, and
91% remained sexually active, and 75% regu- rarely formation of rectovaginal fistula.
larly achieved orgasm [36].
The newly created vagina should be visu-
ally inspected at the time of a pelvic examina- 26.7.5 Adhesion Barrier Lining
tion. Hair growth has been reported to be a
problem with some skin grafts. Transformation Jackson first described the use of an adhe-
to squamous cell carcinoma from skin graft sion barrier to line the neovagina in 1994
has been described [37, 38]. [44]. Oxidized regenerated cellulose
(INTERCEED; Johnson and Johnson Patient
Care Inc., New Brunswick, NJ) forms a gelat-
26.7.4 eritoneal Graft: Davydov
P inous barrier on raw surfaces and thus pre-
Procedure vents adhesion formation. After creation of
the vaginal space, sheets of cloth-like oxidized
Use of the peritoneum to line the newly cre- regenerated cellulose are wrapped around the
ated vaginal space was popularized by mold and placed in the vagina in a manner
Davydov, a Russian gynecologist, and first similar to the McIndoe. The neovaginal space
described by Rothman in the United States in must be free of any bleeding. Epithelialization
1972 [39–41]. In his original description, a is noted to occur within 3–6 months. Small
laparotomy is performed after creation of the areas of granulation tissue may be seen at the
vaginal space as described above with the apex of the vagina and resolve after applica-
McIndoe operation. tion of silver nitrate. Average vaginal depth
A cut is made on the peritoneum overly- ranges from 6 cm to 8 cm. Continuous use of
ing the new vagina. Long sutures are applied mold is encouraged until complete epitheliali-
to the anterior, posterior, and lateral sides of zation has occurred.
this peritoneum. The sutures are then pulled A retrospective review of 52 patients that
down through the vaginal space, thus pulling underwent use of adhesion barrier revealed
the peritoneum to the introitus. The edge of complete epitheliazation of the neovagian
the peritoneum is then stitched to the mucosa within 4–6 months when the patient used the
of the introitus. Closing the peritoneum on mold intermittently first twice a day and later
the abdominal side then forms the top of once a day for 10 minutes. None of the women
the vagina. Several investigators have also complained of vaginal dryness or difficulty
described the laparoscopic modification of with intercourse [45]. The advantages of the
this procedure [42, 43]. use of oxidized regenerated cellulose include
584 M. Attaran
avoidance of any scars, readily available prod- flap is that it avoids the problem of contrac-
uct, and low expense. In addition, the surgical ture encountered with split-thickness grafts.
procedure is simplified into a one-stage The use of gracilis myocutaneous flaps
procedure. and rectus abdominus myocutaneous flaps for
vaginal reconstruction has been reported [50].
This approach has been associated with a con-
26.7.6 Buccal Mucosa spicuous scar and a higher failure rate. Wee
and Joseph in Singapore designed flaps that
26 Buccal mucosa has been used by urologist for maintained good blood supply and innerva-
several decades in urethral reconstruction and tion [51]. Known as a “pudendal-thigh flap
repair of complex hypospadias. It was first vaginoplasty,” this technique has been partic-
reported for use in vaginoplasty in 2003 [46]. ularly successful in patients with vulvar
Some of the properties that make this an anomalies [52].
excellent graft choice are: thick elastic lubri- The patient’s own labia majora and labia
cating epithelium, thin lamina propria, and minora have also been used to create a vagina
same color and texture match to native vagina. [53]. Tissue expansion has also been advo-
In addition, the harvest site is hidden and cated to create labiovaginal flaps, which are
heals very quickly. Once the perineal space is then used to line the neovagina [54, 55].
created, the buccal mucosa from both cheeks
is harvested, placed over a vaginal stent, and
then sown into the new space. Postoperative 26.7.9 Bowel Vaginoplasty
vaginal lengths have measured 8–10 cm in
length and 4–5 cm in width [47]. This is not a procedure of choice in women
with vaginal agenesis. For this procedure, also
known as a colocolpopoiesis, a portion of
26.7.7 Tissue Engineering large bowel with its preserved vascular pedicle
is sutured into the neovagina. In recent years,
The first case in which in vitro cultured vagi- sigmoid colon use has been recommended.
nal tissue was utilized to line the neovagina Continuous use of dilators is not consid-
was published in 2007 [48]. A 1-cm2 biopsy ered necessary, although constriction has been
was performed from the vulvar vestibule. noted when ilium has been used. Success rates
Autologous keratinocyte cultures were cre- of up to 90% have been reported. Reported
ated from this biopsy. The McIndoe proce- complications include profuse vaginal dis-
dure was utilized to create the vaginal space, charge, prolapse, introital stenosis, bowel
and the autologous in-vitro cultured tissue obstruction, and colitis [56, 57]. Finally, there
was used to line the cavity. The length of the is a report of a mucinous adenocarcinoma
vagina is reported to be normal, as is its depth. arising in a neovagina lined with the sigmoid
At 12- month follow-up, the vaginal length colon [58]. Given the increased complication
was 8 cm and width was 2 cm. Histologically, rates, it seems appropriate to reserve this treat-
normal vaginal mucosa was noted at 3 months ment modality for complex situations in
[49]. which a prior vaginoplasty technique has
failed or when there are multiple urogenital
malformations.
26.7.8 Muscle and Skin Flap
These approaches are not procedures of 26.7.10 Obstructed Rudimentary
choice for women with vaginal agenesis. Uterine Bulbs
However, they may be used for those who
require vaginal reconstruction after exposure Patients with Müllerian agenesis commonly
to radiation or multiple surgical procedures. have Müllerian remnants noted on MRI or
The advantage of using a full-thickness skin during a laparoscopy. The MRI has the added
585 26
.. Fig. 26.8 Magnetic resonance image of functioning rudimentary bulbs. (Reproduced with permission from Fal-
cone and Hurd [85])
.. Fig. 26.9 Pathologic specimen of the extirpated

rudimentary bulbs. (Reproduced with permission from .. Fig. 26.10 Schematic representation of cervical
Falcone and Hurd [85]) agenesis. (Reproduced with permission from Falcone
and Hurd [85])
value of determining if any endometrial tissue

exists within these remnants (. Figs. 26.8 and flap. The retroperitoneal space is entered, the
26.9). Patients with functional endometrial ureters identified, and the utero-ovarian liga-
tissue may present after many asymptomatic ments transected. The dissection continues
years with cyclic pelvic pain secondary to with identification and coagulation of the
monthly endometrial shedding, and develop- uterine arteries. Finally, the uterine remnants
ment of endometriosis has been reported in and the fibrous tissue connecting them are
these patients. Symptomatic Müllerian bulbs incised.
should be removed.
26.8 Cervical Agenesis

26.7.11 Surgical Technique
Cervical agenesis is a rare Müllerian anomaly
The procedure is started by placing traction whose prevalence is reported to be between
on the ipsilateral uterine bulb. The round liga- 1/80,000 and 1/100,000 [59] (. Fig. 26.10).
ment is grasped and cut and the peritoneum Various degrees of cervical abnormalities,
incised anteriorly, thereby creating a bladder ranging from dysgenesis to agenesis, have
586 M. Attaran
been described [60]. The vagina may or may

not be present in patients with cervical agene-
sis. In a series of 58 patients with cervical atre-
sia, 48% had isolated congenital cervical
atresia with a normal vagina [61]. The rest of
the patients had either a vaginal dimple or
complete atresia.
26
26.9 Diagnosis
Unlike some of the other Müllerian anoma-

lies, patients with cervical agenesis present very
early in adolescence. Typically, patients pres-
ent between the ages of 12 and 16 with a pri-
mary complaint of pelvic pain secondary to
obstruction of flow from the uterus. Initially,
.. Fig. 26.11 Magnetic resonance image of cervical
the pain is cyclic, but it may evolve with time agenesis. The uterine cavity is distended with clots and
into continuous pain. It is not uncommon for no cervix is identified. (Reproduced with permission
such patients to have been evaluated by their from Falcone and Hurd [85])
pediatricians for other causes of abdominal
pain. Although these girls have amenorrhea,
this symptom fails to raise a red flag since the
patients are so young at presentation that lack 26.10 Management
of menses is not concerning. Continuing men-
struation in an obstructed uterus forms a 26.10.1 Pain Control
hematometra and possibly hematosalpinx,
endometriosis, and adhesions in the pelvis. Pain control should be the first goal of treat-
Imaging of such a pelvis can easily lead to ment. Although analgesia may be required,
a misdiagnosis. Such patients have been taken severe pain will resolve within several days.
to surgery for pain thought to be secondary to Suppressive therapy is used to prevent further
a pelvic mass, only to find that they have a endometrial shedding until definitive surgery
congenital anomaly. While ultrasound may be can be performed. Agents that are commonly
helpful in looking for a cervix, one’s clinical used to achieve this suppression are continu-
suspicion must be communicated directly to ous oral contraceptive pills, norethindrone
the radiologist performing the procedure. acetate, depo-medroxyprogesterone acetate,
MRI is very helpful in visualizing the cervix and GnRH agonists or antagonists.
and can accurately determine its presence or Most adolescents are not emotionally
absence [62, 63] (. Fig. 26.11). ready to decide on a surgical course of action,
Patients with cervical agenesis who lack a which may be as invasive as hysterectomy.
vagina must be differentiated from those with Thus, if suppressive therapy with oral contra-
a high obstructing vaginal septum. MRI is ceptives or depo-medroxyprogesterone has
very helpful in making this differentiation by provided pain relief, many may choose to
showing accumulation of blood in the upper hold off on definitive surgical therapy until
vagina and a cervix in patients with a high they can fully understand the possible conse-
transverse septum. Theoretically, MRI should quences. In addition, this alleviates the bur-
detect absence of the cervix but is unable to den placed upon parents to make a decision
clearly differentiate among the various degrees regarding their daughter’s reproductive
of cervical dysgenesis. future.
587 26
26.10.2 Surgical Approach placement may maintain an open pathway for
menstruation, the lack of epithelialization of
There are no specific guidelines in the litera- the fistula not only increases risk of fibrosis
ture to determine the correct surgical proce- but also may impede sperm migration into the
dure. It is clear, however, that each patient uterus. Advances in artificial reproductive
should be assessed individually. The type of techniques have led to reports of pregnancies
surgical correction depends up the degree of in patients with cervical agenesis [69]. Thus,
cervical anomaly, the length of the vagina, many patients are likely to choose effective
and the wishes of the patient. The surgical continued endometrial suppression over a sur-
options are total hysterectomy, uterovaginal gical solution in hopes of keeping a glimmer
anastamosis, and cervical canalization. The of reproductive hope. With passage of time
definitive and safest treatment of cervical and attainment of adulthood, such patients
agenesis is a total hysterectomy. A hysterec- may be better able to accept the diagnosis and
tomy would diminish continued physical pain its consequences.
and discomfort. In addition, with the advent
of surrogate pregnancy, an early hysterectomy
would potentially preserve more ovarian tis- 26.10.3 Uterine Fusion Defects
sue, which may be used to achieve a pregnancy
via surrogacy and in vitro fertilization. On the Uterine fusion defects include septate, bicor-
other hand, it is a daunting decision to have a nuate, and didelphys uteri. Patients with these
hysterectomy at a young age. isolated uterine anomalies are asymptomatic.
The degree of cervical dysgenesis and asso- The diagnosis is usually made during evalua-
ciation with some length of vagina may open tion of infertility, recurrent pregnancy loss, or
up the option of uterovaginal anastomosis an obstetric complication.
and cervical canalization. There are multiple Correct diagnosis of these anomalies is of
reports in the literature of cervical canaliza- utmost importance, since their management
tion and stent placement [64–67]. Agents such varies significantly. The diagnosis is typically
as bladder mucosa, skin grafts, and perito- made based on evaluation of anatomy via
neal flaps have been used to line the cervical imaging techniques including ultrasonogra-
canal. Although success has been reported phy, hysterosalpingography, and MRI or via
with establishment of menses, some patients laparoscopy and hysteroscopy. Although
will require reoperation secondary to fibro- radiologic guidelines exist to differentiate
sis of the cervical tract and obstruction. In a these entities, the multitude of varieties of
review of patients with cervical agenesis, 59% these malformations can pose a significant
of those that underwent cervical canalization challenge in making the correct diagnosis.
achieved normal menstruation. Four of the
23 who achieved cervical patency required
multiple surgeries [61]. The task is even more 26.11 Septate Uterus
daunting if there is also vaginal agenesis that
requires reconstruction. Although preserving Reproductive difficulties are encountered far
fertility is ultimately the goal of canalization more commonly in women with a septate
procedures, in-depth counseling is necessary uterus than any other uterine fusion defect.
as sepsis and death have been reported subse- The septate uterus is associated with the high-
quent to canalization [68]. est spontaneous abortion rate of uterine
Relatively poorer pregnancy rates are fusion defects.
noted in this category of Müllerian anomaly The management of uterine septum
and may be attributed to several factors. detected after an evaluation for recurrent
Prolonged delay in diagnosis can lead to pregnancy loss is hysteroscopic resection of
extensive endometriosis and scarring in the the septum. However, the management of a
pelvis. Also, while canalization and stent septum found during an infertility investiga-
588 M. Attaran
tion is less straightforward. While the septum 26.13 Surgical Technique:

does not appear to cause infertility, the con- Strassman Metroplasty
cern regarding possible spontaneous abortion
after undergoing infertility treatment may be The Strassman metroplasty is the procedure
enough to justify hysteroscopic removal of the of choice in the uncommon case where unifi-
septum prior to infertility treatment. cation of a bicornuate uterus is indicated. A
transverse incision is made across the fundus
of the bicornuate uterus. The opened cavity is
26 26.12 Bicornuate Uterus then repaired in an anteroposterior fashion
leading to one unified cavity. There are case
This anomaly is usually discovered inciden- reports of viable pregnancies occurring after
tally during an investigation for infertility or this procedure, but lack of controlled studies
recurrent pregnancy loss. It is important to and outcome data should make this proce-
differentiate a bicornuate from a septate dure be indicated only in select patients.
uterus. Hysterosalpingogram (HSG) alone
cannot differentiate these entities, because this
imaging approach cannot evaluate the exter-
26.13.1 Uterus Didelphys
nal contour of the uterus. While laparoscopy
was used primarily for this purpose in the
The uterus didelphys is defined as two com-
past, modern imaging techniques including
pletely separate uteri and cervix (. Fig. 26.12).
3D ultrasonography and MRI can adequately
It accounts for 10% of all uterine anomalies.
differentiate these two entities.
On ultrasonography, the two bulbs of the
A bicornuate uterus has two distinct fundi
uterus are distinctly noted and can be fol-
with an intervening fundal indentation of at
lowed down to their individual cervices.
least 10 mm. A septate uterus, on the other
Surgical correction is not indicated. In a
hand, has a flat or convex fundus or a fundal
long-term follow-up of 49 patients with didel-
indentation <10 mm. On MRI, a septate
phys uteri, 89% of those desiring pregnancy
uterus will fail to show an intervening myome-
had at least one living child [72]. The sponta-
trium between the T2-hypointense septum
neous miscarriage rate was 21%, and only one
that separates the endometrial cavities. In
ectopic pregnancy occurred. The most com-
contrast, a bicornuate uterus will show two
mon problem was preterm delivery, which
T2-hyperintense endometrial cavities, each
occurred in 24% of pregnancies. Fortunately,
with a junctional zone and myometrial band
only 7% of the infants weighed <1500 g at
of intermediate signal intensity.
birth. Breech presentation was noted in 51%
Conception does not appear to be a prob-
of the infants; thus, the cesarean section rate
lem in women with bicornuate uterus.
is increased.
However, higher rates of preterm delivery
(19%) and spontaneous abortion (42%) have
been reported [70]. Uteroplacental insuffi-
ciency and cervical incompetence may play 26.14 Unicornuate Uterus
roles in the higher obstetric complications. and Rudimentary Horn
Thus, the treatment options for bicornuate
uterus may include the Strassman metroplasty A unicornuate uterus may be associated with
and cervical cerclage. Since the benefit of a communicating or noncommunicating
metroplasty has never been established in a rudimentary horn. In either case, patients
controlled study, it is typically considered will have monthly regular periods. If a rudi-
only after multiple pregnancy losses and mentary horn is communicating or a non-
complications [71]. communicating horn has nonfunctioning
589 26
.. Fig. 26.12 The appearance of uterus didelphys at laparoscopy. Note the peritoneal band in between the two
horns. (Reproduced with permission from Falcone and Hurd [85])
endometrium, the patient is unlikely to have

severe dysmenorrhea. The diagnosis in these
patients is usually made at the time of inves-
tigation for infertility and obstetric problems
(including recurrent pregnancy loss) or at the
time of cesarean section. In contrast, if a non-
communicating rudimentary horn has func-
tioning endometrium, most patients will have
severe dysmenorrhea. (. Fig. 26.13).
26.14.1 Diagnosis
Pelvic examination may reveal a deviated .. Fig. 26.13 Noncommunicating uterine horn seen at
uterus or an adnexal mass. Ultrasonography laparoscopy. (Reproduced with permission from Falcone
will be consistent with a unicornuate uterus and Hurd [85])
590 M. Attaran
on one side, while the other side may be inter- uterus with fibrous band, the blood supply is
preted as a rudimentary horn, a pedunculated found within this band. Coagulation and
leiomyoma, or an ovarian endometrioma. transection of the band are all that is required.
Both 3D ultrasonography and MRI are useful In cases where the rudimentary horn is
in making a definitive diagnosis. attached to the uterus via shared myome-
trium, the blood supply cannot be easily
identified, and thus the uterine artery ascend-
26.14.2 Management ing beneath the rudimentary horn should be
26 identified and ligated. It may be difficult to
Management depends on whether the rudi- find a plane of dissection between the horn
mentary horn is functional and/or communi- and the uterus, but care must be taken to
cating. A nonfunctioning, noncommunicating avoid entry into the cavity of the unicornuate
rudimentary horn does not need to be uterus or compromising the integrity of the
removed, as it will be asymptomatic and not myometrial thickness. After this dissection,
put the patient at any risk. In contrast, a the myometrial defect should be carefully re-
functioning, noncommunicating rudimentary approximated with interrupted or continuous
horn should be removed upon diagnosis to sutures to minimize the risk of uterine rupture
alleviate the patient’s often severe dysmenor- during a subsequent pregnancy.
rhea and to avoid the risk of rupture, should a
pregnancy occur in this horn [73]. A function-
ing, communicating rudimentary horn should
26.15 Longitudinal Vaginal
also be removed given there is a risk of devel-
oping a pregnancy in such a horn, leading to Septum
subsequent rupture if undiagnosed [74].
A longitudinal vaginal septum can be either
nonobstructing or obstructing. A nonob-
26.14.3 Surgical Technique: structing vaginal septum is often asymptom-
Removal of a atic and discovered at the time of a pelvic
exam or childbirth. A woman with an
Rudimentary Horn obstructing longitudinal vaginal septum often
presents with an increasingly severe dysmen-
A rudimentary uterine horn can be removed
orrhea and a unilateral vaginal mass.
via laparotomy or laparoscopy using similar
techniques, depending on surgical experience.
After gaining access to the pelvis, the round
ligament of the rudimentary horn is identi- 26.15.1 The Nonobstructing
fied, ligated, and divided. Access is gained Longitudinal Vaginal
into the retroperitoneal space, the ureter is Septum
identified, and the bladder is dissected off the
lower border of the rudimentary horn. Nonobstructing longitudinal vaginal septa
The rudimentary horn should be removed account for 12% of the malformations of the
together with the corresponding fallopian vagina. Although most are asymptomatic,
tube to avoid a future ectopic pregnancy in a some patients complain of continued vaginal
blind residual tube via sperm transmigration. bleeding despite placement of tampon, diffi-
After disconnecting the tube from the meso- culty removing a tampon, or dyspareunia.
salpinx, the utero-ovarian ligament is tran- These septa may be complete or partial and
sected so that the ovary can be spared. can exist in any portion of the vagina
The rudimentary horn may share myome- (. Fig. 26.14). A longitudinal vaginal septum
trial tissue with the unicornuate uterus or be can easily be missed during physical examina-
attached by a band of fibrous tissue. In cases tion, especially if there is a dominant vaginal
where the uterine horn is attached to the canal.
591 26
.. Fig. 26.14 Nonobstructing longitudinal vaginal

septum. (Reproduced with permission from Falcone and
Hurd [85])
Once the diagnosis is made, both the

uterus and renal anatomy should be assessed
for associated anomalies. In one study, 60% of
patients with longitudinal vaginal septa were
found to have a bicornuate uterus [75]. Other
investigators have noted a predominance of
uterus didelphys in such cases [72].
A longitudinal vaginal septum should be
removed in patients with complaints of dys-
pareunia and those who desire to be able to
effectively use a tampon. In cases of uterus
didelphys, removal of the septum may be nec-
essary to allow sufficient access to each cervix .. Fig. 26.15 Schematic of obstructing longitudinal
septum. (Reproduced with permission from Falcone and
for pap smears. Hurd [85])
Some obstetricians advocate the removal
of a longitudinal vaginal septum prior to
delivery to avoid potential dystocia and
larger mucosal defects. The edges of these
laceration of the septum [75]. The number of
mucosal defects are re-approximated with 2–0
patients with vaginal septa who have had suc-
absorbable suture. In some instance, the sep-
cessful vaginal deliveries is unknown.
tum may just be transected when the tissue is
However, it seems reasonable to remove a
not redundant or pliable. Postoperative use of
thick longitudinal septum prior to pregnancy.
a vaginal mold is not necessary.
26.15.2 Surgical Technique 26.15.3 The Obstructing

The goal of surgery is the removal of a wedge Longitudinal Vaginal
of tissue without damaging the cervix, blad- Septum
der, or rectum. A Foley catheter is placed in
the bladder. Since longitudinal vaginal septa Women with an obstructing longitudinal sep-
are well vascularized, the anterior border of tum usually present with normal-onset men-
the septum, followed by the posterior border, arche and increasingly severe dysmenorrhea.
is removed using unipolar electrosurgery. Care These patients are most likely to have uterus
must be taken not to remove the septum too didelphys. One of the uteri has a patent outlet,
close to the vaginal wall, as this will leave and the other is obstructed (. Fig. 26.15).
592 M. Attaran
26.15.4 Surgical Technique
Accurate delineation of anatomy is a prerequi-

site for surgical excision of an obstructing longi-
tudinal vaginal septum. The first step is to place
a needle into the bulging vaginal wall to identify
the correct plane of dissection. The septum can
have varying degrees of thickness. Once blood
26 extrudes from the needle, the adjacent tissue is
incised with electrosurgery to gain access into
the obstructed vagina. Allis clamps are placed
on the edges of this incision and the cavity is
assessed. When removing the medial border of
.. Fig. 26.16 An obstructing longitudinal septum usu- this septum, care must be taken to avoid damag-
ally presents as a bulge in the vagina. (Reproduced with
ing the urethra. The septum should be removed
in its entirety to allow easy access to the second
cervix for pap smears. The raw mucosal edges
If the obstruction is low in the vagina, are approximated with 2–0 absorbable suture.
eventually a bulge may be noted upon exami- Use of a vaginal mold after surgery is not neces-
nation of the lower canal. However, a higher sary, since postresection stenosis is rare. In dif-
obstruction may be completely missed with ficult cases, use of either a resectoscope or
just visual inspection, which is frequently the hysteroscope to remove longitudinal vaginal
case in an adolescent. Digital examination septum has been described [77, 78].
may reveal a tense bulge in the vaginal wall The previously hidden cervix and
(. Fig. 26.16). In many instances, the bulge is obstructed vaginal canal will often appear
toward the anterior portion of the vagina abnormal. The cervix is usually flush with the
between the 12 o’clock and 3 o’clock posi- vaginal fornix and often appears erythema-
tions or 9 o’clock and 12 o’clock positions tous and glandular. Histologically, the
due to the rotation of the two cervices. obstructed vaginal canal and septum on its
Ultrasonography of the pelvis will usually obstructed side will have columnar epithelium
show a pelvic mass, which can be misleading and glandular crypts [76]. Some patients may
unless a vaginal septum is considered in the complain of profuse vaginal discharge after
differential diagnosis. MRI is the best imag- removal of the septum. Metaplastic transfor-
ing mode for definitively diagnosing this mation of the vaginal mucosa to mature squa-
abnormality. Like other Müllerian anoma- mous epithelium can take many years.
lies, a longitudinal vaginal septum is associ- Simultaneous laparoscopy during removal
ated with renal abnormalities, including of a vaginal septum is not recommended
absent kidneys, pelvic kidneys, and double unless the diagnosis is unclear on MRI or
ureters [76]. imaging studies indicate concomitant pelvic
Some longitudinal septa will be found to masses. As in all cases of obstructive Müllerian
be only partially obstructing and a small anomalies, endometriosis is frequently encoun-
opening in the septum can be found during tered, even if the septum is only partially
menses with close inspection. Symptoms may obstructing. With the possible exception of
vary from irregular and prolonged bleeding to endometriomas, excision of the endometriosis
profuse vaginal discharge. Occasionally, the is not recommended, since these lesions will
pinpoint opening provides a pathway for regress after removal of the obstruction [79].
organisms to access the obstructed vagina The obstetric outcome of such patients is
leading to pelvic infection and pyocolpos. similar to that reported for patients with
Physical examination is unlikely to reveal a simple uterine didelphys. Pregnancy rates of
tense bulge, but a slight fullness may some- 87% and live birth rates of 77% have been
times be appreciated in the paravaginal area. reported [76].
593 26
In such instances, a mucocolpos can present
as an abdominal mass. If large enough, this
mass may cause ureteral obstruction with sec-
ondary hydronephrosis. Compression of the
vena cava and cardiopulmonary failure have
also been reported.
26.17.1 Diagnosis
Manual and speculum examinations provide

the most important information for diagnosis
.. Fig. 26.17 Complete transverse septum. Notice that of a transverse vaginal septum. If the septum
there is no bulge with a Valsalva maneuver that would is very low, a vaginal opening may not be
be seen with an imperforate hymen. (Reproduced with
appreciated on evaluation of the external gen-
italia. A low transverse vaginal septum can
usually be differentiated from an imperforate
26.16 Transverse Vaginal Septum hymen by visual inspection. By increasing the
intra-abdominal pressure and increasing the
The incidence of transverse vaginal septum bulge of the imperforate hymen, the
appears to be between 1 in 21,000 and 1 in Valsalva maneuver may further assist in this
72,000 [60]. A transverse vaginal septum may differentiation.
be located in the upper (6%), middle (22%), If an opening to the vagina is noted, a
and lower (72%) third of the vagina [80]. manual or speculum exam may reveal a higher
A transverse vaginal septum may be com- location of the septum. A rectal exam is very
plete or incomplete and varies in thickness helpful in detecting a hematocolpos, since the
(. Fig. 26.17). bulge is readily palpable.
Transperineal and transabdominal ultra-
sonography can sometimes diagnose and
26.17 Presenting Symptoms determine the thickness of a transverse vagi-
nal septum. However, in most cases, an MRI
Patients with a complete transverse vaginal of the pelvis will be required to differenti-
septum generally present with a complaint of ate a transverse vaginal septum from other
primary amenorrhea in early to mid-puberty. Müllerian anomalies such as cervical agenesis.
Pelvic pain is a common, but not universal, These patients should also be evaluated for
presenting complaint. Patients with high associated anomalies, including aortic coarc-
transverse vaginal septa are most likely to tation, atrial septal defects, urinary tract
experience pelvic pain, and the pain will man- anomalies, and malformations of the lumbar
ifest earlier than in patients with septa located spine.
lower in the vagina. This is believed to be sec-
ondary to decreased space for the hematocol-
pos that ensues after initiation of menses. 26.17.2 Surgical Technique
Patients with an incomplete transverse
vaginal septum may complain of profuse vag- Surgical removal of a transverse vaginal sep-
inal discharge, dyspareunia, inability to insert tum is recommended as soon as practical after
tampon, or tear during intercourse with resul- diagnosis to avoid continued retrograde men-
tant bleeding. If asymptomatic, it may not be struation. Endometriosis is common in
discovered until a routine gynecologic patients with a transverse vaginal septum.
examination. However, removal of endometriosis lesions is
Very rarely a transverse vaginal septum not recommended, since relief of the obstruc-
may be detected in an infant or young child. tion leads to their spontaneous resolution.
594 M. Attaran
Delay in detection or treatment of a trans-

verse vaginal septum may lead to impaired fer-
tility secondary to irreversible pelvic adhesions,
hematosalpinges, and endometriosis. In one
long-term follow-up study of 19 patients with
transverse septa, 47% became pregnant [81].
However, a small study in Finland showed a sig-
nificantly higher live birth rate in women who
26 had undergone very early diagnosis and man-
agement of their transverse vaginal septa [82].
The unfortunate consequence of very early
surgical management is an increased rate of
subsequent vaginal stenosis. This is most
likely due to inconsistent use of vaginal dila-
tors by young adolescents, which are a neces-
sary part of treatment of a thick vaginal
septum (see below).
An alternative to early surgery for very
young patients is medical termination of
monthly endometrial shedding using con- .. Fig. 26.18 Placement of angiocath into the trans-
tinuous oral contraceptive pills, depo- verse septum. (Reproduced with permission from Fal-
medroxyprogesterone, or GnRH agonists to cone and Hurd [85])
postpone surgery. Later, when she is emotion-
ally ready for the surgery, the patient can be
instructed to dilate the distal vagina to stretch
the distal vaginal mucosa, potentially decreas-
ing the need for a graft, and to prepare her for
postoperative use of the dilator.
The thickness and location of the septum
will determine the best approach to surgery.
Thin, low transverse vaginal septa are much
easier to repair than thick, high septa.
26.17.3 urgical Technique: Thin

S
Transverse Vaginal Septum
Transverse septa that are thin and lower in the
vagina can usually be excised easily. If visually
a slight bulge cannot be appreciated on exam-
ination, an angiocath needle is placed through .. Fig. 26.19 Re-approximation of distal and proximal
the septum (. Fig. 26.18). With return of vagina mucosa after excision of the septum. (Repro-
thick old blood through the angiocath, the duced with permission from Falcone and Hurd [85])
plane of dissection becomes clear. Access is
gained into the upper vaginal cavity by perfo- to the lower vaginal mucosa using 2–0 absorb-
rating the transverse septum with unipolar able suture (. Fig. 26.19). In most instances,
electrosurgery or scissors. to prevent stenosis of the vagina, use of a
The septum is excised in its entirety and mold is recommended for several weeks after
the upper vaginal mucosa is re-approximated surgery.
595 26
26.17.4 urgical Technique: Thick
S by making oblique crossed incisions through
Transverse Vaginal Septum the vaginal tissue on the hematocolpos side of
the transverse septum. The upper and lower
Managing thick transverse septa can be quite mucosal flaps are separated by sharp and
challenging. Before surgery, the patient must blunt dissection and sutured together at their
be prepared for prolonged use of mold and free edges to form of a continuous z-plasty.
possible split-thickness skin graft to line the Excellent results have been noted on 13
vagina. The main concern is potential bowel patients who underwent this procedure [84]. A
injury; therefore, a bowel preparation is rec- vaginal mold must be used for 5–8 weeks after
ommended. the procedure to avoid vaginal stenosis. If the
During surgery, a bulge will not be seen in patient is not sexually active, a dilator should
the presence of a thick transverse septum. The be used at night for 6–8 additional months.
correct angle of dissection can be determined The patient should be instructed in self-
by inserting an angiocath needle into the examination and should return if she notices
hematocolpos under ultrasound guidance. In any signs of early stenosis.
difficult cases, the septum can be approached In cases of a thick septum where a z-plasty
transfundally via the uterus using laparoscopy technique is not used, a skin graft may be
and laparotomy. required. The technique utilized is similar to
The dissection is carried out, taking care that described for the McIndoe procedure.
to protect the bladder and rectum. A Foley Prolonged use of a mold is required postop-
catheter is placed into the bladder. As the eratively.
loose areolar tissue is being dissected, the rec-
tum is frequently examined to ensure
appropriate angle of dissection. If there is
inadvertent entry into the bladder or the rec-
tum, the procedure should be stopped and ??1. A 12-year-old female presented to her
completed at a future date. After the cervix is pediatrician with cyclic abdominal
visualized, the goal is to re-approximate the pain. Thelarche occurred at the age of
upper mucosal tissue to the lower vaginal 9. She has not yet had menses. During
mucosa. the evaluation of her abdominal pain, a
pelvic exam is done that shows a normal
uterus with minimal amount of fluid in
26.18 Z-Plasty Technique the cavity. On examination, a vaginal
opening cannot be found. Her most
If a thick septum is completely incised, the likely diagnosis is:
distance between the vaginal mucosal of the A. Transverse septum
proximal and distal portions of the vagina B. Cervical agenesis
may be so great that the edges cannot be re- C. Mullerian agenesis
approximated without tension. For this rea- D. Obstructing longitudinal septum
son, a z-plasty technique, as first described by
Garcia et al., should be considered for the cor- ??2. Patients with an obstructing longitudi-
rection of thick transverse vaginal septa or nal vaginal septum will present with the
when the vagina is short [83]. following findings:
For this technique, four lower mucosal A. Unicornuate uterus
flaps are created by making oblique crossed B. Pelvic/vaginal mass
incisions through the vaginal tissue on the C. Amenorrhea
perineal side of the transverse septum, taking D. Dysmenorrhea
care to avoid injuring either the bladder or E. B and D
rectum. Four upper mucosal flaps are created F. A, B, and D
596 M. Attaran
??3. A 17-year-old female patient presents vv2. E

with primary amenorrhea and normal
secondary sexual characteristics. She vvThese patients commonly have didelphys
states she has unsuccessfully attempted uteri and associated renal anomalies. Since
intercourse. An examination reveals one uterus is connected to the obstructed
normal external genitalia but just a vag- vagina, the patient experiences severe dys-
inal dimple. A pelvic ultrasound shows menorrhea within several months from the
a 2 cm × 2 cm × 1 cm band of tissue time her periods begin. In some cases,
26 in the pelvis and normal appearing ova- there is a small opening in the obstructed
ries at the pelvic brim. Incidentally, it is longitudinal vagina, and the patient may
noted that she does not have a right kid- have impression of prolonged bleeding or
ney. What form of therapy would you profuse vaginal discharge. These patients
recommend to this patient? have a palpable vaginal mass or in some
A. Vaginal dilation using dilators cases pelvic mass if the level of the obstruc-
B. McIndoe vaginoplasty tion is higher.
C. Laparoscopy and resection of the
pelvic tissue to clarify diagnosis vv3. A
D. Colocolpopoiesis
vvThis patient’s presentation is consistent

with diagnosis of Müllerian agenesis.
26.20 Answers
While a karyotype can be performed to
confirm the 46XX finding in these patients,
vv1. B
it is clear that she has ovaries and that the
structure noted in the midline is likely a
vvPatients with cervical agenesis present
Müllerian remnant. The next step to con-
much earlier than the other obstructive
firm the diagnosis of this patient will be an
anomalies. This patient is 3 years post the-
MR of the pelvis and a karyotype. There
larche and thus a period is to be expected
are many methods of creation of a vagina,
about this time. But given her youth and
but in the United States, the American
lack of history of menses, most providers
College of Obstetrics and Gynecology rec-
fail to consider this rare diagnosis. Very
ommends use of dilators as the first step.
small amount of blood accumulation in
Success rates as high as 95% have been
the uterus can lead to significant pain and
reported.
with continued monthly bleeding lead to
continued retrograde menses and ulti-
mately endometriosis.
References
vvPatients with transverse septum usually 1. Byrne J, Nussbaum-Blask A, Taylor W. Prevalence
present later and the degree of pain is less of Müllerian duct anomalies detected at ultrasound.
than it is with cervical agenesis. Patients Am J Med Genet. 2000;94(1):9–12.
with Mullerian agenesis may experience 2. Saravelos S, Cocksedge K, Li T. Prevalence and
diagnosis of congenital uterine anomalies in women
cyclic pain secondary to mittleschmerz, with reproductive failure: a critical appraisal. Hum
but the degree of pain is minimal com- Reprod Update. 2008;14(5):415–29.
pared to cervical agenesis. Finally patients 3. Buttram VC Jr, Gibbons WE. Müllerian anomalies:
with an obstructing longitudinal septum a proposed classification (an analysis of 144 cases).
will have one open pathway, and thus will Fertil Steril. 1979;32(1):40–6.
4. Acien P, Acien MI. The history of female genital
have concomitant vaginal bleeding. So tract malformation classification and proposal of an
their primary complaint will be severe dys- updated system. Hum Reprod Update. 2011;17:
menorrhea. 693–705.
597 26
5. Toaff ME, Lev-Toaff AS, Toaff R. Communicating 21. American College of Obstetrics and Gynecology.
uteri: review and classification with introduction of ACOG committee opinion number 728. Mullerian
two previously unreported types. Fertil Steril. agenesis: diagnosis, managment and treatment.
1984;41(5):661–79. Obstet Gynecol. 2018;131:e35–42.
6. Jones HW Jr. Reproductive impairment and the 22. Ingram JM. The bicycle seat stool in the treatment
malformed uterus. Fertil Steril. 1981;36(2):137–48. of vaginal agenesis and stenosis: a preliminary
7. Grimbizis GF, Gordts S, Di Spiezio SA, Brucker S, report. Am J Obstet Gynecol. 1981;140(8):867–73.
De Angelis C, Gergolet M, et al. The ESHRE/ 23. Roberts CP, Haber MJ, Rock JA. Vaginal creation
ESGE consensus on the classification of female for Müllerian agenesis. Am J Obstet Gynecol.
genital tract congenital anomalies. Hum Reprod. 2001;185(6):1349–52. discussion 1352–3
2013;28(8):2032–44. 24. Oleschlager A, Debiec K. Vaginal dilator therapy: a
8. Oppelt P, Renner S, Brucker S. The VCUAM classi- guide for providers for assessing readiness and
fication: a new classification for genital malforma- supporting patients through the process success-

tions. Fertil Steril. 2005;84:1493–7. fully. J Ped Adol Gyn. 2019;32:354–8.
9. The American Fertility Society. The American fer- 25. Weijenborg PT, ter Kuile MM. The effect of a group
tility society classifications of adnexal adhesions, programme on women with the Mayer-Rokitansky-
distal tubal occlusion, tubal occlusion secondary to Kuster-Hauser syndrome. BJOG. 2000;107(3):
tubal ligation, tubal pregnancies, Müllerian anoma- 365–8.
lies and intrauterine adhesions. Fertil Steril. 26. Edmonds DK. Congenital malformations of the
1988;49(6):944–55. genital tract. Obstet Gynecol Clin N Am.
10. American Society of Reproductive Medicine Mul- 2000;27(1):49–62.
lerian Anomalies Classification 2021. Fertil Steril 27. Edmonds DK, Rose GL, Lipton MG, Quek
2021;116:1238–1252. J. Mayer–Rokitansky–Kuster–Hauser syndrome: a
11. Aittomaki K, Eroila H, Kajanoja P. A population- review of 245 consecutive cases managed by a mul-
based study of the incidence of Müllerian aplasia in tidisciplinary approach with vaginal dilators. Fertil
Finland. Fertil Steril. 2001;76(3):624–5. Steril. 2012;97(3):686–90.
12. Reindollar RH, Byrd JR, McDonough PG. Delayed 28. Vecchietti G. Creation of an artificial vagina in Rok-
sexual development: a study of 252 patients. Am J itansky–Kuster–Hauser syndrome. Attual Ostet
Obstet Gynecol. 1981;140(4):371–80. Ginecol. 1965;11(2):131–47.
13. Fraser IS, Baird DT, Hobson BM, Michie EA, 29. Veronikis DK, McClure GB, Nichols DH. The Vec-
Hunter W. Cyclical ovarian function in women with chietti operation for constructing a neovagina: indi-
congenital absence of the uterus and vagina. J Clin cations, instrumentation, and techniques. Obstet
Endocrinol Metab. 1973;36(4):634–7. Gynecol. 1997;90(2):301–4.
14. Oppelt P, Lermann J, Strick R, Dittrich R, Strissel 30. Brucker SY, Gegusch M, Zubke W, Rall K,
P, Rettig I, et al. Malformations in a cohort of 284 Gauwerky JF, Wallwiener D. Neovagina creation in
women with Mayer-Rokitansky-Kuster-Hauser- vaginal agenesis: development of a new laparo-
Syndrome (MRKH). Reproduc Biol Endocrinol. scopic Vecchietti-based procedure and optimized
2012;10:57. instruments in a prospective comparative interven-
15. Strubbe EH, Cremers CW, Dikkers FG, Willemsen tional study in 101 patients. Fertil Steril. 2008;
WN. Hearing loss and the Mayer-Rokitansky- 90(5):1940–52.
Kuster-Hauser syndrome. Am J Otol. 1994; 31. Rall K, Schickner MC, Barresi G, Schonfisch B,
15(3):431–6. Wallwiener M, Wallwiener CW, Wallwiener D. Lap-
16. Willemsen WN. Renal-skeletal-ear- and facial- aroscopically assisted neovaginoplasty in vaginal
anomalies in combination with the Mayer- agenesis: a long-term outcome study in 240 patients.
Rokitansky-Kuster (MRK) syndrome. Eur J Obstet J Pediatr Adolesc Gynecol. 2014;27:379–85.
Gynecol Reprod Biol. 1982;14(2):121–30. 32. Alessandrescu D, Peltecu GC, Buhimschi CS,
17. Letterie GS, Vauss N. Müllerian tract abnormalities Buhimschi IA. Neocolpopoiesis with split-thickness
and associated auditory defects. J Reprod Med. skin graft as a surgical treatment of vaginal agene-
1991;36(11):765–8. sis: retrospective review of 201 cases. Am J Obstet
18. Petrozza JC, Gray MR, Davis AJ, Reindollar Gynecol. 1996;175(1):131–8.
RH. Congenital absence of the uterus and vagina is 33. Romanski P, Bortoletto P, Pfiefer S. Creation of
not commonly transmitted as a dominant genetic novel inflatable vaginal stent for McIndoe vagino-
trait: outcomes of surrogate pregnancies. Fertil plasty. Fertil Steril. 2021;115(3):804–6.
Steril. 1997;67(2):387–9. 34. Hojsgaard A, Villadsen I. McIndoe procedure for
19. Branstromm M, Johannessen L, Bokstrom H, et al. congenital vaginal agenesis: complications and
Live birth after uterus transplant. Lancet. 2015; results. Br J Plast Surg. 1995;48(2):97–102.
385:607–16. 35. Mobus VJ, Kortenhorn K, Kreienberg R, Friedberg
20. Frank R. The formation of an artificial vagina with- V. Long-term results after operative correction of
out operation. Am J Obstet Gynecol. 1938;35: vaginal aplasia. Am J Obstet Gynecol. 1996;175(3
1053–7. Pt 1):617–24.
598 M. Attaran
36. Klingele CJ, Gebhart JB, Croak AJ, DiMarco CS, 52. Joseph VT. Pudendal-thigh flap vaginoplasty in the
Lesnick TG, Lee RA. McIndoe procedure for vagi- reconstruction of genital anomalies. J Pediatr Surg.
nal agenesis: long-term outcome and effect on 1997;32(1):62–5.
quality of life. Am J Obstet Gynecol. 2003;
53. Song R, Wang X, Zhou G. Reconstruction of the
189(6):1569–72; discussion 1572–3 vagina with sensory function. Clin Plast Surg.
37. Hopkins MP, Morley GW. Squamous cell carci- 1982;9(1):105–8.
noma of the neovagina. Obstet Gynecol. 1987;69(3 54. Belloli G, Campobasso P, Musi L. Labial skin-flap
Pt 2):525–7. vaginoplasty using tissue expanders. Pediatr Surg
38. Steiner E, Woernle F, Kuhn W, et al. Carcinoma of Int. 1997;12(2–3):168–71.
the neovagina: case report and review of the litera- 55. Chudacoff RM, Alexander J, Alvero R, Segars
26 ture. Gynecol Oncol. 2002;84:171–5. JH. Tissue expansion vaginoplasty for treatment of
39. Davydov SN. 12-year experience with colpopoiesis congenital vaginal agenesis. Obstet Gynecol.
using the peritoneum. Gynakologe. 1980;13(3): 1996;87(5 Pt 2):865–8.
120–1. 56. Parsons JK, Gearhart SL, Gearhart JP. Vaginal
40. Davydov SN. Colpopoiesis from the peritoneum of reconstruction utilizing sigmoid colon: complica-
the uterorectal space. Aekush Ginekol (Mosk). tions and long-term results. J Pediatr Surg.
1969;45(12):55–7. 2002;37(4):629–33.
41. Rothman D. The use of peritoneum in the 57. Labus LD, Djordjevic ML, Stanojevic DS, Bizic
construction of a vagina. Obstet Gynecol.
MR, Stojanovic BZ, Cavic TM. Rectosigmoid vagi-
1972;40(6):835–8. noplasty in patients with vaginal agenesis: sexual
42. Fedele L, Frontino G, Restelli E, Clappina N, Motta and psychosocial outcomes. Sex Health. 2011;
F, Bianchi S. Creation of a neovagina by Davydov’s 8(3):427–30.
laparoscopic modified technique in patients with 58. Hiroi H, Yasugi T, Matsumoto K, Fujii T, Watanabe
Rokitansky syndrome. Am J Obstet Gynecol. 2010; T, Yoshikawa H, et al. Mucinous adenocarcinoma
202(1):33.e1–6. arising in a neovagina using the sigmoid colon thirty
43. Templeman CL, Hertweck SP, Levine RL, Reich years after operation: a case report. J Surg Oncol.
H. Use of laparoscopically mobilized peritoneum in 2001;77(1):61–4.
the creation of a neovagina. Fertil Steril. 2000; 59. Mikos T, Gordts S, Grimbizis. Current knowledge
74(3):589–92. about the management of congential cervical mal-
44. Jackson ND, Rosenblatt PL. Use of interceed formation: a litereature review. Fertil Steril.
absorbable adhesion barrier for vaginoplasty. Obstet 2020;113:723–32.
Gynecol. 1994;84(6):1048–50. 60. Dietrich J. Surgical management of reproductive
45. Anagani M, Agrawal P, Meka K, Narayana RT, tract anomalies. In: Handa VL, Van Le L, editors.
Bandameedipally R. Novel minimally invsive tech- The Linde’s operative gynecology. 12th ed. Philadel-
nique of neovaginoplasty using an absorbable adhe- phia: Lippincott Williams & Wilkins; 2020.
sion barrier. J Min Invas Gynecol. 2020;27:206–2011. 61. Fujimoto VY, Miller JH, Klein NA, Soules
46. Lin WC, Chang CY, Shen YY, Tsai HD. Use of MR. Congenital cervical atresia: report of seven
autologous buccal mucosa for vaginoplasty: a study cases and review of the literature. Am J Obstet
of eight cases. Hum Reprod. 2003;18:604–7. Gynecol. 1997;177(6):1419–25.
47. Grimsby GM, Baker LA. The use of autologous 62. Markham SM, Parmley TH, Murphy AA, Huggins
Buccal mucosa grafts in vaginal reconstruction. GR, Rock JA. Cervical agenesis combined with
Curr Urol Rep. 2014;15:428. vaginal agenesis diagnosed by magnetic resonance
48. Panici P, Bellati F, Boni T, Francescangeli F, Frati L, imaging. Fertil Steril. 1987;48(1):143–5.
Marchese C. Vaginoplasty using autologous in vitro 63. Reinhold C, Hricak H, Forstner R, Ascher SM, Bret
cultured vaginal tissue in a patient with Mayer von PM, Meyer WR, et al. Primary amenorrhea: evalu-
Rokitansky Kuster Hauser syndrome. Hum Reprod. ation with MR imaging. Radiology. 1997;203(2):
2007;22(7):2025–8. 383–90.
49. Sabatucci I, Palaia I, Marchese C, Muzii L, Morte C, 64. Bugmann P, Amaudruz M, Hanquinet S, La Scala
Giorgini M, Musella A, Ceccarelli S, Vescarelli E, Pan- G, Birraux J, Le Coultre C. Uterocervicoplasty with
ici PB. Treatment of the Mayer–Rokitansky–Kuster– a bladder mucosa layer for the treatment of
Hauser syndrome with autologous in vitro cultured complete cervical agenesis. Fertil Steril. 2002;

vaginal tissue: descriptive study of the long term results 77(4):831–5.
and patient outcomes. BJOG. 2019;126:123–7. 65. Deffarges JV, Haddad B, Musset R, Paniel
50. McCraw JB, Massey FM, Shanklin KD, Horton BJ. Utero-vaginal anastomosis in women with uter-
CE. Vaginal reconstruction with gracilis myocuta- ine cervix atresia: long-term follow-up and repro-
neous flaps. Plast Reconstr Surg. 1976;58(2):176–83. ductive performance. A study of 18 cases. Hum
51. Wee JT, Joseph VT. A new technique of vaginal Reprod. 2001;16(8):1722–5.
reconstruction using neurovascular pudendal-thigh 66. He H, Guo H, Han J, Wu Y, Zhu F. An atresia cervix
flaps: a preliminary report. Plast Reconstr Surg. removal, lower uterine segment substitute for cervix
1989;83(4):701–9. and uterovaginal anastamosis: a case report and lit-
599 26
erature review. Arch Gynecol Obstet. 2015; 76. Candiani GB, Fedele L, Candiani M. Double
291:93–7. uterus, blind hemivagina, and ipsilateral renal agen-
67. Rock JA, Roberts CP, Jones HW Jr. Congenital esis: 36 cases and long-term follow-up. Obstet
anomalies of the uterine cervix: lessons learned Gynecol. 1997;90(1):26–32.
from 30 cases managed clinically by a common pro- 77. Montevecchi L, Valle RF. Resectoscopic treatment
tocol. Fertil Steril. 2010;94:1858–63. of complete longitudinal vaginal septum. Int J Gyn-
68. Casey AC, Laufer MR. Cervical agenesis: septic aecol Obstet. 2004;84(1):65–70.
death after surgery. Obstet Gynecol. 1997;90(4 Pt 78. Tsai EM, Chiang PH, Hsu SC, Su JH, Lee JN. Hys-
2):706–7. teroscopic resection of vaginal septum in an adoles-
69. Huberlant S, Tailland ML, Poirwy S, Mousty R, cent virgin with obstructed hemivagina. Hum
Ripart-Neveu S, Mares P, Tayrac R. Congenital cer- Reprod. 1998;13(6):1500–1.
vical agenesis: pregnancy after trans- myometrial 79. Sanfilippo JS, Wakim NG, Schikler KN, Yussman
embryo transfer. J Gynecol Obstet Biol Reprod. MA. Endometriosis in association with uterine
2014;43:521–5. anomaly. Am J Obstet Gynecol. 1986;154(1):39–43.
70. Acien P. Reproductive performance of women with 80. Williams CE, Nakhal RS, Hall-Cragg MA, Wood
uterine malformations. Hum Reprod. 1993;8(1): D, Cutner A, Pattison SH, Creighton SM. Trans-
122–6. verse vaginal septae: management and long term
71. Lolis D, Paschopoulos M, Makrydimas G, Ziko- outcomes. BJOG. 2014;121:1653–9.
poulos K, Sotiriadis A, Paraskevaidis E. Reproduc- 81. Rock JA, Zacur HA, Dlugi AM, Jone HW Jr,
tive outcome after Strassman metroplasty in women TeLinde RW. Pregnancy success following surgical
with bicornuate uterus. J Reprod Med. correction of imperforate hymen and complete
2005;50(5):297–301. transverse vaginal septum. Obstet Gynecol.
72. Heinonen PK. Clinical implications of the didelphic 1982;59(4):448–51.
uterus: long-term follow-up of 49 cases. Eur J 82. Joki-Erkkila MM, Heinonen PK. Presenting and
Obstet Gynecol Reprod Biol. 2000;91(2): long-term clinical implications and fecundity in
183–90. females with obstructing vaginal malformations. J
73. Jayasinghe Y, Rane A, Stalewski H, Grover S. The Pediatr Adolesc Gynecol. 2003;16(5):307–12.
presentation and early diagnosis of the rudimentary 83. Garcia RF. Z-plasty for correction of congenital
uterine horn. Obstet Gynecol. 2005;105(6):1456–67. transferse vaginal septum. Am J Obstet Gynecol.
74. Li X, Peng P, Liu X, Chen W, Liu J, Yang J, Bian 1967;99(8):1164–5.
X. The pregnancy outcomes of patients with rudi- 84. Wierrani F, Bodner K, Spangler B, Grunberger W.
mentary uterine horn: a 30 year experience. PLoS “Z”-plasty of the transverse vaginal septum using
One. 2019;14(1):e0210788. Garcia’s procedure and the Grünberger modifica-
75. Haddad B, Louis-Sylvestre C, Poitout P, Paniel tion. Fertil Steril. 2003;79(3):608–12.
BJ. Longitudinal vaginal septum: a retrospective 85. Attaran M, Gidwani G. Ross J. In: Falcone T, Hurd
study of 202 cases. Eur J Obstet Gynecol Reprod WW, editors. Clinical reproductive medicine and
Biol. 1997;74(2):197–9. surgery. St. Louis: Mosby/Elsevier; 2007.
601 27
Third-Party Reproduction
Alexander Quaas
Contents
27.1 Sperm Donation – 602

27.1.1 linical Case – 602
C
27.1.2 Practical Aspects of Sperm Donation – 602
27.1.3 Ethical Aspects of Sperm Donation – 603
27.2 Oocyte Donation – 604

C
27.2.2 Practical Aspects of Oocyte Donation – 604
27.2.3 Ethical Aspects of Oocyte Donation – 606
27.3 Embryo Donation – 607

C
27.3.2 Practical Aspects of Embryo Donation – 607
27.3.3 Ethical Aspects of Embryo Donation – 607
27.4 Gestational Surrogacy – 608

C
27.4.2 Practical Aspects of Gestational Surrogacy – 608
27.4.3 Ethical Aspects of Gestational Surrogacy – 609
27.5 Mitochondrial Replacement Therapy:

“Three-Parent Babies” – 609
27.7 Answers – 610
References – 610

https://doi.org/10.1007/978-3-030-99596-6_27
602 A. Quaas
27.1.2 ractical Aspects of Sperm

P
Key Points Donation
55 Modern families are created in much
more diverse ways than 100 or even In cases where sperm for conception is either
50 years ago, due to societal changes, but unavailable or unusable, therapeutic donor
also advances in reproductive options. insemination (TDI) may be performed to
55 For patients with reproductive pathology, achieve pregnancy. In this treatment, thawed
such as men with a lack of functional and washed sperm is transferred into the uter-
sperm, or women with a lack of a func- ine cavity (intrauterine insemination/IUI) or
tional uterus or ovaries, “third- party” the cervix (intracervical insemination/ICI) at
27 reproductive options exist nowadays.
55 The involvement of the (fully func-
the time of ovulation. Intrauterine insemi-
nation is performed more commonly as the
tional) third party is limited to enabling method of choice for TDI in contemporary
the process of reproduction by replac- practice. It may be performed in the natural
ing the defective or missing element in cycle or after ovarian stimulation with oral
question and does not extend to assum- or injectable medications. When male factor
ing custody or parental responsibility is the only indication, it is preferable to pro-
for the resulting offspring. ceed with natural cycle TDI, at least initially,
55 There is also an increasing demand for given the increased risk of multiple gestation
reproductive services from patients who and associated adverse outcomes when using
differ from the heteronormative family, stimulation medications with resulting mul-
such as gay, lesbian, and transgender tifollicular ovulation. A large retrospective
patients, or single mothers or fathers by cohort study analyzing over 76,000 IUI cycles
choice. performed on women with no female factor
55 The purpose of this chapter is to review infertility undergoing TDI demonstrated that
practical (including medical) and ethical the use of ovarian stimulation with either
aspects of all common forms of third- clomiphene citrate or letrozole resulted in a
party reproduction, including sperm less than 1% increase in ongoing pregnancy,
donation, oocyte donation, embryo but a fourfold increase in ongoing multiple
donation, and gestational surrogacy. gestations [1]. The investigators concluded
that natural cycle IUI should be considered
as a first-line treatment for ovulatory women
undergoing TDI.
27.1 Sperm Donation With regard to TDI timing, two main
options exist: instructing the patient to check
27.1.1 Clinical Case ovulation predictor kits and schedule the
TDI procedure the day after the detection
A 35-year-old single gravida 0 would like to of a positive luteinizing hormone (LH) surge
start a family, being aware of the effect of or triggering ovulation and the associated
ovarian aging on her chances to conceive a completion of oocyte maturation with the
child. She has joined the group “Single moth- use of injectable human chorionic gonadotro-
ers by choice” and attends regular local meet- pin (hCG). While many studies have shown
ing of other women with the same plan, who equivalent outcomes of these two methods,
share their views and experiences. Her medi- a randomized controlled trial on this topic
cal history is unremarkable and her periods in 300 patients undergoing IUI (65.7% TDI)
are regular. Her primary Ob/Gyn physician found superior ongoing pregnancy rates in the
ordered an ultrasound and some laboratory spontaneous LH group as compared with the
tests to assess her ovarian reserve, which she HCG group (34/150 versus 16/150, P = 0.008;
was told is “normal.” She is interested in difference 12.0%, 95% CI – 3.6 to 20.4) [2]. In
learning more about her options to conceive patients who are reliably able to detect the LH
using donor sperm. surge using OPKs, this is the simplest and pre-
603 27
Example Treatment Timeline: IUI / TDI
If medicated
cycle: start
Clomid or
Letrozole
Patient Baseline visit Follicular Start monitoring Call your IUI procedure Pregnancy
calls clinic on day 2-5 monitoring for a positive coordinator with On the day after test 14
with day 1 (ultrasound & ultrasound surge around a positive positive ovulation days later
of period bloodwork) around day 10 surge (solid predictor kit or 36
(full flow) day 10-13 smiley face) hours after hCG
trigger
If worry about missing
LH surge: option to
induce ovulation with
hCG trigger
.. Fig. 27.1 Example treatment timeline of the IUI/TDI process
ferred method for TDI scheduling. The hCG megalovirus (CMV) antibody (IgG and IgM),
trigger may be used in patients who are wor- and HTLV type I and II at the discretion of the
ried about missing the LH surge or for sched- provider [3]. Donor sperm may also be used
uling purposes. in the setting of IVF; the same FDA require-
An example timeline for an IUI/TDI cycle ments and ASRM recommendations apply.
is shown in . Fig. 27.1. The donor sperm FDA requirements
Indications for TDI include azoosper- and ASRM recommendations are shown in
mia or severe sperm or seminal fluid abnor- . Table 27.1.
malities, ejaculatory dysfunction, significant
genetic defects or in the male partner, a
sexually transmitted disease that cannot be 27.1.3 thical Aspects of Sperm
E
eradicated, severe Rh-isoimmunization in Donation
the female partner with Rh-positive status in
the male partner, and the desire of a female While sperm donation may be used by hetero-
patient to conceive without a male partner [3]. sexual couples with male factor infertility, a
In preparation for TDI, psychological large proportion of TDI cycles are utilized by
counseling by a qualified mental health pro- single individuals and lesbian couples.
fessional is strongly recommended. It is crucial to recognize that access to this
If a couple is going through the TDI treatment should not be restricted on the basis
process, the partner of the female recipient of the prospective parent(s) marital status or
should undergo a medical evaluation and sexual orientation [4].
infectious disease testing similar to the recipi- Research overwhelmingly suggests that
ent (detailed below). This is not required by children born to lesbian or single women
the FDA, however it is recommended by are less likely to grow up in a supportive and
ASRM. The female recipient should have a nurturing environment or suffer detrimental
comprehensive evaluation including history developmental or psychological consequences
and physical examination as well as precon- from the partner status or sexual orientation
ceptional screening including infectious dis- of their parent(s) [4–7].
ease testing. Again, this is not mandated by Numerous ethical and legal controversies
the FDA but recommended by ASRM. surrounding sperm donation exist. Areas of
Infectious disease screening should include debate and vast geographic variation between
testing for HIV, syphilis, Hepatitis B (surface countries concern donor anonymity, the maxi-
antigen and core antibody), Hepatitis C, Cyto- mum number of offspring from a single sperm
604 A. Quaas
donor, donor recruitment, and compensation,

.. Table 27.1 Donor sperm FDA requirements
and ASRM recommendations
as well as disclosure practices [8]. In many
countries, the demand for donated sperm
Non-identified FDA requirement exceeds availability [9].
(anonymous) Although it is not uncommon for patients
Donor physical exam
sperm donor
Donor questionnaire
to attempt insemination procedures in non-
Medical history medical settings, this may create ethical and
Donor infectious disease legal “gray areas.”
laboratory tests at FDA- As an example, a man responding to a
approved laboratory within Craigslist ad to serve as a sperm donor helped
7 days (before or after) of sperm
27 acquisition
a lesbian couple conceive in a nonmedical set-
ting. When the couple separated, the Kansas
6-month quarantine with repeat
infectious disease testing Department for Children and Families won a
Must be eligible to use tissue judicial order requiring him to pay child sup-
according to FDA eligibility port [10].
criteria
Individuals and couples seeking to use
ASRM recommendation (in donor sperm should be encouraged to undergo
addition to FDA requirements TDI in a medical setting where standard legal
Psychoeducational screening and medical procedures are followed to avoid
Genetic screening ethical, legal, or medical dilemmas.
Infectious disease testing of
recipient and recipient’s sexually
intimate partner(s)
27.2 Oocyte Donation
Directed FDA requirement
(known) sperm
donor
Donor physical exam 27.2.1 Clinical Case
Donor questionnaire
Medical history
Donor infectious disease A 32-year-old gravida 1 Para 0 with a his-
laboratory tests at FDA- tory of one first trimester spontaneous abor-
approved laboratory within tion presents as a referral from her primary
7 days (before or after) of sperm Ob/Gyn physician who did a workup for
acquisition
her 9 months history of secondary amenor-
Ineligible tissue can be used but
with appropriate labeling and rhea. Laboratory testing was remarkable for
consent a FSH level of 89 IU/ml, an estradiol level of
15 pg/mL, and an AMH level of <0.1 ng/ml
ASRM recommendation (in
addition to FDA requirements) (undetectable). She was told by her primary
physician that she has “premature ovarian
Psychoeducational screening
insufficiency”, and would like to learn more
Genetic screening
Infectious disease testing of about her options to start a family.
recipient and recipient’s sexually
intimate partner(s)
Medical history 27.2.2 ractical Aspects of Oocyte
P
Quarantine >35 days followed Donation
by repeat infectious disease
testing
Legal consultation; laws may
The first child born using a donated oocyte
vary by state was reported in Australia in 1984, a few years
after the first live birth from in vitro fertiliza-
Adapted from [3] tion with autologous oocytes in 1978 [11, 12].
It was soon observed that pregnancy rates
605 27
using donated oocytes were independent of
.. Table 27.2 Donor oocyte FDA requirements
the age of the recipient [13, 14], suggesting that and ASRM recommendations
the central limiting factor of female reproduc-
tion consists of the age and the quality of the Oocyte FDA requirement
oocytes, and not the age of the uterus. Once donor
Donor physical exam
the utility of this treatment in overcoming Donor questionnaire
age-related fertility decline was discovered, it Donor infectious disease laboratory tests
has rapidly evolved to become an integral tool at an FDA-approved lab 30 days before
in the field of ART [15]. or up to 7 days after oocyte acquisition
Analogous to sperm donation, oocyte Nonidentified (anonymous): Must be
eligible to use tissue
donation may be done using a directed (known) Directed (known): Ineligible tissue may
or an anonymous donor. Unlike sperm dona- be used but with appropriate labeling and
tion, the process of retrieving female gametes consent
is quite involved and requires that the donor ASRM recommendation (in addition to
undergo ovarian stimulation using injectable FDA requirements)
gonadotropins, followed by the egg retrieval
Psychoeducational screening
procedure [3]. The process is associated with a Genetic screening
significant time commitment, physical discom- Medical history
fort, and medical risks to the oocyte donor. Infectious disease testing of recipient
Indications for oocyte donation include and recipient’s sexually intimate
diminished ovarian reserve, premature ovar- partner(s)
Legal consultation, particularly for
ian insufficiency, advanced reproductive age, directed donation
carrier status of genetic defects for which pre-
implantation genetic testing is not an option Adapted from [3]
or undesired, a prior history of unsuccessful
ART attempts with autologous oocytes, and
fertility treatment for couples or individuals donor were synchronized with the endometrial
without involvement of a female partner with preparation of the recipient in order to enable
at least one functioning ovary. a “fresh” embryo transfer. With the advent
Oocyte donor screening requirements and of much improved cryopreservation technol-
recommendations are similar to those for ogy, most significantly vitrification techniques
sperm donation. A comprehensive screening allowing for improved cryosurvival of gametes
for infectious, genetic, and medical conditions and embryos [16], more flexible and efficient
should be undertaken prior to proceeding with treatment protocols exist.
a candidate oocyte donor. In addition, donors With regard to donor oocyte cycles in gen-
should preferably be between the age of 21 and eral, cumbersome synchronization of donor
34 and have age-appropriate ovarian reserve and recipient treatments is no longer neces-
testing by ultrasonographic antral follicle sary and the treatment process may be seg-
count, serum ovarian reserve markers includ- mentalized: following theoocyte donor egg
ing anti-Müllerian hormone (AMH), and retrieval, oocytes are fertilized in the standard
prior ovarian response to stimulation, if avail- fashion and grown to the blastocyst stage.
able. Analogous to the setting of sperm dona- At this time, the embryos are cryopreserved
tion, a “directed” known oocyte donor or a with or without trophectoderm biopsy prior
nonidentified anonymous donor may be used. to vitrification, if the recipient chooses to
Legal consultation is recommended, particu- proceed with preimplantation genetic diagno-
larly in the setting of directed oocyte donation. sis for aneuploidy (PGT-A) of the embryos,
Donor oocyte FDA requirements and ASRM although this does not improve the chance of
recommendations are shown in . Table 27.2. live birth [17].
In the early days of oocyte donation, the At some point following the generation of
ovarian stimulation and oocyte retrieval of the vitrified blastocysts, the recipient undergoes
606 A. Quaas
a frozen embryo transfer (FET) cycle with ceed with egg retrievals of eligible donors fol-
transfer of one of the vitrified blastocysts, lowed by oocyte vitrification [20]. This creates
using a medicated (programmed) or natural a “pool” of readily available oocytes, which
cycle FET protocol. may be used by multiple recipients: oocytes
Concerning the source of the oocytes, are commonly made available to recipients in
another phenomenon has streamlined the egg batches of six, limiting the number of gener-
donation treatment and helped decrease some ated embryos and allowing multiple parties to
of the involved redundancy: the advent of benefit from one donor egg retrieval. Different
“egg banks” [15, 18]. When a recipient chooses operational models exist: a CEB may be affili-
a dedicated oocyte donor who undergoes a ated with a single ART clinic as an “in-house”
27 whole retrieval cycle solely intended for this
one recipient, the inevitable result of stimu-
source of oocytes, linked to a network of clin-
ics, or provide oocytes to any interested ART
lating a young noninfertile woman is often a clinic (. Fig. 27.2) [15]. Careful communica-
large numbers of eggs leading to unnecessarily tion between labs is paramount to the success
high quantities donor-derived embryos. With of donor egg bank-based treatments, given
recipients often being of advanced reproduc- that different vitrification technologies exist.
tive age, desiring one to two children, this
commonly results in unused embryos clogging
up storage tanks or being discarded and may 27.2.3 thical Aspects of Oocyte
E
represent a moral dilemma for some recipients. Donation
Following significant improvements in
oocyte cryopreservation technology and the The controversial topic of oocyte donation
removal of its “experimental” label by ASRM abounds with ethical issues and vast geo-
[19], commercial egg banks (CEBs) have graphic variations exist with regard to its
rapidly emerged to remedy the above pitfall usage patterns and legality [21]. National poli-
of “fresh” oocyte donation and decrease its cies vary greatly, and in many countries, egg
redundancy [18]. These entities screen poten- donation is still illegal [22], leading to cross-
tial egg donors according to FDA regulations border reproductive care, otherwise known as
and ASRM recommendations, and then pro- “reproductive tourism” [23, 24].
a b c
Single
Affiliated
ART clinic ART clinic A ART clinic A
(Network)
ART clinic I ART clinic B
ART clinic H ART clinic C

CEB CEB CEB
ART clinic C ART clinic B

(Network) (Network)
ART clinic G ART clinic D
ART clinic F ART clinic E
.. Fig. 27.2 Operational models for commercial egg clinic, b CEB providing cryopreserved oocytes to net-
banks. (CEBs; adapted from [15]). a CEB providing cryo- work of affiliated clinics, c CEB providing cryopreserved
preserved oocytes exclusively to single affiliated ART oocytes to any interested ART clinic
607 27
One area of controversy surrounds the
.. Table 27.3 Donor embryo FDA require-
medical risks assumed by the oocyte donor ments and ASRM recommendations
[3], potentially motivated by financial incen-
tives. Compensation should be provided based Directed (known) FDA requirement
on ethical grounds; an ASRM ethics commit- and nonidentified
(anonymous) Attempt, if feasible, to
tee opinion on this topic exists [25]. Given the perform infectious disease
embryo donation
acute procedural risks of the egg retrieval, the- testing on both the oocyte
oretical and practical physical and psychologi- and sperm source
cal long-term consequences, as well as the risk Ineligible embryos may be
of inadvertent consanguinity, ASRM recom- used if tissue is appropriately
labeled and recipients are
mends that “it may be reasonable and prudent consented
to limit the number of stimulated cycles for a
given oocyte donor to no more than six” [26]. ASRM recommendation (in
addition to FDA require-
ments)
27.3 Embryo Donation Psychological counseling of

donor and recipients
Medical history
27.3.1 Clinical Case Genetic history
Infectious disease testing of
recipient and recipient’s
A 45-year-old gravida 0 presents for consulta-
sexually intimate partner(s)
tion after three unsuccessful in vitro fertiliza- Legal consultation
tion (IVF) attempts at another clinic, using
her own eggs and sperm from her husband Adapted from [3]
derived from a surgical sperm extraction pro-
cedure done for the indication of a prior vasec-
tomy. The couple has no vials of cryopreserved recommendations exist and are summarized in
sperm samples remaining and is interested in . Table 27.3 [3].
third-party reproductive options to conceive. When all preparations are completed and
FDA requirements and ASRM recommen-
dations are fulfilled, the recipient undergoes
27.3.2 ractical Aspects of Embryo
P a frozen embryo transfer (FET) cycle with
Donation transfer of a donated cryopreserved embryo,
using a medicated (programmed) or natural
In the contemporary practice of ART, increas- cycle FET protocol.
ing numbers of surplus embryos are constantly
generated, particularly in the setting of oocyte
donation treatment cycles. This phenomenon, 27.3.3 thical Aspects of Embryo
E
along with marked improvements in embryo Donation
cryopreservation technology, has resulted in
increases in the use of embryo donation [27]. While practices may facilitate the process of
Couples who do not wish to discard excess embryo donation and charge fees for rendered
embryos have the option of donating them coordination and laboratory services, the
to other individuals. From a recipient per- “selling” of embryos per se is ethically unac-
spective, this may represent a simpler and less ceptable [3]. It is also recommended that all
costly option than egg and/or sperm donation employees of an infertility practice, includ-
depending on the clinical circumstances. ing physicians, are excluded from serving as
Similar to the setting of male or female gam- embryo donation recipients or donors within
ete donation, FDA requirements and ASRM their practice.
608 A. Quaas
27.4 Gestational Surrogacy synechiae, or Mullerian anomalies associated

with an unacceptably risk of pregnancy loss or
27.4.1 Clinical Case complications. Medical contraindications to
pregnancy may include cardiopulmonary mor-
A 27-year-old gravida 0 with a history of bidity, such as pulmonary hypertension, creat-
primary amenorrhea was diagnosed with ing an unacceptably high risk to the mother
Mayer–Rokitansky–Küster–Hauser (MRKH) if she were to carry a p regnancy. The ASRM
syndrome at age 15. She and her husband are recommendations on the topic also allow for
interested in the option of conceiving biologi- consideration of gestational surrogacy in cases
cal children in the context of her congenital of unidentified endometrial factors leading
27 absence of a uterus. to recurrent implantation failure or recurrent
pregnancy loss in the setting of IVF [30].
Prior to proceeding with gestational sur-
rogacy, the IPs should undergo psychosocial
27.4.2 Practical Aspects education, undergo a genetic and medical
of Gestational Surrogacy evaluation, and be screened in the same way as
recommended for gamete donors [3]. Within
For absolute uterine factor infertility, pres- 6 months of embryo transfer to the GC, the IPs
ent in women who either do not have a uterus must undergo a complete physical examination,
at all, or who have a uterus that is unable in order to determine whether the IPs are eli-
to carry a pregnancy, the option of uterine gible or ineligible. Standard physical examina-
transplantation has recently been success- tion forms can be found on the website of the
fully employed [28]. However, the procedure is Society for Assisted Reproductive Technology
highly sophisticated and only few cases have at 7 www.sart.com. Infectious disease testing
been performed worldwide. More commonly, according to the FDA requirements should be
women with absolute uterine factor infertility, performed within 30 days of oocyte retrieval
such as MRKH, use gestational surrogacy in and within 7 days of sperm collection to mini-
order to become parents. mize the risk of transmission of infectious
Gestational surrogacy is the process agents from the IPs to the GC. All GCs should
by which intended parents contract with a be offered the option of cryopreserving and
woman to carry a fetus that the intended par- quarantining embryos for 180 days, with release
ents (IPs) will raise [29]. of embryos after negative retesting of IPs at
Two types of surrogacy exist. Traditional that point [30]. IPs must have legal counsel by a
surrogacy, where the surrogate also donates practitioner with experience in this area.
the oocyte, is generally not legal in the United The GC should undergo psychosocial
States. Therefore, this chapter focuses on ges- evaluation and counseling, and also undergo
tational surrogacy, a process where the gesta- infectious disease screening. Although the lat-
tional surrogate or gestational carrier (GC) ter is not required by the FDA, ASRM rec-
carries a pregnancy arising from an embryo ommends this within 30 days prior to embryo
that was created from the intended mother transfer “to protect the health and interests
(or oocyte donor) and the intended father (or of all parties involved.” The GC should be of
sperm donor) [29]. Gestational surrogacy may legal age between the ages of 21 and 45 years
be compensated or uncompensated. and should have had at least one-term uncom-
Broadly, indications for gestational surro- plicated pregnancy to be considered. A medi-
gacy include uterine conditions, medical con- cal evaluation and a full physical exam should
traindications to pregnancy, and the desire to be performed. The GC should be counseled
conceive by single males or males in same-sex regarding potential complications of any per-
relationships. Uterine conditions may include formed procedures and administered medi-
the congenital or acquired absence of the cations, as well as risks associated with the
uterus, significant uterine anomalies such as pregnancy. Like the IPs, a GC should have
inoperable uterine leiomyomatosis, irreparable ongoing legal representation.
609 27
Once all preparations are in place, the GC in mitochondrial DNA (mtDNA) and fre-
undergoes an embryo transfer, most com- quently fatal, are therefore passed from the
monly a frozen embryo transfer (FET) cycle mother to the offspring [33]. Mitochondrial
using a medicated (programmed) or natural dysfunction is also implicated in age-related
cycle FET protocol. infertility [34]. Mitochondrial replacement
therapy (MRT) aims to prevent transmis-
sion of mitochondrial disease: the fertilized
27.4.3 Ethical Aspects nucleus from an oocyte burdened with dis-
of Gestational Surrogacy eased mitochondria is injected into the cyto-
plasm of an enucleated donor oocyte with
The practice of gestational surrogacy is ethically mitochondria free of mtDNA mutations [35].
and legally controversial, as differences in local While MRT represents a promising approach
regulations demonstrate. Many countries ban to conceive healthy offspring for women at
all forms of surrogacy or allow uncompensated risk of transmitting mitochondrial disease,
surrogacy only [29]. Compensated gestational safety concerns of this technology include the
surrogacy raises concerns regarding coercion possibility of a donor-recipient mismatch and
or even commercial exploitation of vulnerable persistent disease transmission through inad-
women [31]. In addition, the high cost of com- vertent transfer of small amounts of mutated
pensated gestational surrogacy to IPs may lead mtDNA [36]. There are also ethical concerns
to pressure on GCs to transfer more than one regarding potential germline modifications in
embryo as recommended by ASRM [30], expos- the offspring of “three-membered” parent-
ing GCs to the additional risk of multifetal age. While the UK Human Fertilisation &
pregnancies. With regard to the obstetric care of Embryology Authority (HFEA) ruled in 2016
GCs, it is important to remember that the GC that MRT “can be used cautiously for risk
is the patient, and the provider’s primary obli- reduction treatments in certain cases,”, a US
gation is to her; she is the final decision maker congressional bill from 2016 banned the FDA
regardless of contractual obligations [29]. from evaluating “research in which a human
Concerns over psychosocial consequences embryo is intentionally created or modified to
of gestational surrogacy also exist, arising include heritable genetic modification,” effec-
from the planned forced separation of the GC tively banning the practice of MRT in the
from the child as well as the intentional “non- United States until further notice [36].
bonding” during pregnancy. However, these
concerns are primarily theoretical and not
supported by evidence. While small case series Conclusion
and retrospective cohort studies have been Third-party reproductive options for fam-
done on this topic, more research is necessary ily building are constantly evolving and
on the medical, psychosocial, and legal issues expanding. Treatments are available for
involved in gestational surrogacy [32]. couples with abnormalities in male and
female gametes, individuals or couples
without a functional uterus, single women
27.5 Mitochondrial Replacement and men, and those in same-sex relation-
Therapy: “Three-Parent ships wishing to conceive. As the field of
Babies” third-party reproduction is growing, adher-
ence to FDA requirements, ASRM recom-
In human reproduction, mitochondria mendations, and ethical standards is of
are maternally inherited via the oocyte. paramount importance.
Mitochondrial diseases, caused by mutations
610 A. Quaas
27.6 Review Questions B. With regard to the obstetric care of

gestational carriers (GCs), the pro-
??1.
Which of the following statements vider’s primary obligation is to the
regarding therapeutic donor insemina- intended parents (IPs).
tion (TDI) is false? C. While mitochondrial replacement
A. Indications for TDI include azo- therapy (MRT) is not commonly
ospermia in the male partner, a performed, it is legal in the United
sexually transmitted disease that States.
cannot be eradicated, and the
desire of a female patient to con-
27 ceive without a male partner. 27.7 Answers
B. Ovarian stimulation with clomi-
phene or letrozole only results in a vv1. C
small increase in the chance of an
ongoing pregnancy, while signifi- vv2. B
cantly increasing the risk of multi-
ple gestation. vv3. A
C. Triggering ovulation using inject-
able hCG is associated with supe-
rior ongoing pregnancy rates after References
TDI compared to TDI scheduling
with the use of ovulation predictor 1. Carpinello OJ, et al. Does ovarian stimulation ben-
efit ovulatory women undergoing therapeutic donor
kits.
insemination? Fertil Steril. 2021;115(3):638–45.
2. Kyrou D, et al. Spontaneous triggering of ovulation
??2.
Which of the following statements versus HCG administration in patients undergo-
regarding oocyte donation is true? ing IUI: a prospective randomized study. Reprod
A. The underlying biological principle Biomed Online. 2012;25(3):278–83.
of oocyte donation treatment con-
Reproductive, M. and A.a.o. the Practice Com-
sists of the notion that the age of mittee for the Society for Assisted Reproductive
the uterus is the limiting factor of Technology. Electronic address, Guidance regard-
female reproduction. ing gamete and embryo donation. Fertil Steril.
B. A comprehensive screening for 2021;115(6):1395–410.
4. Ethics Committee of American Society for Repro-
infectious, genetic, and medical
ductive, M. Access to fertility treatment by gays,
conditions should be undertaken lesbians, and unmarried persons: a committee opin-
prior to proceeding with a candi- ion. Fertil Steril. 2013;100(6):1524–7.
date oocyte donor. 5. Anderssen N, Amlie C, Ytteroy EA. Outcomes
C. Preimplantation genetic diagnosis for children with lesbian or gay parents. A review
of studies from 1978 to 2000. Scand J Psychol.
for aneuploidy (PGT-A) of the
2002;43(4):335–51.
donor oocyte-derived embryos 6. Golombok S, Tasker F, Murray C. Children raised
improves the chance of live birth in fatherless families from infancy: family relation-
for donor oocyte recipients. ships and the socioemotional development of chil-
dren of lesbian and single heterosexual mothers. J
Child Psychol Psychiatry. 1997;38(7):783–91.
??3.
Which of the following statements is
7. Maccallum F, Golombok S. Children raised in
true? fatherless families from infancy: a follow-up of
A. Employees of an infertility practice, children of lesbian and single heterosexual moth-
including physicians, are excluded ers at early adolescence. J Child Psychol Psychiatry.
from serving as embryo donation 2004;45(8):1407–19.
8. Van den Broeck U, et al. A systematic review
recipients or donors within their
of sperm donors: demographic characteristics,
practice. attitudes, motives and experiences of the pro-
611 27
cess of sperm donation. Hum Reprod Update. of reproductive technologies. Reprod Biomed
2013;19(1):37–51. Online. 2010;20(2):261–6.
9. Murray C, Golombok S. Oocyte and semen dona- 24. Ethics Committee of the American Society for
tion: a survey of UK licensed centres. Hum Reprod. Reproductive Medicine. Electronic address, A.a.o.
2000;15(10):2133–9. and M. Ethics Committee of the American Soci-
10. Appleton SF. Between the binaries: exploring the ety for Reproductive, Cross-border reproductive
legal boundaries of nonanonymous sperm dona- care: an Ethics Committee opinion. Fertil Steril.
tion. Family Law Quarterly. 2015;49(1):93–115. 2016;106(7):1627–33.
11. Trounson A, et al. Pregnancy established in 25. Ethics Committee of the American Society for
an infertile patient after transfer of a donated Reproductive Medicine. Financial compensation
embryo fertilised in vitro. Br Med J (Clin Res Ed). of oocyte donors: an Ethics Committee opinion.
1983;286(6368):835–8. Fertility and Sterility. 2021;116(2):319–25.
12. Lutjen P, et al. The establishment and maintenance 26. Practice Committee of the American Society for
of pregnancy using in vitro fertilization and embryo Reproductive, M. and a.a.o. Practice Committee of
donation in a patient with primary ovarian failure. the Society for Assisted Reproductive Technology.
Nature. 1984;307(5947):174–5. Electronic address, repetitive oocyte donation: a
13. Sauer MV, Paulson RJ, Lobo RA. A preliminary committee opinion. Fertil Steril. 2020;113(6):1150–3.
report on oocyte donation extending reproduc- 27. Kawwass JF, et al. Embryo donation: national
tive potential to women over 40. N Engl J Med. trends and outcomes, 2000 through 2013. Am J
1990;323(17):1157–60. Obstet Gynecol. 2016;215(6):747 e1–5.
14. Sauer MV, Paulson RJ, Lobo RA. Reversing the 28. Jones BP, et al. Human uterine transplantation: a
natural decline in human fertility. An extended clini- review of outcomes from the first 45 cases. BJOG.
cal trial of oocyte donation to women of advanced 2019;126(11):1310–9.
reproductive age. JAMA. 1992;268(10):1275–9. 29. Swanson K, et al. Understanding gestational sur-
15. Quaas AM, et al. Egg banking in the United States: rogacy in the United States: a primer for obstetri-
current status of commercially available cryopre- cians and gynecologists. Am J Obstet Gynecol.
served oocytes. Fertil Steril. 2013;99(3):827–31. 2020;222(4):330–7.
16. Cobo A, et al. New options in assisted reproduction 30. Practice Committee of the American Society for
technology: the Cryotop method of oocyte vitrifica- reproductive, M, et al. Recommendations for prac-
tion. Reprod Biomed Online. 2008;17(1):68–72. tices utilizing gestational carriers: a committee
17. Doyle N, et al. Donor oocyte recipients do not opinion. Fertil Steril. 2017;107(2):e3–e10.
benefit from preimplantation genetic testing for 31. Reproduction, F.C.f.E.A.o.H. and H. Women’s.
aneuploidy to improve pregnancy outcomes. Hum FIGO Committee Report: surrogacy. Int J Gynae-
Reprod. 2020;35(11):2548–55. col Obstet. 2008;102(3):312–3.
18. Quaas AM, Pennings G. The current status of 32. Dar S, et al. Assisted reproduction involving ges-
oocyte banks: domestic and international perspec- tational surrogacy: an analysis of the medical,
tives. Fertil Steril. 2018;110(7):1203–8. psychosocial and legal issues: experience from a
19. Practice Committees of the American Society for large surrogacy program. Hum Reprod. 2015;30(2):
Reproductive, M. and T. the Society for Assisted 345–52.
Reproductive. Mature oocyte cryopreservation: a 33. Adashi EY, Cohen IG. Mitochondrial replacement
guideline. Fertil Steril. 2013;99(1):37–43. therapy: born in the USA: the untold story of a
20. Akin JW, et al. Initial experience with a donor egg conceptual breakthrough. Am J Obstet Gynecol.
bank. Fertil Steril. 2007;88(2):497 e1-4. 2017;217(5):561–3.
21. Quaas AM. Local privileges not universal rights: 34. Wolf DP, Mitalipov N, Mitalipov S. Mitochon-
geographic variations in the science and clinical drial replacement therapy in reproductive medicine.
practice of reproductive medicine. J Assist Reprod Trends Mol Med. 2015;21(2):68–76.
Genet. 2018;35(9):1559–63. 35. Reinhardt K, Dowling DK, Morrow EH, Medicine.
22. Van Hoof W, Pennings G. Extraterritorial laws for Mitochondrial replacement, evolution, and the
cross-border reproductive care: the issue of legal clinic. Science. 2013;341(6152):1345–6.
diversity. Eur J Health Law. 2012;19(2):187–200. 36. Adashi EY, Cohen IG. Mitochondrial replace-
23. Ferraretti AP, et al. Cross-border reproductive care: ment therapy: unmade in the USA. JAMA.
a phenomenon expressing the controversial aspects 2017;317(6):574–5.
613 28
Uterus Transplantation
Elliott G. Richards and Jenna M. Rehmer
Contents
28.2 Indications for Uterus Transplantation – 616

28.3 reparation Prior to Performing Uterus
P
Transplantation – 617
28.4 Selecting Appropriate Candidates – 617

28.4.1 otential Deceased Donors – 617
P
28.4.2 Potential Living Donors – 618
28.4.3 Potential Recipients – 619
28.4.4 Matching Donor to Recipient – 619
28.5 Uterus Recovery Procedure – 619
28.6 Uterus Transplant Procedure – 620
28.7 Complications – 620
28.8 Immunosuppression and Graft Monitoring – 621
28.9 Embryo Transfer – 621
28.10 Pregnancy Following Uterus Transplantation – 622
28.11 terus Transplantation in a Post

U
COVID-19 World – 622
28.12 Looking Ahead to the Future – 623

28.12.1 A ddressing the Shortage of Available Donors – 623
28.12.2 Expanding the Pool of Potential Recipients – 623
28.12.3 Studying the Feasibility of Alternative Sources
of Vascular Outflow – 623

https://doi.org/10.1007/978-3-030-99596-6_28
28.14 Answers – 625
References – 625
615 28
ways: (1) a uterus transplant is an ephemeral
Key Points transplant, meaning it is transplanted with the
55 Uterus transplantation has a rich his- intention to eventually be removed, usually
tory involving multiple animal and after 1–2 live births [3]; (2) a uterus transplant
human trials and is rapidly transition- is a life-propagating transplant, allowing for
ing from experimental therapy to estab- the possibility of pregnancy, which affects the
lished clinical practice. health of the transplanted individual and any
55 Indications for uterus transplanta- children if pregnancy is successful; (3) a uterus
tion include congenital absence of the transplant is an organ taken from a donor who
uterus, hysterectomy, and severe ana- may longer need or desire the organ, unlike the
tomic abnormalities (uterine synechiae, face or hands; (4) a uterus transplant is not
adenomyosis, fibroids). considered “successful” until birth of a child,
55 The use of living versus deceased donors which may occur months or years after trans-
in uterus transplantation involves numer- plantation (though vascular graft perfusion,
ous complex medical and ethical consid- graft rejection, menstrual onset, and pregnancy
erations. induction are relevant clinical milestones and
55 Uterus transplantation is a multi- can be used as indicators of intermediate suc-
phase process that requires a multi- cess [4]); (5) a uterus transplant requires addi-
disciplinary effort by a team of highly tional procedures beyond the two surgeries of
coordinated specialists. organ recovery and transplantation: embryo
55 Success rates are encouraging but long- transfer, cesarean delivery, and ultimately graft
term outcomes data for living donors, hysterectomy.
recipients, and offspring are needed. Years of extensive research were under-
taken in a variety of animal species prior to
the establishment of the first clinical trials
of UTx. In 1971, James Scott and colleagues
28.1 Introduction published an innovative study of autologous
and allogeneic uterus transplantation in rhe-
Uterus transplantation (UTx) is a fertility sus monkeys. In the early 2000s, UTx models
treatment that is rapidly transitioning from an were developed in mice [5, 6], rats [7], pigs [8,
experimental therapy to an established clinical 9], sheep [10, 11], and primates [12].
practice. In the United States, there are at least The first clinical trial of UTx was con-
3 active centers performing transplants with ducted in 2013 in Sweden. Prior to this land-
over 32 procedures performed and at least 20 mark trial, however, there were two isolated
live born children; as of July 2021, one active attempts at UTx performed outside of a
center is now performing the procedure out- clinical trial. The first in 2000 in Saudi Arabia
side of clinical trials. In October 2020, the involved a 26-year-old woman with a history
American Medical Association adopted seven of postpartum hysterectomy who received a
class III CPT codes for uterine transplant sur- uterus from a 46-year-old living donor. The
gery [1]. While enthusiasm for UTx and the graft failed approximately 3 months later due
number of uterus transplants and live births to vascular complications and inadequate
continue to increase, questions about UTx pelvic support. The second attempt was in
safety and efficacy remain, given the paucity 2011 in Turkey, where a 21-year-old with
of long-term data. congenital absence of the uterus received a
Uterus transplants are classified as vascular- uterus from a 22-year-old deceased donor.
ized composite allografts (VCAs) [2]. VCAs are While the procedure was a technical success
a unique subset of life-enhancing organs rather and the organ remained in situ, the recipient
than life-saving organs and include transplants had recurrent implantation failure and mis-
of the face and hands. Among VCAs, uterus carriage, though ultimately resulting in a live
transplants are unique in several important born child in 2020 [13].
616 E. G. Richards and J. M. Rehmer
The first ever live born child from UTx UTx. The second most common indication
was in 2014, from a patient participating for UTx to date has been surgical absence of
in the first clinical trial in Sweden [14]. The the uterus, which is the most common cause
second ever live birth occurred in 2017 in of UFI overall. In the United States, there
the United States at the Baylor University are more than 10,000 hysterectomy surger-
Medical Center in Dallas [15]. Both of these ies each year on women of childbearing age
landmark events exclusively involved living due to obstetric complications or gynecologic
donors. Later that year, Brazil had the first disease, including postpartum hemorrhage or
deceased donor UTx birth in the world [16], early-stage cervical cancer.
followed shortly thereafter by the Cleveland Other causes of congenital absence of
Clinic [17]. As of July 2021, there have been the uterus may be a consideration for UTx.
over 31 live births following UTx reported Complete androgen insensitivity syndrome
in the literature [1], with at least 8 more not (CAIS) is an X-linked recessive inheritance
28 yet published but reported in the media. disorder in which the patient’s phenotype is
Uterus transplantation is a global endeavor, female and their genotype is male due to muta-
with transplants being performed in Sweden, tions in the androgen receptor gene. Most of
Brazil, Lebanon, Germany, China, Czech these patients self-identify as women but lack
Republic, Italy, India, and France. a uterus and functional ovaries. UTx may be
offered to these women in the future. In addi-
tion, it is anticipated that UTx will eventually
Case Vignette be offered to transgender women who desire
to establish pregnancy [19, 20]. These patients
Uterus Transplantation- A 27-year-old could use their own cryopreserved or fresh
gravida 0 with a history of primary amen- sperm to generate embryos with a partner’s
orrhea was diagnosed with Mayer–Roki- egg or an egg donor, then gestate the preg-
tansky–Küster–Hauser (MRKH) syndrome nancy in a transplanted uterus.
at age 15. She and her husband are inter- UTx may be indicated in some patients
ested in the option of conceiving biological with an existing uterus, such as the presence
children in the context of her congenital of severe intrauterine adhesions. Asherman’s
absence of a uterus. syndrome was the indication for hysterec-
tomy prior to uterus transplantation in a UTx
patient in India [21]. Uterine leiomyomata
28.2 Indications for Uterus (fibroids) are a common cause of infertility
Transplantation and are associated with adverse consequences
of pregnancy, such as miscarriage, premature
UTx may be indicated for patients who suffer labor, and postpartum bleeding; some fibroid
from uterine factor infertility (UFI). Various cases may be refractory or not amenable to
forms of UFI, including congenital absence surgical excision or other methods of fibroid
of the uterus, are believed to affect over 3–5% treatment, thus suggesting a role for hysterec-
of women worldwide [18]. This estimation is tomy with subsequent uterus transplantation.
limited, however, by incomplete data and the Adenomyosis, likewise, is a uterine condition
large number of related conditions within that may prevent pregnancy and may not be
UFI. In published data of UTx outcomes to amenable to conservative surgical treatment.
date, the most common indication for UTx Pelvic radiation causes irreversible radiation
has been Mayer-Rokitansky-Küster-Hauser damage to the uterus and is characterized by
(MRKH) syndrome, which has an estimated a decrease in uterine volume; these women are
prevalence of 1:4500–5000. In MRKH syn- not considered suitable candidates for UTx at
drome, while the ovaries are typically unaf- this time due to their history of malignancy,
fected, all or part of the vagina is often pelvic scarring, adhesions, and diminished tis-
underdeveloped or missing, which may pose sue healing, but perhaps may be candidates
some challenges for vaginal anastomosis in for UTx in the future.
617 28
For patients with UFI, there are presently transplant medicine, oversees daily activities,
no alternative medical or surgical therapies and provides key communication between
that allow them to carry their own child. leaders, patients, and teams.
Critics of UTx point out that these patients Prospective UTx centers must determine
or couples may have alternatives to starting a whether to utilize a living donor (LD), a
family outside of carrying one’s child, such as deceased donor (DD), or a combined strategy.
adoption or gestational surrogacy. In many The LD model is in many ways easier to imple-
cases, these alternatives may not be avail- ment because it is independent of the availabil-
able or desirable for personal, cultural, legal, ity of DD organs; however, the complexity of
ethical reasons. Gestational surrogacy pres- the procurement process presents serious risks
ents unique challenges and is illegal in many to living donors [28, 29]. In the short term, the
countries around the world, while adoption DD model may eliminate donor risk, but it is
involves complex laws and social systems and unclear whether recipient outcomes are com-
does not afford patients to have children that parable or better. Importantly, with the DD
are genetically related to them. model, only a limited medical history can be
Ethical discussion has been central in obtained and the time of ischemia may be lon-
the modern era of UTx. Researchers, doc- ger. Moreover, the benefits of the DD model
tors, patients, and bioethicists collaborated must be weighed against the scarcity of avail-
to develop a scientific roadmap for UTx able DD. Preliminary evidence suggests no
research, with first steps being to establish an clear consensus by recipients on a preferred
ethical basis for conducting the study [22–24]. donor model [27]. Some centers have adopted
Early ethical frameworks of UTx centered a combined approach to both models [30, 31].
on the desire of patients with UFI to experi- In terms of efficacy, preliminary data suggests
ence pregnancy, with UTx being a means of that the two approaches are comparable, but
fulfilling that desire [25, 26]. Recent work has data is still limited.
demonstrated the motivations of patients to
be complex, centering around reproductive
autonomy and desire to take an active role in 28.4 Selecting Appropriate
prenatal health and well-being [27]. Candidates
28.3 Preparation Prior 28.4.1 Potential Deceased Donors

to Performing Uterus
Transplantation In a DD model, all reported transplants have
used brain-dead donors, as opposed to dona-
UTx should not be seen as a single event but tion after cardiac death donors. Screening of
rather a long-term, decades-long endeavor for potential donors is critical, especially since a
an organization that requires significant man- complete medical history is often not avail-
agement and key stakeholder involvement. able. Donors are preferred when they have a
Uterus transplantation is appropriate for a history of at least one prior full-term birth,
tertiary care center where interdisciplinary though they have been considered when no
teams can be coordinated. In addition to the history of infertility is present. Additional
primary surgical transplant team, specialists selection criteria include the absence of any
in reproductive endocrinology, maternal-fetal chronic disease, the absence of any conditions
medicine, anesthesiology, infectious diseases, that would affect survival of the graft, a BMI
psychiatry/psychology, bioethics, pathology, less than 30 kg/m2, and the structural suitabil-
social work, etc., participate as key members ity of the uterus (assessed by ultrasound, CT,
of the team. Most importantly, the team needs and/or hysteroscopy).
an experienced coordinator (physician, phy- In the DD model, there must be consent
sician assistant, nurse) who is familiar with from next of kin explicitly for the use of the
uterus for transplant. Like a face transplant, draining the uterus. It is not known whether
one could imagine that most people who sign thromboembolism, preeclampsia, and pre-
up to be organ donors have not contemplated term birth occur more frequently with a
uterus donation as one of the outcomes. postmenopausal uterus [34]. Perioperative
Individuals “often hold complex preferences estrogen may be administered to the donor
regarding donation such that they may be less in preparation for procurement to improve
willing to donate non-vital rather than vital reproductive tissues and the quality of the
organs after their death and may be more supporting blood vessels in peri- and post-
averse still to donating reproductive organs” menopausal women [14]. However, estrogen
[32]. The UK NHS Transplant Activity is a known risk factor for venous thrombo-
Report highlights the complexity of the pref- embolism, particularly in the higher doses
erences of organ donors: 88% are willing to used in these protocols [35].
donate all tissues and organs after death, Informed consent is critical in LD selec-
28 whereas 12% are selective, with the latter hold- tion, as patients must be aware that uterus
ing strong preferences against specific organs recovery for transplantation confers much
such as the heart or cornea [32]. Reassuringly, greater risk than a typical hysterectomy. UTx
however, a survey of a diverse sampling of the is a completely elective procedure, as UFI
US population showed that most women were is not life-threatening. One justification for
willing to donate their uterus (74.4%) [33]. allowing LDs in UTx is the ethical permissi-
Discussion with surviving family members bility of supererogatory acts (actions “above
can help to gain a better sense if donation is the call of duty” that are morally good but not
something the deceased individual would have morally required), but even here, comprehen-
considered, but living donation affords a more sive informed consent is critical.
definitive and authentic first-person consent. Use of directed LDs is an especially com-
plex area of UTx ethics. Coercion is a serious
concern for directed LDs, particularly when
28.4.2 Potential Living Donors considering pronatalist societies where “reli-
ance on close family members and friends for
In an LD model, the donor-to-recipient dyads donation presents the potentially confound-
can either be known (“directed”) or anony- ing issue that networks of family members
mous (“non-directed”). In the Swedish trial, and friends often maintain reciprocal rela-
all involved directed donation, with mother- tionships of gift exchange” [36]. Prospective
to-
daughter donation being the most com- donors might accept risks that they would
mon [14]. Age criterion for a living donor not otherwise accept due to cultural or famil-
program is typically 40–65 years, and most ial pressures to donate. Furthermore, when a
protocols require that the prospective donors transplant surgery is not successful, a known
have had at least one prior full-term live birth. LD may feel that they have “failed” the recipi-
Screening for HPV, HIV, hepatitis B/C, gon- ent, particularly if the donor is the mother of
orrhea, chlamydia, syphilis, HSV is typically the recipient and already harbors feelings of
required. The uterus is assessed by ultrasound guilt over the recipient’s congenital uterine
and CT. Prospective donors are typically factor infertility. Alternatively, when a donor
excluded if they have had a cancer diagnosis surgery has complications, the recipient may
in the preceding 5 years, any active infection, likewise feel guilty and responsible for this
recent Zika exposure, preexisting medical poor outcome for the donor.
conditions or high-risk behaviors that would In both directed and nondirected models,
pose increased risk, or unwillingness to com- use of LDs involves a balancing act between
ply with protocols. respecting autonomy and avoiding coercion;
A uterus derived from a postmenopausal a thorough discussion of these topics and a
LD may present technical challenges due comprehensive informed consent process is
to the smaller size of vessels supplying and critical.
619 28
28.4.3 Potential Recipients These IVF cycles may or may not involve pre-
implantation genetic diagnosis for aneuploidy
Given that UTx is still considered an emerg- (PGT-A), which is an area of some contro-
ing therapy, the criteria for patients applying versy. Some argue that use of PGT-A may
must be relatively strict to ensure safety and reduce the time to pregnancy and the duration
to allow determination of the effectiveness of of immunosuppressive administration [37].
the treatment before expanding the treatment Previous randomized trials suggested PGT-
more broadly. Active centers in the United A’s effectiveness in decreasing time to preg-
States have historically limited participation nancy for women of all ages, but these trials
to women with XX karyotype of childbearing have received considerable criticism. Of note,
age (from 18 to 45 years of age, with embryos most prospective recipients of UTx belong to
ideally generated when they were between an age group in which PGT-A has not been
21 from 39 years of age), patent vagina, and shown to be beneficial [38].
absolute UFI. Applicants undergo rigor-
ous medical and psychosocial evaluation to
ensure that they are willing and able to receive 28.4.4 Matching Donor to Recipient
in vitro fertilization, uterine transplantation,
caesarean section, hysterectomy, high doses The ABO blood group is the main criterion
of immunosuppressive therapy, and vaccines. for donor-recipient compatibility. Many cen-
Typical exclusion criteria include tobacco and ters also use cytomegalovirus (CMV) infec-
drug dependence, chronic diseases (obesity, tion status to match donors and recipients,
hypertension, diabetes, hepatitis, HIV; heart, but this is not universal.
liver, kidney, brain disease; etc.), and cancer DD availability is unpredictable and there-
(excluding early-stage cervical cancer). Once fore the primary recovery and transplant
passing the initial screening phase, applicants teams, as well as the prospective recipients,
undergo a comprehensive evaluation that must be prepared for long waits and more
includes multiple interviews, imaging, and challenging logistics with regard to schedul-
clinical examinations. ing of procedures.
Prior to the transplant surgery itself, a pre-
determined number of high-quality embryos
are generated through in vitro fertilization 28.5 Uterus Recovery Procedure
and then are cryopreserved. While in vitro
fertilization has occasionally been performed In the DD model, a large transverse incision
posttransplant in many centers worldwide, (or modified transverse incision known as the
IVF is always performed prior to transplant Tzakis incision [29]) removes the uterus along
to assess fertility potential and to minimize with the life-saving organs. During the exten-
risks to the recipient, who will be on high- sive pelvic dissection of a DD, which typically
dose immunosuppression following trans- takes 1–3 hours, there is no need to protect or
plant. After a sufficient number of embryos preserve important retroperitoneal structures
have been cryopreserved, participants are as there would be for an LD, allowing for more
added to the transplant list to await an appro- generous dissection of vascular pedicles. In a
priate donor. DD recovery procedure, one must also con-
At present, there is no consensus on the sider the potential recipients of the donor’s
ideal or minimum number of banked embryos other organs, including the heart, lungs, liver,
required before transplant surgery. The and kidneys. To minimize this risk, the DD
American Society for Reproductive Medicine procedure can be planned in such a way that
(ASRM) recommends that recipients have neither the uterus nor the life-saving organs to
“an adequate number of good embryos.” be procured are compromised [28].
In the LD model, recovery of the uterus opened transversely to maximal diameter and
is removed by either laparotomy or laparos- the recipient vaginal mucosa is tagged with
copy. LD uterus procurement is similar in suture for later vaginal anastomosis. The graft
overall complexity to a radical hysterectomy is then taken from the back table and placed in
and should only be attempted by experienced an orthotopic position. The vascular anasto-
gynecologic surgeons (e.g., gynecologic- mosis is usually performed first, once assured
oncologists). Venous flow in the transplanted that proximity to the future site of vaginal
organ is most commonly achieved through anastomosis is sufficient. Bilateral end-to-
anastomosis between the inferior uterine side vascular anastomoses are performed to
veins and the internal iliac veins. The variable the external iliac vessels of the recipient for
and anomalous nature of the uterine vein, arterial supply to the graft. For venous drain-
paired with the close proximity of the ure- age, anastomosis is typically through inferior
ter, makes this the most challenging part of uterine veins of the graft into the internal iliac
28 the surgery and most prone to complications. vein, but alternative or additional anastomo-
The use of superior uterine veins (also known ses are often performed using the superior
as the utero-ovarian veins [4]) for outflow has uterine (utero-ovarian) veins. Vaginal anasto-
been proposed and is discussed later in this mosis is then performed either through a series
chapter. of interrupted horizontal mattress sutures or
by a running suture [39].
28.6 Uterus Transplant Procedure

28.7 Complications
While all LDs (and many DDs) will be recov-
ered at the same facility as the transplantation Complications have been reported for both
surgery, many DDs will be at a geographically LDs and recipients. For LDs, reported com-
distant location. In this case, it is important plications include bleeding requiring re-
to cooperate with the procurement team to exploration, ureteral injury, dehiscence of
reduce cold ischemia time for the graft, which the vaginal cuff, and buttock pain [40, 41].
ideally should be within 6 hours, and to avoid Ureteric injury for LDs (including fistula for-
unnecessary anesthesia and surgery for the mation) occurs in 5–14% of cases. Of note,
recipient. After recovery of the uterus and the risk of mental health-related quality of
transport to the recipient operating room, life concerns is increased in LDs when there is
preparation of the graft is performed at a graft failure, defined by removal of the uterus
back table to test for vessel patency and per- prior to the achievement of a live birth [42].
form vascular reconstructions as necessary. In recipients, perioperative complications
The recipient surgery should not begin until are the greatest threat to the transplanted
the uterus recovery team confirms suitability uterus in the immediate postoperative period.
of the uterus and vascular pedicles. The most common severe complication is
The transplant surgery is performed arterial or venous thrombosis. Overall vas-
via laparotomy with coordination between cular complication rate is approximately 20%
transplant and gynecologic surgery teams. and most commonly results in graft hysterec-
Preparation of the planned sites of vascular tomy [41].
anastomosis is typically performed first, with Infection and thrombosis must be actively
exposure of the external iliac vessels. This prevented with pre-, intra-, and postopera-
is followed by preparation of the vagina for tive prophylaxis including antibiotics and
anastomosis and preparation of existing pel- anticoagulation. Protocols usually contain
vic structures for uterine fixation. The bladder trimethoprim-sulfamethoxazole for 6 months
is dissected away from the apical end of the to prevent Toxoplasma gondii, Nocardia,
vagina, which is often anomalous and densely Pneumocystis pneumoniae, and Listeria.
adherent to surrounding tissues. The vagina is Antifungals are also used for 6 months against
621 28
Candida albicans. Acyclovir/valganciclovir for versible rejection of UTx in monkeys show
3–6 months is used to prevent CMV and other that even without hysterectomy, severe rejec-
systemic viral diseases. Given the potential tion is neither fatal nor life-threatening [44].
for a varicella-zoster virus reaction, contin- In human trials, nearly all reported cases of
ued prevention with acyclovir after stopping rejection have been cellular and not humoral,
CMV prophylaxis should be considered. with some notable exceptions [17]. In the com-
Narrowing of the site of vaginal anastomo- bined 27+ rejection episodes reported in the
sis is a common occurrence that may require first trials performed in Sweden, the Czech
intervention. During the transplant proce- Republic, and Baylor, all were successfully
dure, there is often a discrepancy between treated with complete resolution.
donor and recipient vaginal diameter, which As with other solid organ transplants,
can contribute to subsequent vaginal stenosis. immunosuppression in the recipient is essen-
Attempts to prevent stenosis have included tial. Induction therapy begins at the time
vaginal stents, use of vaginal estrogens, and of transplantation (usually thymoglobulin,
vaginal dilators before and after surgery [39, mycophenolate mofetil [MMF] or azathio-
43]. The anastomosis must be patent enough prine, methylprednisolone, tacrolimus) and
for passage of menstrual effluent, access for is followed by maintenance treatment (tacro-
cervical biopsies, and transferring of embryos. limus, prednisone). Many programs forgo
The long-term consequences of UTx are MMF for azathioprine altogether due to the
unknown. Data are greatly needed to assess teratogenicity of MMF and the need to even-
the long-term effects of living donors, failed tually switch to azathioprine. Management of
graft recipients, successful pregnancy recipi- immunosuppression and weekly monitoring
ents, donor and recipient families, and off- of labs are typically performed by a transplant
spring. These data should include not only the surgeon or transplant physician on the team.
clinical outcomes but also the psychological Following transplantation, the patient is
consequences for these groups. monitored closely and the graft is regularly
assessed for signs of rejection. Periodic ultra-
sounds are performed to ensure continuous
28.8 Immunosuppression and Graft perfusion of the graft and to measure the size
Monitoring of the graft. Unlike other internal abdominal
organ transplants, which are not easily acces-
The most important criterion for success in sible after transplantation, the cervix can be
UTx is the safe delivery of a newborn, an accessed through noninvasive in-office gyne-
event that is often a year or more after the cological examination. The transplanted cer-
initial transplant surgery. In addition to this vix is biopsied for evidence of rejection, and
strict definition of success, the US Uterus the biopsy is scored according to standardized
Transplant Consortium (USUTC) published criteria [45].
a set of milestones in 2020 to assess the ongo-
ing success of a uterus transplant attempt [4].
These milestones include technical success 28.9 Embryo Transfer
(defined by established outflow after surgery
and implant survival), menstruation, embryo In the original Swedish study, 12 months
implantation, pregnancy, childbirth, safe were required after transplant to proceed to
removal of the graft, and long-term health of embryo transfer. In the Baylor study, embryo
the participants. transfer was initially performed 6 months
Monitoring for rejection of the graft is a later, but later shortened to 3 months [46].
common practice in fixed organ transplants. Hysteroscopy or saline infusion sonogram is
Rejection is not considered a complication, performed prior to embryo transfer as with
rather an essential aspect of managing the over IVF patients. The transfer procedure is
transplanted uterus. Studies of severe, irre- often complicated by stricturing at the vagi-
nal anastomosis site, a phenomenon which updated data is needed [41]. All reported deliv-
is common in uterus transplant recipients. eries to date have been by cesarean section and
Procedures to relieve the vaginal stricture can all delivered a healthy neonate between 31 and
be performed in the weeks to months prior to 37 weeks. Preeclampsia is the most common
transfer, often in the operating room under complication, occurring in 19% of UTx preg-
anesthesia. Self-dilation is taught and per- nancies [41, 48]. In the original Swedish study,
formed in select patients. The use of a self- 3 out of 9 women developed preeclampsia; all
expanding intravaginal stent before embryo women had unilateral renal agenesis, suggest-
transfer has also been reported [47]. ing the incidence may be particularly high in
Data is limited with regard to IVF out- this group.
comes in UTx [48, 49]. Globally, the reported Data is limited on neonatal outcomes. The
pregnancy rate per functional graft is as low greatest risk is preterm delivery. All infants
as 42%, while in the United States, the rate born thus far have been reported to be healthy
28 is 67–79%. It is helpful to note that IVF pro- without congenital anomalies. While preterm
tocols, practices, and outcomes vary widely birth has been reported in 62.5% of deliver-
worldwide. While more data are needed, pre- ies, this rate appears to decrease as centers
liminary evidence suggests no difference in perform more uterus transplants. More data
pregnancy rates between patients with uteri from larger cohorts with long-term follow-up
from LD versus DD. are needed.
28.10 regnancy Following Uterus

P 28.11 Uterus Transplantation
Transplantation in a Post COVID-19 World
Although the number of uterus transplants As UTx is not a life-saving procedure, most
and subsequent live infants continue to grow if not all centers suspended operations in
rapidly, very limited data on pregnancy out- 2020 as the worldwide COVID19 pandemic
comes in UTx have been reported. No answer began. Following widespread availability of
has yet been given regarding antenatal care COVID- 19 vaccines, most centers resumed
and optimal timing of delivery. Currently, UTx in 2021.
antenatal care guidelines used in women who Pregnant UTx recipients are a particu-
have had other solid organ transplants are used larly vulnerable population, given their addi-
in the uterus transplant population. Careful tional pharmacologic immunosuppression.
monitoring of immunosuppression using Outside of UTx, COVID-19 infection during
serum drug levels, surveillance of fetal growth, pregnancy puts patients at increased risk for
prevention of maternal infections, and screen- severe complications, leading to ICU admis-
ing of blood pressure and kidney function are sion, intubation/ventilation, and death [50].
the primary focus during pregnancy. Neonates of COVID-19 infected mothers are
Tacrolimus, azathioprine, and prednisone more likely to be born premature, have lower
are the most widely used immunosuppres- birth weights, and experience severe complica-
sants during pregnancy. Tacrolimus is not tions including hypoxic-ischemic encephalop-
associated with teratogenicity, but can cause athy, blindness associated with prematurity,
maternal nephrotoxicity. Azathioprine, which and intraventricular hemorrhage [51].
is not considered teratogenic in humans, is Patients who undergo UTx are organ trans-
associated with premature labor and low birth plant recipients; therefore, programs should
weight. The overall rate of fetal malforma- follow CDC guidelines for organ recipients
tions associated with prednisone use is similar with regard to vaccination and precaution-
to that of the general population, but data on ary measures. Most if not all centers mandate
the risk of cleft lip are inconsistent. that participants be fully vaccinated in order
The rate of maternal complications in to participate in UTx. There is no biologically
UTx has been reported as high as 37.5%, but plausible reason that SARS-CoV-2 vaccines,
623 28
including the mRNA vaccines, pose any threat the procurement procedure. Alternate sources
to the transplanted uterus or to the fertility of of vascular outflow have been proposed and
UTx participants. attempted.
Use of the ovarian vein requires oopho-
rectomy and therefore presents unacceptable
risks to an LD. Oophorectomy is associ-
28.12 Looking Ahead to the Future
ated with symptoms of early menopause and
increased overall morbidity and mortality
for women younger than 65 years. In the ini-
28.12.1 Addressing the Shortage
tial Dallas series, one postmenopausal donor
of Available Donors (age 55, with last menstrual period approxi-
mately 1 year preceding the operation) under-
Estimates of total demand and number of went salpingo-oophorectomy as part of the
available deceased donors suggest that supply procurement; she suffered minor depression
is inadequate for an exclusively DD approach. postoperatively, which was attributed to the
Use of LDs will allow increased access for hormonal changes following removal of the
more patients. Despite this, Use of DDs will ovaries. More worryingly, other cases have
likely continue to be a viable approach – and reported oophorectomy of premenopausal
arguably the preferred option, given that even LDs. In China, one premenopausal donor
with increased innovations in LD procure- (age 45) provided her uterus for her daughter
ment, it will always be safer with regard to via a robotic-assisted laparoscopic approach;
donor risk. For both LD and DD programs, during the course of surgery, the utero-ovarian
education and public awareness will continue veins were ultimately chosen for venous anas-
to be critical to maintaining trust and ensur- tomosis due to difficulty in isolating the uter-
ing a continual supply of donors. ine veins, and salpingo-oophorectomy was
performed. Likewise, two reported laparo-
scopic cases in India involved bilateral oopho-
28.12.2 Expanding the Pool rectomy in order to access the ovarian vein; the
of Potential Recipients LDs were 45 and 42 years of age with normal
menstruation [52]. Bilateral oophorectomy
The inclusion and exclusion criteria for pro- results in surgical menopause, involving an
spective recipients are currently quite strin- abrupt and dramatic change in reproductive
gent to ensure safety for participants and to hormones. Large-scale epidemiologic stud-
determine the effectiveness of the treatment ies have demonstrated convincing evidence of
during this early phase of its development. detrimental effects of oophorectomy on pre-
As uterus transplantation matures as a field, and peri-menopausal women, with significant
it is expected that the treatment will be offered increase in all-cause mortality, cognitive func-
to more patients, including transgender indi- tion, cardiovascular disease, mood disorders,
viduals. sexual dysfunction, and osteoporotic fractures
[53, 54]. Whether or not these risks can be fully
mitigated by hormone replacement therapy is
28.12.3 Studying the Feasibility debatable. In the absence of an LD’s individ-
of Alternative Sources ual indications for oophorectomy, it is difficult
of Vascular Outflow to see how these risks are justified for an LD.
Several publications, including primate
Organ drainage via the inferior uterine to inter- models and human studies, have reported
nal iliac vein is the most common approach for technically successful transplants utilizing the
the vascular anastomosis in UTx. However, ovarian veins and utero-ovarian veins for uter-
dissection of the internal iliac vein is one of ine drainage. Baboon studies have also shown
the most technically challenging aspects of that exclusive use of the superior uterine vein
can lead to healthy liveborn offspring, despite transplantable uteri that are not hindered by
the much shorter length of the superior uter- risks of infection or harm to a living donor.
ine vein [55, 56]. Using this technique, at least Early pilot studies in rats and pigs have
two living babies have been born to humans brought the field of regeneration medicine
[15]. This innovation has the promise to expe- to uterus transplant [59, 60]. In these studies,
dite and simplify the procurement procedure. de-cellularization of the murine or porcine
uterus was performed with preservation of a
28.12.3.1 efining Minimal Invasive
R functional scaffold and/or vascular network,
Surgery Techniques which was then followed by recellularization
and Immunosuppression of this scaffold in vitro. Such rudimentary
Protocols bioengineered uterine tissue has been shown
One promising area for uterine transplan- to be capable of supporting pregnancy in a
tation is minimally invasive surgery (MIS). rat model [60, 61]. The field is in a very early
28 The gynecological surgery literature indicates stage, but future innovations could forgo the
that MIS can improve surgical outcome for ethical issues inherent in living and deceased
patients and reduce the risk of surgery for OC uterus organ donation.
by reducing surgery time, reducing bleeding
and infection rates, and promoting recovery
after surgery [40, 57, 58]. 28.13 Review Questions
In addition, immunosuppression regimens
are likely to be simplified in the future as expe- ??1. What is the most likely pregnancy com-
rience with uterus transplantation grows. plication following uterus transplanta-
tion?
28.12.3.2 Considering Fallopian Tube A. Placenta accreta
Preservation B. Preterm delivery
In published reports of uterus transplant, the C. Early pregnancy loss
fallopian tubes are removed prior to reim- D. Labor dystocia
plantation of the uterus. By preserving the
tubes, spontaneous conception could theoret- ??2. Which of the following is most likely to
ically be possible, as the donor fallopian tubes increase preeclampsia risk in UTx?
would theoretically be able to perform oocyte A. Prolonged warm ischemia time
pick up at ovulation and transport the devel- B. Prolonged cold ischemia time
oping embryo to the uterine cavity. This inno- C. Nulliparity in donor
vation could reduce the overall cost of uterus D. Unilateral renal agenesis in recipient
transplant, obviating the need for in vitro
fertilization and embryo transfer. However, ??3.
Venous drainage is achieved in the
retention of the fallopian tubes would add the majority of cases through anastomosis
risk of ectopic pregnancy. In addition, forgo- using which major vessel of the graft?
ing IVF and embryo transfer would increase A. Ovarian/gonadal vein
the time to pregnancy (and time while on B. Inferior uterine vein
immunosuppression) for many patients. C. External iliac vein
D. Internal mammary vein
28.12.3.3 oving Beyond Uterus
M
Transplantation with Tissue ??4. What is the primary consideration to
Biotechnology match donor to recipient?
A. ABO group
One technology that may eventually supplant
B. BMI
uterus transplantation is the bioengineered
C. Age
uterus. Innovations such as 3D printing of
D. Ethnicity
biologic tissues could allow for the supply of
625 28
28.14 Answers 11. Ramirez ER, Ramirez DK, Pillari VT, Vasquez
H, Ramirez HA. Modified uterine transplant
procedure in the sheep model. J Minim Invasive
vv1. B Gynecol. 2008;15(3):311–4.
12. Enskog A, Johannesson L, Chai DC, Dahm-Kähler
vv2. D P, Marcickiewicz J, Nyachieo A, et al. Uterus
transplantation in the baboon: methodology and
long-term function after autotransplantation.
vv3. B
Hum Reprod. 2010;25(8):1980–7.
13. Turkey: World’s first uterus recipient gives birth
vv4. A [Internet]. [cited 2021 Sep 1]. Available from:
https://www.a a.c om.t r/en/health/turkey-worlds-
first-uterus-recipient-gives-birth/1891233.
14. Brännström M, Johannesson L, Bokström H,
References Kvarnström N, Mölne J, Dahm-Kähler P, et al.
Livebirth after uterus transplantation. Lancet.
1. Richards EG, Farrell RM, Ricci S, Perni U, Quin- 2015;385(9968):607–16.
tini C, Tzakis A, et al. Uterus transplantation: 15. Testa G, McKenna GJ, Gunby RT, Anthony T,
state of the art in 2021. J Assist Reprod Genet. Koon EC, Warren AM, et al. First live birth after
2021;38(9):2251–9. uterus transplantation in the United States. Am J
2. Johannesson L, Wall A, Tzakis A, Quintini C, Rich- Transplant. 2018;18(5):1270–4.
ards EG, O’Neill K, et al. Life underneath the VCA 16. Ejzenberg D, Andraus W, Baratelli Carelli
umbrella: perspectives from the US uterus trans- Mendes LR, Ducatti L, Song A, Tanigawa R,
plant consortium. Am J Transplant. 2021;21(5): et al. Livebirth after uterus transplantation from a
1699–704. deceased donor in a recipient with uterine infertil-
3. Tzakis AG. Nonhuman primates as models ity. Lancet. 2019;392(10165):2697–704.
for transplantation of the uterus. Fertil Steril. 17. Flyckt R, Falcone T, Quintini C, Perni U, Eghtesad
2013;100(1):61. B, Richards EG, et al. First birth from a deceased
4. Johannesson L, Testa G, Flyckt R, Farrell R, donor uterus in the United States: from severe
Quintini C, Wall A, et al. Guidelines for standard- graft rejection to successful cesarean delivery. Am
ized nomenclature and reporting in uterus trans- J Obstet Gynecol. 2020;
plantation: an opinion from the United States 18. Brännström M, Dahm Kähler P, Greite R, Mölne
Uterus Transplant Consortium. Am J Transplant. J, Díaz-García C, Tullius SG. Uterus transplanta-
2020;20(12):3319–25. tion: a rapidly expanding field. Transplantation.
5. Racho El-Akouri R, Kurlberg G, Dindelegan G, 2018;102(4):569–77.
Mölne J, Wallin A, Brännström M. Heterotopic uter- 19. Jones BP, Williams NJ, Saso S, Thum M-Y,
ine transplantation by vascular anastomosis in the Quiroga I, Yazbek J, et al. Uterine transplantation
mouse. J Endocrinol. 2002;174(2):157–66. in transgender women. BJOG. 2019;126(2):152.
6. Racho El-Akouri R, Kurlberg G, Brännström 20. Mookerjee VG, Kwan D. Uterus transplantation
M. Successful uterine transplantation in the as a fertility option in transgender healthcare. Int J
mouse: pregnancy and post-natal development of Transgend Health. 2019;21(2):122–4.
offspring. Hum Reprod. 2003;18(10):2018–23. 21. India’s first womb transplant recipients to undergo
7. Jiga LP, Lupu CM, Zoica BS, Ionac M. Experimental embryo transfer in Pune [Internet]. Hindustan Times.
model of heterotopic uterus transplantation in the 2017 [cited 2021 Sep 1]. Available from: https://www.
laboratory rat. Microsurgery. 2003;23(3):246–50. hindustantimes.com/pune-news/india-s-first-womb-
8. Avison DL, DeFaria W, Tryphonopoulos P, Tekin transplant-recipients-to-undergo-embryo-transfer-in-
A, Attia GR, Takahashi H, et al. Heterotopic uterus pune/story-ZCJ8iVPNJn5TCBvKapukyJ.html.
transplantation in a swine model. Transplantation. 22. Emanuel EJ, Wendler D, Grady C. What
2009;88(4):465–9. makes clinical research ethical? JAMA.
9. Wranning CA, El-Akouri RR, Lundmark C, 2000;283(20):2701–11.
Dahm-Kähler P, Mölne J, Enskog A, et al. Auto- 23. Farrell RM, Johannesson L, Flyckt R, Richards
transplantation of the uterus in the domestic EG, Testa G, Tzakis A, et al. Evolving ethical
pig (Sus scrofa): surgical technique and early issues with advances in uterus transplantation. Am
reperfusion events. J Obstet Gynaecol Res. J Obstet Gynecol. 2020;222(6):584.e1–5.
2006;32(4):358–67. 24. Farrell RM, Falcone T. Uterine transplant: new
10. Gonzalez-Pinto IM, Tryphonopoulos P, Avison medical and ethical considerations. Lancet.
DL, Nishida S, Tekin A, Santiago S, et al. Uterus 2015;385(9968):581–2.
transplantation model in sheep with heterotopic 25. Lefkowitz A, Edwards M, Balayla J. The Montreal
whole graft and aorta and cava anastomoses. criteria for the ethical feasibility of uterine trans-
Transplant Proc. 2013;45(5):1802–4. plantation. Transpl Int. 2012;25(4):439–47.
26. Lefkowitz A, Edwards M, Balayla J. Ethical con- in the uterine transplantation patient. Fertil Steril
siderations in the era of the uterine transplant: an [Internet]. 2020 Jul 16 [cited 2020 Aug 6];0(0).
update of the Montreal Criteria for the Ethical Available from: https://www.fertstert.org/article/
Feasibility of Uterine Transplantation. Fertil S0015-0282(20)30502-1/abstract.
Steril. 2013;100(4):924–6. 40. Johannesson L, Koon EC, Bayer J, McKenna
27. Richards EG, Agatisa PK, Davis AC, Flyckt R, GJ, Wall A, Fernandez H, et al. DUETS (Dallas
Mabel H, Falcone T, et al. Framing the diagnosis UtErus Transplant Study): early outcomes
and treatment of absolute uterine factor infertil- and complications of robot-assisted hysterec-
ity: insights from in-depth interviews with uterus tomy for living uterus donors. Transplantation.
transplant trial participants. AJOB Empir Bioeth. 2021;105(1):225–30.
2019;10(1):23–35. 41. Jones BP, Saso S, Bracewell-Milnes T, Thum M-Y,
28. Flyckt RL, Farrell RM, Perni UC, Tzakis AG, Nicopoullos J, Diaz-Garcia C, et al. Human uter-
Falcone T. Deceased donor uterine transplanta- ine transplantation: a review of outcomes from
tion: innovation and adaptation. Obstet Gynecol. the first 45 cases. BJOG Int J Obstet Gynaecol.
2016;128(4):837–42. 2019;126(11):1310–9.
28 29. Richards EG, Flyckt R, Tzakis A, Falcone
T. Uterus transplantation: organ procure-
42. Järvholm S, Kvarnström N, Dahm-Kähler P,
Brännström M. Donors’ health-related quality-
ment in a deceased donor model. Fertil Steril. of-life and psychosocial outcomes 3 years after
2018;110(1):183. uterus donation for transplantation. Hum Reprod.
30. Fronek J, Kristek J, Chlupac J, Janousek L, 2019;34(7):1270–7.
Olausson M. Human uterus transplantation from 43. Chmel R, Novackova M, Pastor Z. Lessons
living and deceased donors: the interim results of learned from the Czech uterus transplant trial
the first 10 cases of the Czech trial. J Clin Med. related to surgical technique that may affect repro-
2021;10(4):586. ductive success. Aust N Z J Obstet Gynaecol.
31. Lavoué V, Vigneau C, Duros S, Boudjema 2020;60(4):625–7.
K, Levêque J, Piver P, et al. Which donor for 44. Kisu I, Emoto K, Masugi Y, Yamada Y, Matsubara
uterus transplants: brain-dead donor or living K, Obara H, et al. Clinical features of irreversible
donor? A systematic review. Transplantation. rejection after allogeneic uterus transplantation in
2017;101(2):267–73. cynomolgus macaques. Sci Rep. 2020;10(1):13910.
32. Williams N. Should deceased donation be mor- 45. Mölne J, Broecker V, Ekberg J, Nilsson O, Dahm-
ally preferred in uterine transplantation trials? Kähler P, Brännström M. Monitoring of human
Bioethics. 2016;30(6):415–24. uterus transplantation with cervical biopsies: a
33. Rodrigue JR, Tomich D, Fleishman A, Glazier provisional scoring system for rejection. Am J
AK. Vascularized composite allograft dona- Transplant. 2017;17(6):1628–36.
tion and transplantation: a survey of public atti- 46. Johannesson L, Wall A, Putman JM, Zhang L,
tudes in the United States. Am J Transplant. Testa G, Diaz-Garcia C. Rethinking the time inter-
2017;17(10):2687–95. val to embryo transfer after uterus transplanta-
34. Robertson JA. Impact of uterus transplant on tion - DUETS (Dallas UtErus Transplant Study).
fetuses and resulting children: a response to Daar BJOG Int J Obstet Gynaecol. 2019;126(11):
and Klipstein. J Law Biosci. 2016;3(3):710–7. 1305–9.
35. Oedingen C, Scholz S, Razum O. Systematic review 47. Fronek J, Janousek L, Kristek J, Chlupac J, Pluta
and meta-analysis of the association of combined M, Novotny R, et al. Live birth following uter-
oral contraceptives on the risk of venous throm- ine transplantation from a nulliparous deceased
boembolism: the role of the progestogen type and donor. Transplantation. 2021;105(5):1077–81.
estrogen dose. Thromb Res. 2018;165:68–78. 48. Daolio J, Palomba S, Paganelli S, Falbo A,
36. Dickens BM. Legal and ethical issues of Aguzzoli L. Uterine transplantation and IVF for
uterus transplantation. Int J Gynaecol Obstet. congenital or acquired uterine factor infertility: a
2016;133(1):125–8. systematic review of safety and efficacy outcomes
37. Chattopadhyay R, Richards E, Libby V, Flyckt in the first 52 recipients. PLoS One [Internet].
R. Preimplantation genetic testing for aneuploidy 2020 Apr 29 [cited 2021 May 10];15(4). Available
in uterus transplant patients. Ther Adv Reprod from: https://www.ncbi.nlm.nih.gov/pmc/articles/
Health. 2021;15:26334941211009850. PMC7190173/
38. Munné S, Kaplan B, Frattarelli JL, Child T, 49. Johannesson L, Testa G, Putman JM, McKenna
Nakhuda G, Shamma FN, et al. Preimplantation GJ, Koon EC, York JR, et al. Twelve live births
genetic testing for aneuploidy versus morphol- after uterus transplantation in the Dallas
ogy as selection criteria for single frozen-thawed UtErus Transplant Study. Obstet Gynecol.
embryo transfer in good-prognosis patients: a 2021;137(2):241–9.
multicenter randomized clinical trial. Fertil Steril. 50. DeBolt CA, Bianco A, Limaye MA, Silverstein J,
2019;112(6):1071–1079.e7. Penfield CA, Roman AS, et al. Pregnant women
39. Rehmer JM, Ferrando CA, Flyckt R, Falcone with severe or critical coronavirus disease 2019
T. Techniques for successful vaginal anastomosis have increased composite morbidity compared
627 28
with nonpregnant matched controls. Am J Obstet eral utero-ovarian microsurgical anastomoses
Gynecol. 2021;224(5):510.e1–510.e12. alone. Hum Reprod. 2017;32(9):1819–26.
51. Villar J, Ariff S, Gunier RB, Thiruvengadam 56. Shockley M, Arnolds K, Beran B, Rivas K,
R, Rauch S, Kholin A, et al. Maternal and neo- Escobar P, Tzakis A, et al. Uterine viability in
natal morbidity and mortality among pregnant the baboon after ligation of uterine vasculature:
women with and without COVID-19 infection: the a pilot study to assess alternative perfusion and
INTERCOVID multinational cohort study. JAMA venous return for uterine transplantation. Fertil
Pediatr. 2021;175(8):817–26. Steril. 2017;107(4):1078–82.
52. Puntambekar S, Telang M, Kulkarni P, 57. Brännström M, Kvarnström N, Groth K, Akouri
Puntambekar S, Jadhav S, Panse M, et al. R, Wiman L, Enskog A, et al. Evolution of sur-
Laparoscopic- assisted uterus retrieval from live gical steps in robotics-assisted donor surgery for
organ donors for uterine transplant: our experi- uterus transplantation: results of the eight cases
ence of two patients. J Minim Invasive Gynecol. in the Swedish trial. Fertil Steril. 2020;114(5):
2018;25(4):622–31. 1097–107.
53. Parker WH, Feskanich D, Broder MS, Chang E, 58. Iavazzo C, Gkegkes ID. Possible role of DaVinci
Shoupe D, Farquhar CM, et al. Long-term mortal- Robot in uterine transplantation. J Turk Ger
ity associated with oophorectomy compared with Gynecol Assoc. 2015;16(3):179–80.
ovarian conservation in the nurses’ health study. 59. Campo H, Baptista PM, López-Pérez N, Faus A,
Obstet Gynecol. 2013;121(4):709–16. Cervelló I, Simón C. De- and recellularization of
54. Rocca WA, Grossardt BR, de Andrade M, the pig uterus: a bioengineering pilot study. Biol
Malkasian GD, Melton LJ. Survival patterns Reprod. 2017;96(1):34–45.
after oophorectomy in premenopausal women: 60. Hellström M, Bandstein S, Brännström M. Uterine
a population-based cohort study. Lancet Oncol. tissue engineering and the future of uterus trans-
2006;7(10):821–8. plantation. Ann Biomed Eng. 2017;45(7):1718–30.
55. Beran B, Arnolds K, Shockley M, Rivas K, 61. Hellström M, Moreno-Moya JM, Bandstein S, Bom
Medina M, Escobar PF, et al. Livebirth and E, Akouri RR, Miyazaki K, et al. Bioengineered
utero-placental insufficiency in Papio hamadryas uterine tissue supports pregnancy in a rat model.
baboons with uterus angiosome perfused by bilat- Fertil Steril. 2016;106(2):487–496.e1.
629 I
Supplementary
Information
Glossary – 630
Index – 635
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
https://doi.org/10.1007/978-3-030-99596-6
630 Glossary
Glossary
Adenomyosis Growth of endometrial Cortical reaction Release of proteolytic enzymes

glands and stroma within the myometrium, from egg cortical granules causes cleavage of
which makes the uterine walls thicker and ZP2, with subsequent dissociation of ZP2 from
stiffer ZP3. Thus, after the cortical reaction, sperm
can no longer bind to ZP3
Anti-Müllerian hormone A glycopeptide
that is produced predominantly by granu- Deep endometriosis When the endometrial
losa cells whose expression is highest in tissue invades deeper than 5 mm
secondary, preantral, and small antral
follicles Delayed puberty Defined as lack of thelarche
by 13 years of age or when more than 4 years
Antral follicle count An ultrasound observa- pass between thelarche (SMR Tanner Stage
tion of the number of visible ovarian follicles II) and menarche
(2–10 mm mean diameter) in the early follicu-
lar phase (cycle days 2–5) Gender dysphoria Incongruence between a
person’s experienced or expressed gender and
Bicornuate uterus Incomplete fusion of the their assigned gender.
Müllerian ducts leading to serosal myometrial
invagination of at least 1 cm Direct trocar entry Insertion of primary tro-
car without a pneumoperitoneum
Blastomere biopsy The removal of one to two
cells (blastomeres) from the embryo when it Discriminatory zone Quantitative beta-hCG
reaches the eight-cell stage level above which a single intrauterine gesta-
tional sac should be visualized, if present, by
Blastomeres Totipotent cells that make up the transvaginal ultrasound
early embryo
Embryo donation A reproductive treatment
Central precocious puberty When pubertal that enables embryos either that were created
onset occurs before 8 years of age, as a result of by patients undergoing fertility treatment to
premature activation of hypothalamic neurons be transferred to infertile patients in order to
achieve a pregnancy.
Cervical agenesis Lack of development
or incomplete development of the cervix. Embryo freezing Method to cryopreserve
Patients present with cryptomenorrhea and embryos at −196 °C
cyclic pelvic pain
Endometrioma Ovarian cyst lined by endo-
Chronic pelvic pain Pain below the umbili- metrial tissue and containing thick, brown,
cus that is of at least 6 months’ duration and tar-like fluid
causes functional disability
Endometriosis Endometrial cells found out-
Controlled ovarian stimulation The use of side the uterus and lead to symptoms such as
fertility drugs to stimulate ovaries to produce severe pelvic pain, dysmenorrhea, dyspareu-
multiple follicles nia, and subfertility
631
Glossary
Fertility preservation Branch of reproductive Inner cell mass The morphologic area of the
medicine aiming at preserving future fertility early embryo that will eventually give rise to
for patients stricken by cancer or other medi- the embryo and extraembryonic tissues
cal conditions requiring chemo-/radiotherapy.
Lately used also for preserving fertility for Laparoendoscopic single-site surgery (LESS) Lap-
elective reasons aroscopic surgery performed using a single spe-
cially designed port for the laparoscope and the
Fertilization The fusion of gametes into a dip- operating instruments
loid cell, called a zygote
Linear salpingostomy Surgical incision into
Fimbrioplasty Reconstruction of the distal the tubal lumen for the purposes of removing
aspect of an abnormal or obstructed fallopian an ectopic pregnancy while preserving the fal-
tube with particular attention to the preserva- lopian tube
tion of the fimbriated portion
Microarray-based comparative genomic
Follicle Structural unit consisting of a single hybridization (aCGH) Molecular testing tech-
immature oocyte and supportive granulosa nique which compares DNA content from
and thecal cells two differentially labeled genomes: a test (or
patient) and a reference (or control)
Gestational surrogacy A procedure that
enables a couple or reproductive party with- Müllerian agenesis Lack of development
out a functional uterus to have a baby, by or complete resorption of the Müllerian
using a women (the gestational carrier / ges- ducts leading to lack of development of a
tational surrogate) to carry the pregnancy and uterus
deliver the baby.
Müllerianosis Endometrial tissue located at
Heterotopic pregnancy Simultaneous intra- sites outside of the uterus during the embryo-
uterine and extrauterine pregnancies logic period of organogenesis
Hysterosalpingo-contrast sonography (HyCoSy) Multifunctional laparoscopic devices Any lapa-

A test to evaluate fallopian tube patency and roscopic instrument that grasps, dissects, coag-
the uterine cavity without radiation exposure ulates, and cut tissue
Hydrosalpinx A fluid-filled, dilated fallopian Next-generation sequencing (NGS) Umbrella

tube caused by distal tubal obstruction, often term, also called high-throughput sequencing,
the result of prior pelvic infection, endome- which describes several modern DNA analy-
triosis, or pelvic adhesions sis techniques which allow for increased speed
and decreased cost of sequencing when com-
Hysterosalpingo-foam sonography (HyFoSy) pared to traditional Sanger sequencing
A test to evaluate fallopian tube patency with-
out radiation exposure Normal Puberty Activation of the hypotha-
lamic–pituitary–gonadal axis results in pul-
Hysterosalpingogram (HSG) Transcervical injec- satile release of GnRH and eventual steroid
tion of contrast media to obtain radiologic hormone production. Normal puberty typi-
images of the uterine cavity and demonstrate cally occurs between 6 and 13 years of age
tubal patency depending on ethnicity
632 Glossary
Oocyte donation A reproductive treatment Proximal tubal occlusion Obstruction of the

where a woman (the oocyte donor) gives her fallopian tube at the uterine cornua associated
eggs to another party (recipient) to allow the with SIN, prior pelvic infection, intratubal
recipient to have a baby. endometriosis, mucus plugging, or anatomic
malformations
Oogenesis The process by which the mature
ovum is differentiated Resectoscopy The use of a monopolar or
bipolar resectoscope.
Ovarian reserve A description of the quantity
and quality of the oocytes left in the ovary Saline infusion sonography (SIS) Ultrasound
procedure whereby saline is infused into the
Palmer’s point A point on the left upper uterus during ultrasound scanning to evaluate
quadrant of the anterior abdominal wall for the uterine cavity
laparoscopic trocar insertion located two-
finger breadth below the costal margin at the Salpingitis isthmica nodosa (SIN) Multiple
midclavicular line nodular diverticula of the proximal endosal-
pinx diagnosed by HSG or histology
PGT-A: preimplantation genetic testing for
aneuploidy Use of molecular genetic testing Sampson’s theory Retrograde menstruum
to determine if an embryo produced through exits through the fallopian tubes into the pel-
IVF has whole chromosomal aneuploidy, is vis, and in some women this could eventually
mosaic, or is missing large portions of DNA lead to the development and establishment of
or whole chromosomes endometriosis
PGT-M: preimplantation genetic testing mono- Scintillation Images seen as a flash or sparkle
genic disorders Use of molecular genetic test- through the fallopian tubes and/or around the
ing to determine if chromosomal disorders ovaries during a HyCoSy procedure if tubal
(single gene disorders) are present in embryos patency is present. Scintillations are a result
produced through IVF of the air-fluid mixture moving through and
exiting the distal fallopian tube
PGT-SR: preimplantation genetic testing for
structural rearrangements Use of molecu- Septate uterus Incomplete fusion of the Mül-
lar genetic testing to determine if a struc- lerian ducts leading to persistence of midline
tural rearrangement such as a translocation tissue in the uterine cavity
or inversion is present in embryos produced
through IVF Single nucleotide polymorphism array (SNP
array) Molecular technique capable of detect-
Fimbrial Phimosis Agglutination of fimbria ing SNPs within a DNA sample utilizing
leading to a narrowed tubal opening array technology
Pinopodes These morphologic structures Sonologist A person performing ultrasound

occur on the apical surface of endometrial scans. This term is used for either a sonogra-
cells. They are bleb-like protrusions into the pher, or a physician, performing the scan
uterine lumen and are found in large numbers
between days 19 and 21 in an idealized 28-day Sonolucency An image during an ultra-
menstrual cycle sound exam that appears black, since it
allows passage of ultrasound waves without
Power morcellation Cutting surgical specimens reflecting them back, also called an anechoic
to small pieces using electric morcellators structure
633
Glossary
Subfertility Reduced fertility over a prolonged Trophectoderm biopsy The removal of five
period of time to ten cells (trophectoderm) from the embryo
when it reaches the blastocyst stage on day 5
Submucous myomectomy Including the or day 6
removal of type 0, I, II, and III myomas, Ash-
erman’s syndrome—the presence of intrauter- Trophoblasts/trophoectoderm The outer layer
ine scar tissue. of blastomeres that eventually give rise to the
placenta. Implantation can be divided into
Targeted amplification The use of highly three stages: apposition, adhesion, and invasion
multiplexed reactions to amplify the DNA
through the genome to allow sequencing at Uterus didelphys Complete lack of fusion of
greater depth to allow assessment of aneu- the Müllerian ducts leading to development
ploidy, mosaicism, or segmental abnormali- of two uteri each with one fallopian tube
ties
Whole genome amplification (WGA) A term
Third- party reproduction The use of oocytes, which encompasses several techniques used to
sperm, or embryos that have been donated by amplify the entire genome, starting with very
a third person (donor) to enable an infertile small amounts of DNA and amplifying it sev-
individual or couple (intended recipient) to eral fold
become a parent (or parents). This also refers
to the use of a gestational carrier. Zona pellucida A glycoprotein structure sur-
rounding the oocyte. There are three major
Transverse vaginal septum Results from ver- glycoproteins that compose the zona pellu-
tical fusion defect leading to persistence of cida and have distinct roles in this structure:
transverse band of tissue in the vaginal which ZP1, ZP2, and ZP3
may be complete or incomplete
635 A
Index
A –– hormonal treatment of anovulatory bleeding

–– oral contraceptives 192
Abdominal metroplasty 454 –– progestin therapy 192
Abdominal wall vessels –– hysterosalpingogram 189
–– prevention 481 –– hysteroscopy 190
–– superficial and deep vessels 480 –– laboratory evaluation
–– treatment 481 –– blood test 188
Abnormal uterine bleeding (AUB) 494 –– for hemostatic disorders 188
–– acquired bleeding disorders 180 –– initial evaluation 187
–– anticoagulant therapy 180 –– urine test 187
–– benign uterine neoplasms –– LNG-IUDs 192, 193
–– adenomyosis 183, 184 –– medical history 187
–– endometrial polyps 183 –– outpatient treatment 191
–– leiomyomas 183 –– ovulation induction 192
–– bimanual pelvic examination 173 –– in ovulatory patients
–– cause 174 –– combination oral contraceptives 193
–– cervical dysplasia 184 –– nonsteroidal anti-inflammatory drugs 194
–– cervicitis 182, 183 –– progestin 193, 194
–– coagulopathies 180 –– tranexamic acid 194
–– contraceptive method 173 –– papanicolaou smear 188
–– definition 174 –– physical examination 187
–– diagnosis and management 173 –– progestin endometrial synchronization 191
–– endocervical polyps 184 –– surgical treatment
–– endometrial atrophy 177 –– endometrial ablation 195
–– endometrial hyperplasia 184 –– hysterectomy 195
–– endometritis 182 –– myomectomy 195
–– estrogen breakthrough bleeding 176, 177 –– of uterine leiomyomas with GnRH analogues 195
–– etiology of 173 –– transvaginal ultrasonography and sonohysterogra-
–– hereditary bleeding disorders 180 phy 189
–– hormone contraceptives 179, 180 Abstinence 563
–– laboratory evaluation 173 Acanthosis nigricans 289
–– menstruation 174 Acrosomal reaction 82, 84, 87–89
–– normal menstrual cycle 174 Adenomyosis 95, 115, 116, 183, 184, 616
–– ovarian malignancies 184, 185 Adhesion barrier lining 583, 584
–– ovulatory dysfunction (See Ovulatory dysfunction) Adhesions 122
–– PALM-COEIN classification 175 AFC, see Antral follicle count (AFC)
–– pelvic inflammatory disease 181 Alzheimer’s disease (AD) 223
–– polycystic ovary syndrome 173 Amenorrhea 153, 154
–– pregnancy –– classification 143–145
–– early pregnancy loss 181 –– history 141
–– ectopic pregnancy 181 –– imaging 142, 143
–– molar pregnancy 181 –– laboratory testing 141, 142
–– vaginal bleeding 180 –– patient history 140
–– viable intrauterine pregnancy 181 –– physical examination 141
–– prevalence 174 –– primary
–– SPIN clarification 175, 176 –– AIS 146, 147
–– vaginal malignancies 185 –– congenital and acquired conditions 143
–– vaginitis 183 –– delayed puberty 146
Abnormal uterine bleeding associated with ovulatory –– gonadal dysgenesis 143
dysfunction (AUB-O) 174 –– hypothalamic/pituitary disorders 146
Abnormal vaginal bleeding (AUB) 557 –– Mullerian agenesis 145, 146
–– characterization 185 –– obstructive genital tract abnormalities 147
–– clinical evaluation 185, 186 –– secondary
–– endometrial biopsy 189 –– acquired disorders 150
–– etiology 185 –– anterior pituitary gland 149
–– exclude pregnancy 185 –– Cushing disease and syndrome 150
–– for hemodynamically unstable patients 190, 191
636 Index
Amenorrhea (cont.) –– assessment 399

–– elevated androgen states 148, 149 –– methods 376
–– hyperprolactinemia 149 –– freeze-only with cryopreserved transfer vs. fresh
–– hypothalamic disorders 147, 148 embryo transfer 384
–– PCOS 148 –– gestational carrier 381
–– pituitary apoplexy 150 –– GnRH agonists 374
–– POI 151, 153 –– GnRH antagonists 375, 376
–– post-contraception amenorrhea 148 –– gonadotrophins 373
–– post-irradiation hypopituitarism 150 –– history 371
–– postpartum pituitary necrosis 149 –– indications 370
–– prolactin-secreting adenomas 149 –– intracytoplasmic sperm injection 398, 399
American Association of Clinical Endocrinologists –– IVF
(AACE) 209, 256 –– outcomes 381, 382
American College of Obstetricians and Gynecologists –– process of 372–379
(ACOG) 175, 209 –– lifestyle and environmental factors 370
American College of Sports Medicine 242 –– laboratory 404
American Society for Reproductive Medicine –– luteal phase hormonal support 377
(ASRM) 268, 447, 448 –– media preparation 404, 405
American Urological Association (AUA) 268 –– microdose, or “flare,” protocols 374, 375
AMH, see Anti-Müllerian hormone (AMH) –– monitoring clinical outcomes
Androgen insensitivity syndrome (AIS) 70, 146, 147 –– blastocyst formation 405
Androgen receptor (AR) gene 70 –– cryo-survival 405
Aneuploidy screening 413, 414 –– day 2 cleavage 405
Anovulation 148, 190, 355 –– day 3 embryo development 405
Anovulatory bleeding 174 –– embryo freezing 405
Anovulatory infertility 355 –– fertilization rates 405
Anti-convulsant medications 566 –– implantation 405
Anti-Müllerian hormone (AMH) 16, 32, 33, 165, 292, –– live birth outcomes 405
306, 324, 326, 328, 331 –– pregnancy rates 406
Antinuclear antibodies (ANA) 345 –– obstetrical complications 382, 383
Anti-osteoporotic drugs 241 –– offspring 383
Antiphospholipid syndrome (APS) 345, 346 –– OHSS 381, 382
Antisperm antibodies (ASA) 273 –– oocyte assessment 395, 396
Antral follicle count (AFC) 164, 292, 306, 324, 326, –– oocyte donation 379
329, 331 –– evaluation of 380
Aromatase inhibitors (AI) 358, 502, 503, 546 –– indications for 379
–– dosage and administration 358 –– optimizing IVF outcomes 372
–– effectiveness 359 –– ovarian reserve testing 371
–– pharmacology and mechanism of action 358 –– ovarian stimulation 372, 373
–– side effects and risks 358 –– ovulation prevention 374
Arterial embolization 191 –– ovulation trigger 376
Artifacts 128 –– physical examination 370
Artificial intelligence 403, 406 –– pregnancy rates versus interventions 378
Asherman’s syndrome (AS) 150, 443, 446, 616 –– pre-implantation genetic testing 384, 385, 402
Assisted hatching 401, 402 –– premature progesterone elevation, IVF cycles 385, 386
Assisted reproductive technologies (ARTs) –– prevalence 369
295, 305, 313 –– risk of cancer in women 382
–– artificial intelligence 403 –– slow-rate freezing 403
–– assisted hatching 401, 402 –– spermatozoa collection 397
–– conventional insemination 398 –– sperm isolation, IVF and ICSI 397, 398
–– cryopreservation 402 –– sperm donation
–– culture conditions 405 –– evaluation of 380
–– cycle timing 373, 374 –– indications for 380
–– embryos –– sperm testing 372
–– assessment 399, 400 –– third party reproduction 379
–– biopsy 402 –– time lapse imaging 401
–– cryopreservation of 378, 379 –– uterine evaluation 371, 372
–– donation 381 –– vitrification 403
–– disposition of 379 Autism spectrum disorders (ASD) 63
–– transfer 377, 378 Autoimmune conditions 305
–– evaluation and processing 397 Autosomal/sex-linked genetic disorders 370
–– fertilization Azoospermia 275
Index
637 A–D
B Complete androgen insensitivity syndrome
(CAIS) 616
Balanced chromosomal translocations 370 Computer-aided semen analysis (CASA) 273
Barker hypothesis 58 Conception strategies 270
Barrier contraceptives Condoms 561, 562
–– cervical cap 562 Congenital absence of uterus and vagina (CAUV) 70
–– condoms 561, 562 Congenital adrenal hyperplasia (CAH) 64, 356
–– diaphragms 562 Congenital galactosemia 70
–– spermicides 562, 563 Congenital malformations 340
Basal estradiol 327 Congenital unilateral absence of the vas deferens
Basal follicle stimulating hormone 327 (CUAVD) 269
Basal FSH plus estradiol levels 324 Congenital uterine abnormalities 340
Basic multicellular units (BMUs) 239 Congenital uterine malformations 340
Beta-hCG 525, 526 Conscious sedation 437, 438
Bicornuate uterus 588 Contraception
Biochemical markers 324 –– barrier contraceptives
Bipolar electrosurgery 466 –– cervical cap 562
Bisphosphonate 241 –– condoms 561, 562
Bladder injuries –– diaphragms 562
–– full thickness 484 –– spermicides 562, 563
–– prevention 484 –– behavioral methods 563
–– recognition 484 –– counseling patients 567
–– treatment 485 –– delayed childbearing 554
Blastocyst-stage embryo grading system 400 –– emergency contraception 556, 563, 564
Blastomere biopsy 416 –– LARC 556–558
Bone marrow derivative cells (BMDC) 96 –– medical considerations
Bone morphogenetic proteins (BMPs) 33 –– hormonal contraceptives 564, 566
Bowel vaginoplasty 584 –– IUDs 566, 567
Buccal mucosa 584 –– MEC 564
–– modern contraceptives 554
–– permanent methods
C –– female sterilization 555
Centers for Disease Control and Prevention –– male sterilization 556
(CDC) 283 –– short-acting reversible methods (See Short-acting
Central precocious puberty (CPP) 63 reversible methods)
Cervical agenesis 585 –– in U.S. 554
Cervical cancer 311 Contraceptive vaginal ring (CVR) 559, 560
Cervical cap 562 Conventional insemination 398
Cervical dysplasia 184 Copper-bearing IUDs (Cu-IUDs) 557
Cervical incompetence 341 Corona radiata 30
Cervicitis 182, 183 Corpus luteum 4, 9, 15
Chemotherapy 305–307 Corticosteroids 362
Chemotherapy-induced gonadotoxicity 306 Corticotropin-releasing hormone (CRH) 150
Chronic fatigue syndrome 539 COVID19 622, 623
Chronological age 326 Cryomyolysis 507, 508
c-Kit 34 Cryopreservation 315, 402
Cleavage-stage embryo single-step grading system 399 Cryptospermia 267
Cleavage-stage embryo two-step grading system 400 Culture medium 404
Climacteric 205 Cumulus cell (CC)/granulosa cell (GC)
Clomiphene citrate metabolism 86
–– dosage and administration 359 Cumulus oocyte complexes (COCs) 35
–– effectiveness 360 Cushing’s syndrome 148, 289
–– pharmacology and mechanism of action 359 Cycle timing 373, 374
–– side effects and risks 360 Cystic fibrosis 269
Clomiphene citrate challenge test (CCCT) 292, 293, 329 Cytochrome P450 system 566
Coitus interruptus 563 Cytogenetic abnormalities 341
Combined hormonal contraceptives (CHCs) Cytoplasmic droplet 43
–– acne and hirsutism 558
–– COCs 558, 559
–– CVR 559, 560
D
–– TDS 559 da Vinci system 473, 474
Combined oral contraceptive pill (COC) 558, 559 Deceased donors (DD) 617, 618
638 Index
Decreased ovarian reserve (DOR) 326–328, –– transfer 377, 378

330, 331 Emergency contraception (EC) 556, 563, 564
Delayed puberty End stage renal disease (ESRD) 269
–– definition 146 Endocervical polyps 184
–– evaluation 70, 71 Endometrial ablation 195, 444
–– flowchart 68 –– first-generation hysteroscopy 444
–– hypergonadotropic hypogonadism 68, 69 –– second-generation hysteroscopy 446
–– hypogonadotropic hypogonadism 69 Endometrial atrophy 177
–– imaging 71 Endometrial cancer 163, 311
–– primary amenorrhea 69, 70 Endometrial hyperplasia 184
–– treatment 72, 73 Endometrial polyps 183
Denosumab (Prolia®) 255 Endometrial receptivity 102
Depo medroxyprogesterone (Depo-Provera) 148 –– anatomic changes 95, 96
Depo medroxyprogesterone acetate (DMPA) 560, 561 –– stem cells 96
Dermoid cysts 120 –– window of implantation 95
Diabetes mellitus (DM) 162 Endometriomas 120, 544
Diaphragms 562 Endometriosis
Diminished ovarian reserve (DOR) 344, 345 –– anatomic sites 539
Direct trocar insertion 463, 464, 479 –– associated disease processes 539
Discriminatory zone 526 –– chronic pelvic pain
Distal tubal disease 522, 523 –– aromatase inhibitors 546
Dominant follicle 3, 14 –– GnRH agonists 546
Donor insemination 380 –– GnRH antagonist 546
Dopamine agonists 362 –– hysterectomy 547
DOR, see Decreased ovarian reserve (DOR) –– medical management 544, 545
Drug holiday 257 –– neurectomy 547
Dual x-ray absorptiometry (DXA) 246 –– posthysterectomy recurrence 547
Dysfunctional uterine bleeding (DUB) 174 –– progestins 544, 545
–– retrocervical septum endometriosis 547
–– surgical management 546, 547
–– classification 539, 540
E –– deep endometriosis 540
Early menopause 205 –– definition 537
Early pregnancy loss 181 –– diagnosis 537–539
Eating disorders 242 –– endometriomas 544
Ectopic pregnancy 181, 469 –– endometriosison extragenital organs
–– definition 524 –– gastrointestinal endometriosis 547
–– expectant management 530 –– genitourinary system 548
–– heterotopic pregnancy 525 –– respiratory system 548
–– incidence 525 –– sciatic nerve involvement 548
–– medical management 526–529 –– extrapelvic endometriosis 541
–– presentation and diagnosis 525–527 –– infertile couple 543
–– risk factors 525 –– IVF 543, 544
–– surgical management 528, 530 –– mechanism of infertility 542
Elagolix 546 –– mechanism of pain 543
Electrocoagulation 466 –– ovarian endometriosis 540
Embryonic aneuploidy rate 423 –– pathophysiology 541, 542
Embryo(s) –– predisposing factors 541
–– assessment –– prevalence 537
–– blastocyst-stage embryo grading system 400 –– surgical treatment 543
–– cleavage-stage embryo single-step grading Endometriosis lesions 469
system 399 Endometriosison extragenital organs
–– cleavage-stage embryo two-step grading sys- –– gastrointestinal endometriosis 547
tem 400 –– genitourinary system 548
–– biopsy 402 –– respiratory system 548
–– cryopreservation 313, 314, 378, 379 –– sciatic nerve involvement 548
–– disposition of 379 Endometritis 182
–– donation 381 Endometrium 113, 122, 123
–– ethical aspects 607 Endomyometrial resection 444
–– patient history 607 Enzyme-linked immunosorbent assay (ELISA) test 215
–– practical aspects 607 Ephemeral transplant 615
Index
639 D–F
Estradiol 327 –– treatment
Estrogen breakthrough bleeding 176, 177 –– ART 295
Estrogen monotherapy 218 –– childfree living 296
Estrogen receptor agonist/antagonists (ERAAS) 252 –– donor gametes 295, 296
Ethinyl estradiol (EE) 558 –– IUI 295
Etonogestrel (ENG) 557 –– oral medications 294
Eugonadotropic euestrogenic anovulation 356 –– ovarian stimulation 294, 295
European Association of Urology (EAU) 268 –– vitamin D insufficiency 285
European Society of Human Reproduction and Female sterilization 555
Embryology (ESHRE) guidelines 214 Fertility awareness methods (FAM) 563
ExAblate system 506 Fertility preservation
Excessive bleeding 180 –– anti-Müllerian hormone 306
–– antral follicle count 306
–– assisted reproductive technology 305, 313
F –– cancer patients 305
–– cervical cancer 311
Female athlete triad 242, 243 –– chemotherapy and ovarian damage 306–307
Female infertility –– cryopreservation of ovarian tissue 315
–– causes of 284 –– day 3 FSH and estradiol 306
–– definition 283 –– elective/social 305
–– diagnostic criteria 283 –– embryo cryopreservation 313, 314
–– diagnostic testing –– endometrial cancer 311
–– ovarian reserve testing 292, 293 –– gonadal damage
–– ovulatory function 291, 292 –– markers 308
–– preconception screening 290 –– risk factors 307, 308
–– prolactin 291 –– gonadotropin-releasing hormone agonists 312, 313
–– TSH 291 –– in vitro maturation 316
–– endometriosis 284, 285 –– letrozole 315
–– evaluation vs. international protocols 296–298 –– oocyte cryopreservation 314
–– HSG 293 –– ovarian cancer 311
–– hypothyroidism 285 –– ovarian damage, risk factors 308, 309
–– hysteroscopy 293 –– ovarian transposition 311, 312
–– initial evaluation, infertile couple 286 –– patient population 306
–– abdomen, adipose tissue distribution 289 –– premature ovarian failure 307
–– anatomical abnormalities 289 –– quality of life after cancer 305
–– bimanual examination 290 –– radiation therapy
–– BMI 288, 289 –– pregnancy after 309
–– breast examination 289 –– and ovarian damage 308
–– cervix examination 290 –– and uterine damage 309
–– demographics 286 –– strategies 309, 310
–– endocrine pathology 289 –– surgical techniques 311
–– environmental exposures 287 –– tamoxifen 315
–– family history 287 –– unconventional stimulations protocols 315
–– gynecological history 286 –– whole ovary cryopreservation 316
–– headaches 288 Fertility-enhancing procedures 469
–– LGBTQ+ patients 288 Fertilization
–– medical history 286 –– assessment 399
–– obstetrical history 286 –– clinical relevance 101, 102
–– social history 287 –– cortical reaction 89
–– surgical history 287 –– cytokines 98
–– thyroid hormone disorders 289 –– early embryonic development 91, 92
–– visual impairment 288 –– endometrial receptivity 102
–– vital signs 288 –– anatomic changes 95, 96
–– laparoscopy 293, 294 –– stem cells 96
–– male factor 283 –– window of implantation 95
–– ovulatory dysfunction 283, 284 –– genomic union 91
–– pelvic and tubal adhesions 285 –– HOX genes 99, 100
–– primary infertility 283 –– implantation 94, 95
–– secondary infertility 283 –– integrins 97
–– sonohysterography 293 –– interleukins 98, 99
–– transvaginal ultrasonography 293 –– LIFR 98
640 Index
Fertilization (cont.) –– agonists 64–66, 312, 313, 374, 500, 501, 546
–– male pronucleus formation 91 –– antagonists 375, 376
–– methods 376 Gonadotropins 373
–– mucins 97, 98 –– dosage and administration 361
–– oocyte activation 90, 91 –– effectiveness 361
–– pinopodes 96 –– pharmacology and mechanism of action 360
–– prostaglandins 99 –– side effects and risks 361
–– receptive endometrium 102 Granulosa cell 29, 30, 49, 184
–– selectins 96, 97 Growth differentiation factor-9 (GDF-9) 33, 86
–– sperm penetration Growth hormone-releasing hormone (GHRH) 18
–– cumulus oophorus 87 –– activins and inhibins 16
–– zona pellucida 88, 89 –– agonists and antagonists 11, 12
–– sperm-oocyte membrane fusion 89, 90 –– AMH 16
–– trophoblastic development and invasion 92–94 –– follicular phase 13, 14
–– trophoblast–leukocyte interactions 100, 101 –– follistatin 16
FertiQoL 266 –– gonadotropins structure 12
Fimbrial phimosis 522 –– kisspeptin 17
Fluorescent in situ hybridization (FISH) 412–414 –– leptin 16
Foetal karyotyping 342 –– luteal phase 3, 14–16
Foley catheter 595 –– opioids 17
Follicles 28–30 –– overview 10, 11
Follicle-stimulating hormone (FSH) 145, 292, 324, –– pulsatility 12
326–330 –– sex steroids 12–14
Folliculogenesis 32 Gynecologic laparoscopy
Fracture risk calculator tools 248 –– abdominal wall vessels
FRAX® calculation 248 –– prevention 481
Functional hypothalamic amenorrhea (FHA) 356 –– superficial and deep vessels 480
–– treatment 481
–– bladder injuries
–– full thickness 484
G –– prevention 484
Garvan fracture prediction tool 249 –– recognition 484
Gastrointestinal endometriosis 547 –– treatment 485
Gastrointestinal injury –– clinical applications 476, 477
–– prevention 482 –– complications 478
–– risk of 481 –– diagnostic laparoscopy 467, 468
–– Veress needle injuries 482 –– ectopic pregnancy treatment 469
Gender dysphoria 73 –– excision and fulguration of endometriosis 469
Genetic counselling 342 –– gastrointestinal injury
Genetic evaluation 342 –– prevention 482
Genetic predisposition disorders 413 –– risk of 481
Genitourinary syndrome of menopause (GSM) 214 –– Veress needle injuries 482
–– local hormone therapy 225 –– history 462
–– non-hormonal treatment options 227 –– hysterectomy
–– vaginal DHEA 226 –– laparoscopic hysterectomy 471
–– vaginal estrogen 226 –– LAVH 471
Genitourinary system 548 –– supracervical hysterectomy 471, 472
Germ cell 26, 27 –– large intestine injury 483
Germ stem cells (GSCs) 26 –– lysis of adhesion and tubal reconstructive sur-
Gestational carrier (GC) 381, 608, 609 gery 468, 469
Gestational surrogacy –– minimally invasive surgery 461
–– ethical aspects 609 –– multifunctional laparoscopic instruments 466, 467
–– patient history 608 –– myomectomy 470
–– practical aspects 608, 609 –– oncologic procedures 473
Glial cell line-derived neurotrophic factor (GDNF) 46 –– oncology 473
GNRH, see Gonadotropin releasing hormone (GnRH) –– ovarian cystectomy and oophorectomy 469
Gonadal damage –– patient history 461
–– markers 308 –– pelvic pain 470
–– risk factors 307, 308 –– port-site hernia 483, 484
Gonadal dysgenesis 143 –– power morcellation 472, 473
Gonadotoxic therapy/pelvic irradiation 324 –– primary trocar placement
Gonadotropin releasing hormone (GnRH) 49, 57, 58 –– approaches 462
Index
641 F–I
–– direct trocar insertion 463, 464 Hypothalamic amenorrhea 241, 242
–– LUQ 464, 465 Hypothalamic suppression 64–66
–– open laparoscopy 464 Hypothalamic/pituitary disorders 146
–– standard closed technique 462, 463 Hypothalamic–pituitary–gonadal (HPG) axis 57
–– removal of ports and port-site closure 466 Hypothalamic-pituitary-ovarian (HPO) axis, see
–– retroperitoneal vessel injury 478 Menstrual cycle
–– alternative primary trocars 480 Hypothyroidism 343
–– direct trocar insertion 479 Hypotonic nonelectrolyte-containing fluids 434
–– high-pressure entry 478, 479 Hysterectomy 195
–– LUQ 479, 480 Hystero-salpingo contrast sonography (HyCoSy)
–– open laparoscopy 479 –– indications and scanning techniques 123, 125
–– patient’s position 478 –– limitations 126
–– prevention 478 –– technical considerations 125, 126
–– treatment 480 Hystero-salpingo foam sonography (HyFoSy)
–– Veress needle location 479 –– indications and scanning techniques
–– robotic gynecologic surgery 474 123, 125
–– robotically assisted laparoscopic surgery 473, 474 –– limitations 126
–– robotically assisted myomectomy 475, 476 –– technical considerations 125, 126
–– robotically assisted resection of endometriosis 476 Hysterosalpingogram (HSG) 293, 372, 499
–– robotically assisted tubal reanastomosis 475 –– contraindications 518, 519
–– secondary ports 465, 466 –– indications 126, 127, 133, 518
–– single-port laparoscopy 477, 478 –– limitations 129
–– small intestine injury 482, 483 –– PTO 521
–– stomach injury 482 –– risks and benefits 518, 519
–– tubal sterilization 468 –– technical considerations 127–129
–– ureter injuries 485 –– technical quality 519
–– tubal abnormalities 519, 520
–– uterine cavity abnormalities 519
H Hysteroscopic adhesiolysis 340, 450
Hysteroscopic hardware
Hanging drop test 463 –– carbon dioxide 434
Headaches 288 –– complications 435
Heavy menstrual bleeding 174 –– conscious sedation 437, 438
Hematological disorders 305 –– dextran 70 434
Hemoglobin A1c (HbA1c) 162 –– diagnostic hysteroscopy 434, 435
Hereditary thrombophilia 346 –– distention media 433
Heterotopic pregnancy 525 –– equipment 436
High-dose dexamethasone suppression test (HD- –– low-viscosity fluids 434
DST) 150 –– NSAIDs 437
High-pressure entry 478, 479 –– office hysteroscopy 435
Hip fractures 238 –– operative hysteroscopy 435
Hirsutism 164, 166, 289 –– pain management 436
Home fertility tests 329 –– paracervical block 437
Homeobox (HOX) genes 99, 100 –– patient selection 438
Hormonal contraceptives 564, 566 –– technique 436
Hormonal IUDs 557 –– topical analgesia 437
Hormone contraceptives 179, 180 –– types 433
Hormone replacement therapy (HRT) 218 Hysteroscopic metroplasty 453
Human chorionic gonadotropin (hCG) 316 Hysteroscopic myomectomy 440, 444
Human lymphocyte antigen (HLA) matching 413 Hysteroscopic polypectomy 439
Hydatidiform mole 181 Hysteroscopy 190, 448, 449
Hydrosalpinges 522
Hydrosalpinx 121, 122, 523, 524
Hyperandrogenism 160, 163, 164
Hypergonadotropic hypogonadism 68, 69
I
Hyperprolactinemia 149, 284, 344 Iatrogenic menopause 205
Hyperprolactinemic anovulation 357 In vitro fertilization (IVF) 81, 167–168, 325, 370, 524,
Hyperthyroidism 344 543, 544
Hypoestrogenemia 179 In vitro maturation (IVM) 35, 316
Hypogonadism 68, 179, 268, 269 Inferior uterine veins 620
Hypogonadotropic hypogonadism (HA) Infertility 101, 102, 162, 163
69, 356 Inhibin B 328, 329
642 Index
Insulin resistance (IR) 161, 162 –– surgical treatment

Insulin-like growth factor (IGF1) 46 –– complications 449
Intended parents (IPs) 608 –– hysteroscopy 448, 449
Intermenstrual bleeding 174 –– outcomes 449, 450
International Federation of Gynaecology and –– postoperative adjunctive therapy 449
Obstetrics (FIGO) 174 –– uterine septum
International Society for Clinical Densitometry –– classification systems 451
(ISCD) 247 –– diagnosis 452
Interstitial cystitis 539 –– etiology 450, 451
Intracytoplasmic sperm injection (ICSI) 383, 398, 399 –– hysterosalpingogram 452
Intramural myomas 494 –– incidence 451
Intrauterine adhesions 340 –– magnetic resonance imaging 452
Intrauterine devices (IUDs) –– pathogenesis of pregnancy complications 451
–– LARC 556, 557 –– surgical treatment 453–455
–– pregnancy 566, 567 –– ultrasonography 452
Intrauterine disorders Intrauterine insemination (IUI) 277, 295, 326, 602, 603
–– American Society for Reproductive Medicine Intrauterine masses 341
Classification 447, 448 Isotonic electrolyte-containing fluids 434
–– clinical manifestations 447 IVF outcomes 381, 382
–– complications
–– bleeding 439
–– classification 440 K
–– endometrial ablation 444, 446
Kallman syndrome 270
–– first-generation hysteroscopy 444
Key performance indicators (KPIs) 404
–– second-generation hysteroscopy 446
Kit Ligand (KL) 34, 46
–– fertility preservation 443
Klinefelter syndrome 269
–– fluid intravasation 438
KNDy neurons 17
–– hysteroscopic myomectomy 440, 444
–– hysteroscopic polypectomy 439
–– hysteroscopic resection of adhesions 446
–– intraoperative ultrasonography 443
L
–– morcellators 442, 443 Lactotroph tumors 149
–– pathophysiology 447 Laparoscopic hysterectomy (LH) 471
–– perforation 439 Laparoscopic ovarian drilling/wedge resection 362, 363
–– resectoscope 442 Laparoscopic presacral neurectomy (LPSN) 470
–– rollerball and endomyometrial resection 445 Laparoscopic uterosacral nerve ablation (LUNA) 470
–– surgical approach 440, 442 Laparoscopic-assisted vaginal hysterectomy
–– technique 440 (LAVH) 471
–– vasopressin 445 Large intestine injury 483
–– vasovagal reaction 439 Late menopause 205
–– hysteroscopic hardware Left upper quadrant (LUQ) Technique 464, 465, 479,
–– carbon dioxide 434 480
–– complications 435 Leiomyomas 95, 96, 183, 495
–– conscious sedation 437, 438 Letrozole 315
–– dextran 70 434 Leukemia inhibitory factor (LIF) 46
–– diagnostic hysteroscopy 434, 435 Leukocytospermia assessment 273
–– distention media 433 Levonorgestrel 564
–– equipment 436 Levonorgestrel-releasing intrauterine devices (LNG-
–– low-viscosity fluids 434 IUDs) 192, 193, 557
–– NSAIDs 437 Leydig cells 36, 37
–– office hysteroscopy 435 LGBTQ+ population 288
–– operative hysteroscopy 435 LIF receptor (LIFR) 98
–– pain management 436 Liver hemangioma 468
–– paracervical block 437 Living donors (LD) 616–618
–– patient selection 438 Long-acting reversible contraceptive (LARC) meth-
–– technique 436 ods 556–558
–– topical analgesia 437 Longitudinal vaginal septum 590
–– types 433 –– non-obstructing 590, 591
–– hysteroscopy 448 –– obstructing 591, 592
–– March classification system 447 Loss of consciousness (LOC) 150
–– sonohysterogram 448 Lupus 305
Index
643 I–M
Luteal phase deficiency 342, 343 Mammalian spermatogenesis 266
Luteal phase hormonal support 377 March classification system 447
Luteinizing hormone (LH) 28, 36, 602 Mayer–Rokitanksy–Kuster–Hauser (MRKH)
Lysis of adhesion 468, 469 syndrome 69, 145, 146, 608, 616
McCune-Albright syndrome 67
Mechanical index (MI) 113
Meiosis 40, 42
M Menarche 204
Magnetic resonance imaging (MRI) Menopause
–– indications 129–132 –– age of 203
–– limitations 133 –– Alzheimer’s disease 223
–– technical considerations 132, 133 –– breast cancer 223
Male gametogenesis, see Spermatogenesis –– cardiovascular disease 223, 224
Male infertility –– climacteric 205
–– antisperm antibodies 273 –– clinical history 215, 217
–– asthenospermic 268 –– diagnosis of 214, 228
–– basic semen analysis 268 –– early menopause 205
–– capacitation assays 273 –– estrogens, physiological effects 208, 228
–– cryptospermia 267 –– adipose tissue 209
–– cystic fibrosis 269 –– bone 209
–– diagnosis and management 266, 268 –– bowel 210
–– diagnostic testicular biopsy 275 –– breast tissue 208
–– DNA fragmentation 273 –– cardiovascular system 208, 209
–– ESRD 269 –– central nervous system 208
–– history 269, 270 –– eyes 211
–– hormonal axis aberrations 268 –– hair 210
–– HPG axis manipulation –– liver 209, 210
–– for for idiopathic subfertility 275 –– pelvic floor 211
–– for hypogonadism 274, 275 –– pulmonary system 210
–– for hypogonadotropic hypogonadism 275 –– skin 210
–– imaging 274 –– urinary tract 211, 213
–– infertility and hypogonadism 268, 269 –– vulvovaginal tissue 211, 212
–– intrauterine insemination 277 –– general counseling and recommendations 217
–– Klinefelter syndrome 269 –– genitourinary syndrome of menopause (GSM) 214
–– laboratory workup –– local hormone therapy 225
–– bloodwork 274 –– non-hormonal treatment options 227
–– genetic evaluation 274 –– vaginal DHEA 226
–– leukocytospermia assessment 273 –– vaginal estrogen 226
–– medical management 266, 274 –– hormone changes 216
–– mental health deterioration 267 –– hormone therapy
–– non-obstructive etiologies 267 –– combined therapy 222
–– OAT 268 –– contraindications 219
–– obstructive etiologies 267 –– estrogen therapy formulations 219
–– oxidative stress 273 –– estrogen monotherapy 218
–– physical examination 270, 272 –– hormone replacement therapy 218
–– pituitary masses 269 –– indications for 218
–– prevalence 267 –– oral estrogens 220
–– primary male infertility 267 –– oral vs. transdermal hormone therapy 220
–– psychological impact 266–267 –– perimenopause 217, 218
–– psychosocial effects 266 –– progestogen therapy 221
–– semen analysis 272, 273 –– transdermal estrogen + progestogen therapy 222
–– semen concentration 267 –– transdermal estrogens 221
–– surgical management 275 –– impacts of 204
–– surgical sperm retrieval 276 –– induced menopause 205
–– symptoms 267 –– late menopause 205
–– teratospermic 268 –– menarche 204
–– undescended testicles/hernia repair 266 –– menopause transition 205–207
–– varicocelectomy 275 –– morbidity 203
–– vasectomy reversal 276 –– mortality data 224
–– viability testing 273 –– natural menopause 205
Male sterilization 556 –– non-hormonal therapeutic options
644 Index
Menopause (cont.) –– associated anomalies 577

–– herbal remedies 225 –– bicornuate uterus 588
–– neurokinin 3 receptor antagonists 225 –– bowel vaginoplasty 584
–– non-hormonal pharmacologic therapy –– buccal mucosa 584
options 225 –– cervical agenesis 585
–– peri and menopausal symptoms 214, 215 –– classification 576, 577
–– perimenopause 204 –– clinical presentation 577
–– physical examination 215–217 –– Davydov procedure 583
–– POI 204, 207, 208 –– diagnosis 578–580, 586
–– postmenopause 205 –– etiology 578
–– premenopause 204–206 –– female congenital anomalies 576
–– risk factor 203 –– longitudinal vaginal septum
–– symptoms 204 –– definition 590
–– systemic hormone therapy 228 –– non-obstruction 590, 591
–– unregulated hormone therapy 224 –– obstruction 591, 592
–– vasomotor symptoms 211, 212 –– management
–– venous thromboembolism 223 –– pain control 586
–– Women’s Health Initiative 219, 223 –– surgical approach 587
Menopause transition (MT) 205–207 –– uterine fusion defects 587
Menorrhagia 174 –– McIndoe procedure 580–583
Menstrual cycle 326 –– muscle and skin flap 584
–– early luteal phase 3, 4 –– obstructed rudimentary uterine bulbs 584, 585
–– endometrium 17 –– patient history 576
–– follicular (proliferative) phase 3 –– rudimentary horn 588–590
–– GnRH 18 –– septate uterus 587, 588
–– activins and inhibins 16 –– Strassman metroplasty 588, 589
–– agonists and antagonists 11, 12 –– surgical technique 585
–– AMH 16 –– symptoms 593–595
–– follicular phase 13, 14 –– tissue engineering 584
–– follistatin 16 –– transverse vaginal septum 593
–– gonadotropins structure 12 –– unicornuate uterus 588–590
–– kisspeptin 17 –– vaginoplasty techniques 580
–– leptin 16 –– Vecchietti procedure 580
–– luteal phase 3, 14–16 –– z-plasty technique 595
–– opioids 17 Multiple annealing and looping based amplification
–– overview 10, 11 cycles (MALBAC) 414
–– pulsatility 12 Multiple sclerosis 305
–– sex steroids 12–14 Mycoplasma species 518
–– hypothalamus 5, 6 Myomectomy 470
–– infundibulopelvic ligament 18
–– mid to late luteal phase 4, 5
–– ovaries 8, 9 N
–– pituitary gland 5–8
Natural family planning (NFP) 563
–– reproductive hormones 2, 3
Natural killer T (NKT) cells 101
–– uterus 9, 10
Natural menopause 205
Menstruation 174
Negative predictive value (NPV) 326
Metabolic problems 162, 168
Neovagina 579, 580
Metabolic syndrome 162
Neurokinin 3 receptor (NK3R) antagonists 225
Methotrexate (MTX) 526–529
Neuropeptide Y (NPY) 58
Metrorrhagia 174
Next-generation sequencing 414
Microdose, or “flare,” protocols 374, 375
Non classical (late onset) congenital adrenal hyperpla-
Microsurgical epididymal sperm aspiration
sia (NCCAH) 362
(MESA) 276
Nonsteroidal anti-inflammatory drugs
Mitochondrial replacement therapy (MRT) 609
(NSAIDs) 437
Mitosis 40
Norethindrone acetate (NETA) 545
Molar pregnancy 181
North American Menopause Society (NAMS) 209
Morcellators 442, 443
M-phase promoting factor (MPF) 31, 32
Mullerian agenesis 145, 146
Mullerian anomalies 115, 117
O
Müllerian ducts Obesity 162
–– adhesion barrier lining 583, 584 Obstetrician-gynecologists 324
Index
645 M–O
Obstructed rudimentary uterine bulbs –– anabolic agents 255
584, 585 –– anabolic treatments 259
OHSS, see Ovarian hyperstimulation is ovarian –– bisphosphonates 252, 255
hyperstimulation syndrome (OHSS) –– combination therapy 256
Oil-soluble media (OSM) 520 –– cost-effectiveness of FDA-approved osteoporosis
Oligoasthenoteratozoospermia (OAT) 268 treatments 253–254
Oligo-ovulation 160 –– estrogen receptor agonist/antagonist 252
Oocyte assessment 395, 396 –– estrogen therapy 250, 252
Oocyte cryopreservation (OC) 34, 314 –– hormonal replacement therapy 259
Oocyte development –– nonpharmacologic modalities 249, 250
–– early follicular development 85, 86 –– oral raloxifene 259
–– late follicular development 86, 87 –– pharmacologic therapies 250, 251
–– oocyte–CC interaction 86 –– PTH analogs, teriparatide and abaloparatide 255
Oocyte donation 379 –– Romosozumab (Evenity®) 256
–– ethical aspects 606, 607 Ovarian cancer 311
–– evaluation of 380 Ovarian cystectomy 469
–– indications for 379 Ovarian damage 306–307
–– patient history 604 –– radiation therapy and 308
–– practical aspects 604–606 –– risk factors 308, 309
Oocyte-secreted factors (OSF) 86 Ovarian endometriosis 540
Oogenesis Ovarian hyperstimulation is ovarian hyperstimulation
–– activin and inhibin 33 syndrome (OHSS) 328, 381, 382
–– AMH 33 Ovarian malignancies 184, 185
–– BMPs 33 Ovarian reserve testing 371
–– cAMP 31 –– antral follicle count and ovarian volume 324
–– challenges 34, 35 –– application 326
–– c-Kit and KL 34 –– biochemical markers 324
–– clinical history 25 –– AMH 328
–– fertilization 49 –– basal estradiol 327
–– follicle development 28–30 –– basal follicle stimulating hormone 327
–– folliculogenesis 31, 32 –– CCCT 329
–– GDF-9 33 –– home fertility tests 329
–– meiosis and ovulation 30, 31 –– inhibin B 328, 329
–– oocyte development and meiosis 27, 28 –– chronological age 326
–– oocyte growth 30 –– counseling and planning process 325
–– ovary structure 25, 26 –– evaluation of 305
–– overview 26, 27 –– gonadotoxic therapy/pelvic irradiation 324
–– TGF-β 31 –– infertility 326
Oogonia 32 –– intrauterine insemination 326
Oophorectomy 469 –– obstetrician-gynecologists 324
Oral contraceptive pills (OCPs) 148, 373, 374 –– oocyte quantity and quality 325
Osteoblasts 239 –– oocytes 325
Osteoclasts 239 –– principles of screening tests 326
Osteoporosis –– quantity and quality of oocytes 324
–– bone mineral density 237 –– risk factors 325
–– clinical symptoms 244, 246 –– shortened menstrual cycle 326
–– diagnostic criteria 246–249, 259 –– ultrasound evaluation
–– drug holiday 257 –– antral follicle count 329
–– epidemiology 238 –– combined ovarian reserve tests 330
–– female athlete triad 242, 243 –– ovarian volume 330
–– hormonal therapy 258 –– repetitive testing 330
–– hypothalamic amenorrhea 241, 242 Ovarian stimulation 372, 373
–– medication cost 258 Ovarian tissue cryopreservation (OTC)
–– medications 244 34, 35, 315
–– menopause transition 240, 241 Ovarian transposition 311, 312
–– monitoring bone health 256, 257 Ovarian volume 330
–– pathophysiology 239, 240 Ovarian-adnexal reporting and data system
–– premenopausal and bone health 241 (O-RADS) 121
–– primary osteoporosis 243 Overweight 167
–– risk factors 243 Ovulation 2–4, 14, 30, 31, 86
–– secondary osteoporosis 243–246 Ovulation induction (OI) 167
–– treatment Ovulation prevention 374
646 Index
Ovulation trigger 376 –– history 163, 164

Ovulatory disorders –– incidence 159
–– aromatase inhibitors 358 –– infertility 162, 163
–– dosage and administration 358 –– insulin resistance 161, 162
–– effectiveness 359 –– laboratory evaluation 161
–– pharmacology and mechanism of action 358 –– amenorrhea 165
–– side effects and risks 358 –– AMH 165
–– clomiphene citrate –– androgens 164, 165
–– dosage and administration 359 –– Cushing syndrome 165
–– effectiveness 360 –– oligomenorrhea 165
–– pharmacology and mechanism of action 359 –– management
–– side effects and risks 360 –– periodic testing 166
–– corticosteroids 362 –– treatment 166–168
–– diagnosis of 355 –– metabolic syndrome 162
–– dopamine agonists 362 –– obesity 162
–– gonadotropins –– pathophysiology 161
–– dosage and administration 361 –– patient history 159
–– effectiveness 361 –– pelvic ultrasound 164
–– pharmacology and mechanism of action 360 –– physical examination 164
–– side effects and risks 361 –– prevalence 159
–– hyperprolactinemic anovulation 357 Polyostotic fibrous dysplasia 67
–– hypogonadotropic hypogonadism 356 Polyps 114, 123, 440
–– insulin sensitizing agents 362 Polyspermy 102
–– laparoscopic ovarian drilling or wedge resection 362, Port-site hernia 483, 484
363 Positive predictive value (PPV) 326
–– lifestyle modifications 357, 358 Postmenopause 205
–– polycystic ovary syndrome 356 Postnuclear cap 45
–– primary ovarian insufficiency 356, 357 Postoperative adjunctive therapy 449
–– pulsatile GnRH agonists 362 Postpartum pituitary necrosis 149
–– treatment options 357 Power morcellation 472, 473
Ovulatory dysfunction 175 PPV, see Positive predictive value (PPV)
–– hypogonadism 179 Pre-antral follicles 85
–– PCOS 177, 178 Precocious puberty
–– on adult height 63
–– autonomous ovarian estrogen production 66, 67
–– causes 62
P –– CPP 63
PALM-COEIN classification system 175 –– delayed puberty
Parental chromosomal disorders 342 –– evaluation 70, 71
Passive smoke exposure 370 –– flowchart 68
Patient centered care 567 –– hypergonadotropic hypogonadism 68, 69
Peak bone mass (PBM) 239 –– hypogonadotropic hypogonadism 69
Pelvic and tubal adhesions 285 –– imaging 71
Pelvic inflammatory disease (PID) 181 –– patient history 73
Pelvic pain 470 –– primary amenorrhea 69, 70
Pelvic radiation 616 –– treatment 72, 73
Percutaneous epididymal sperm aspiration (PESA) 276 –– environmental factors 63
Perimenopause 204 –– hypothalamic suppression 64–66
Perrault syndrome 70 –– imaging studies 64, 65
PGT-A, see Preimplantation genetic testing for –– laboratory findings 63, 64
aneuploidy (PGT-A) –– McCune-Albright syndrome 67
PGT-M, see Preimplantation genetic testing for –– neurobehavioural factors 63
monogenic conditions (PGT-M) –– patient history 74
Phosphodiesterases (PDEs) 31 –– premature adrenarche 67
Pituitary masses 269 –– premature thelarche 67
Polar body (PB) analysis 416 –– recombinant growth hormone 66
Polycystic ovary syndrome (PCOS) 148, 168, 177, 178, –– treatment 64, 67
284, 289, 328, 337, 343, 356 Preeclampsia 622
–– diabetes mellitus 162 Pregnancy-induced osteoporosis 241
–– diagnosis 159–161, 163 Preimplantation genetic diagnosis 411
–– endometrial cancer 163 Preimplantation genetic screening 411
Index
647 O–R
Preimplantation genetic testing (PGT) 378, 384, 385, –– McCune-Albright syndrome 67
402 –– neurobehavioural factors 63
–– aneuploidy screening 413, 414 –– premature adrenarche 67
–– blastomere biopsy 416 –– premature thelarche 67
–– developmental stages 415 –– recombinant growth hormone 66
–– factors 415 –– treatment 64, 67
–– HLA matching 413 –– sexual development characteristics 59, 60
–– human embryos –– thelarche 60
–– genetic predisposition disorders 413 Pulsatile GnRH agonists 362
–– sex-linked diseases 412
–– single gene diseases 412
–– translocations 412, 413
–– PGT-A 420–422
R
–– PGT-M Radiation therapy 309
–– alternative strategies 420 –– and ovarian damage 308
–– single gene defect 419, 420 –– pregnancy after 309
–– polar body analysis 416 –– and uterine damage 309
–– trophectoderm biopsy 418, 419 Receiver operating characteristic (ROC) curves 326
Preimplantation genetic testing for aneuploidy Recurrent pregnancy loss (RPL)
(PGT-A) 410, 420–422 –– anatomic risk factors
Preimplantation genetic testing for monogenic –– cervical incompetence 341
conditions (PGT-M) 410, 412 –– congenital malformations 340
–– alternative strategies 420 –– intrauterine adhesions 340
–– single gene defect 419, 420 –– intrauterine masses 341
Premature menopause 179, 204 –– clinical cases 337
Premature ovarian failure 307 –– definition 337
Premature ovarian insufficiency (POI) 204, 207, 208 –– endocrine risk factors
Premenopause 204–206 –– abnormal glucose metabolism 344
Premenstrual dysphoric disorder (PMDD) 558 –– diminished ovarian reserve 344, 345
Premenstrual syndrome (PMS) 558 –– hyperprolactinaemia 344
Primary amenorrhea 69, 70, 74 –– luteal phase deficiency 342, 343
Primary ovarian insufficiency (POI) 151–153, 179, 356, –– polycystic ovarian syndrome 343
357 –– thyroid dysfunction 343, 344
Primordial follicle 85, 86 –– environmental and psychological factors 347
Primordial germ cells (PGCs) 26 –– epidemiological risk factors 339
Processing medium 404 –– evidence-based treatments 339
Progestin endometrial synchronization 191 –– factors 337
Progestin therapy 192 –– genetic factors
Progestin-only contraceptives –– cytogenetic abnormalities 341
–– estrogen 560 –– genetic evaluation 342
–– injectable contraceptives 560, 561 –– parental chromosomal disorders 342
–– POPs 560 –– immunologic factors 345
Progestin-only pills (POPs) 560 –– infection 347
Prostaglandins (PGs) 99 –– initial evaluation 337–339
Proximal tubal occlusion (PTO) 519, 521 –– investigations 338, 339
Pubertal development –– management 338
–– adrenarche 61 –– outcomes 347
–– growth spurt 61 –– thrombophilia
–– menarche 61, 62 –– antiphospholipid syndrome 345, 346
–– normal age range 57, 58 –– hereditary 346
–– onset of 58, 59 –– unexplained pregnancy loss 347
–– precocious puberty Repetitive testing 330
–– on adult height 63 Resectoscope 442
–– autonomous ovarian estrogen production 66, 67 Resorption pits 239
–– causes 62 Respiratory system 548
–– CPP 63 Retrocervical septum endometriosis 547
–– delayed puberty (See Delayed puberty) Retrograde cystogram 485
–– environmental factors 63 Retroperitoneal vessel injury 478
–– hypothalamic suppression 64–66 –– alternative primary trocars 480
–– imaging studies 64, 65 –– direct trocar insertion 479
–– laboratory findings 63, 64 –– high-pressure entry 478, 479
648 Index
Retroperitoneal vessel injury (cont.) Sonohysterography, see Saline infusion sonography

–– LUQ 479, 480 (SIS)
–– open laparoscopy 479 Sperm capacitation 84, 85
–– patient’s position 478 Sperm donation
–– prevention 478 –– ethical aspects 603, 604
–– treatment 480 –– evaluation of 380
–– Veress needle location 479 –– indications for 380
Rifamycin antibiotics 566 –– patient history 602
Robotically assisted myomectomy 475, 476 –– practical aspects 602–604
Robotically assisted resection of endometriosis 476 Sperm transport
Robotically assisted tubal reanastomosis 475 –– in female reproductive tract 83, 84
Rollerball and endomyometrial resection 445 –– in male reproductive tract 81–83
Rollerball endometrial ablation 444 Spermatocytogenesis 40
Romosozumab (Evenity®) 256 Spermatogenesis 49
Rudimentary horn 588–590 –– development stages 39
–– efficiency 44
–– extrinsic regulation 46, 47
–– intrinsic regulation 46
S –– meiosis 40, 42
Saline infusion sonography (SIS) 293 –– mitosis 40
Saline infusion sonohysterography (SIS) 133 –– nuclear development 42, 43
–– indications 122, 123 –– representation of 39
–– limitations 123 –– seminiferous epithelium 43, 44
–– patient history 133 –– spermatocytogenesis 40
–– uterine cavity evaluation 123 –– spermatozoa (See Spermatozoa)
Salpingitis isthmica nodosa 519, 520 –– spermiation 43
Sciatic nerve involvement 548 –– spermiogenesis 42, 43
Scintillation 125, 126 –– tight junction barrier 39
Scrotal trauma 270 –– types 40, 41
Selective estrogen receptor modulators (SERMs) 218, Spermatogenic waves 44
292, 329, 501 Spermatozoa 43
Selective progesterone receptor modulators –– acrosome reaction 48, 49
(SPRM) 501, 502 –– capacitation 48
Sella turcica 5 –– cervical mucus 48
Semen analysis 283 –– collection 397
Senhance surgical system 473 –– epididymis 47, 48
Septate uterus 587, 588 –– head of 45
Sertoli cells 37, 38, 50 –– Leydig cells 36, 37
Sex-linked diseases 412 –– neck 45
Sexually transmitted infections (STIs) 563 –– overview 35, 36
Sheehan syndrome 149 –– patient history 36
Short-acting reversible methods –– sertoli cells 37, 38
–– CHCs –– tail 45, 46
–– acne and hirsutism 558 –– testis organization 36, 37
–– COCs 558, 559 Spermatozoon 39
–– CVR 559, 560 Spermiation 43
–– TDS 559 Spermicides 562, 563
–– progestin-only contraceptive Spermiogenesis 42, 43
–– estrogen 560 SPIN clarification 175
–– injectable contraceptives 560, 561 Stages of Reproductive Aging Workshop
–– POPs 560 (STRAW+10) 204
Simple cyst 119 Standard closed technique 462, 463
Single gene diseases 412 Sterilization reversal 521, 522
Single-port laparoscopy 477, 478 Stomach injury 482
Sliding microtbule Theory 45 Strassman metroplasty 588, 589
Slow-freezing technique 379 Study of Women's Health Across the Nation
Slow-rate freezing 403 (SWAN) 240
Small intestine injury 482, 483 Submucosal leiomyomas 495
Society for Assisted Reproductive Technology Submucosal myomas 494
(SART) 381 Suboptimal thyroid function 372
Sonohysterogram 448 Subserosal myomas 494
Index
649 R–U
Superior uterine veins 620 –– indications 112
Supracervical hysterectomy 471, 472 –– limitations 112, 113
Surgical menopause 205 –– ovaries 119–121
Swim-up method 398 –– overview 111
Synapsis 32 –– posterior cul-de-sac 121, 122
Systemic diseases 305 –– scanning techniques 113, 114
–– uterus 114–119
–– weak reflectors 111
Transdermal contraceptive system (TDS) 559
T Transforming growth factor-β (TGF-β) 31
Tacrolimus 622 Transillumination 481
Tamoxifen 315 Translocations 412, 413
Testicular aspiration (TESA) 276 Transurethral resection of the ejaculatory ducts
Testicular sperm extraction (TESE) 276 (TURED) 275
Thalassemias 305 Transvaginal ultrasound (TVUS)
Therapeutic donor insemination (TDI) 602, 603 –– Doppler modes 111, 112
Thermal index (TI) 113 –– evaluation 110, 111
Thick transverse vaginal septum 595 –– fallopian tubes 121
Thin transverse vaginal septum 594 –– indications 112
Third party reproduction 379 –– limitations 112, 113
–– embryo donation –– ovaries 119–121
–– ethical aspects 607 –– overview 111
–– patient history 607 –– posterior cul-de-sac 121, 122
–– practical aspects 607 –– scanning techniques 113, 114
–– gestational surrogacy –– uterus 114–119
–– ethical aspects 609 –– weak reflectors 111
–– patient history 608 Transverse vaginal septum 593
–– practical aspects 608, 609 Trophectoderm biopsy 418, 419
–– MRT 609 Tubal disease
–– oocyte donation –– distal tubal disease 522, 523
–– ethical aspects 606, 607 –– fallopian tubes, imaging 518, 519
–– patient history 604 –– hydrosalpinx and IVF 524
–– practical aspects 604–606 –– incidence 517
–– sperm donation –– mechanisms of tubal damage 517, 518
–– ethical aspects 603, 604 –– patient history 517, 524
–– patient history 602 –– PTO 521
–– practical aspects 602–604 –– sterilization reversal 521, 522
3D transvaginal ultrasound (3D-TVUS) 134 –– surgical management 521
Three-parent babies 609 –– technique and troubleshooting 520, 521
Thrombophilia –– tubal abnormalities 519, 520
–– antiphospholipid syndrome 345, 346 –– uterine cavity abnormalities 519
–– hereditary 346 –– WSM vs. OSM 520
Thyroid autoimmunity 344 Tubal reconstructive surgery 468, 469
Thyroid dysfunction 343 Tubal sterilization 468
–– hyperthyroidism 344 Tuberculosis 518
–– hypothyroidism 343 Turner’s syndrome 69, 143
–– management 344
–– thyroid autoimmunity 344
Thyroid homeostasis 344
Thyroid-stimulating hormone (TSH) 291
U
Thyrotropin (TSH) 285 Ulipristal acetate 564
Tight junctions 37 Ultrasonic scalpel 467
Time lapse imaging (TLI) 401 Unconventional stimulations protocols 315
Time-lapse embryo selection algorithms (ESAs) 401 Unexplained pregnancy loss 347
Tissue engineering 584 Unicornuate uterus 588–590
Trabecular bone score (TBS) 247 Unipolar electrosurgery 466
Tranexamic acid 194 Universal genetic carrier screening 371
Transabdominal ultrasound (TAUS) Ureter injury 485
–– Doppler modes 111, 112 Urinary luteinizing hormone (LH) 292
–– evaluation 110, 111 U.S. Bureau of Labor statistics 204
–– fallopian tubes 121 U.S. medical eligibility criteria (MEC) 565
650 Index
Uterine artery embolization (UAE) 505, 506 –– candidates

Uterine cavity 116, 122, 371, 372, 433 –– deceased donors 617, 618
Uterine cavity abnormalities 519 –– living donors 618
Uterine damage 309 –– matching donor 619
Uterine evaluation 371, 372 –– recipients 619
Uterine factor infertility (UFI) 616 –– clinical trials 615, 616
Uterine fibroid embolization (UFE) 505 –– complications 620, 621
Uterine fusion defects 587 –– COVID19 622, 623
Uterine leiomyomas –– definition 615
–– abnormal uterine bleeding 494 –– embryo transfer 621, 622
–– chronic pelvic pain 495 –– fallopian tube preservation 624
–– classification 494 –– immunosuppression and graft monitoring 621
–– clinical impact 494 –– indications 616, 617
–– cryomyolysis 507, 508 –– MIS techniques and immunosuppression proto-
–– endocrinology 496–498 cols 624
–– epidemiology 495, 496 –– pregnancy 622
–– genetics 496 –– preparation 617
–– hysterosalpingography 499 –– recovery procedure 619, 620
–– laparoscopic uterine artery ligation 508 –– tissue biotechnology 624
–– magnetic resonance imaging 499 –– transplantation procedure 620
–– MRI-guided focused ultrasound therapy 506, 507 –– vascular outflow 623, 624
–– pathology 496 –– VCAs 615
–– pregnancy 498
–– prevalence 493, 494
–– reproductive function 495 V
–– surgical therapy Vaginal dilation 579
–– hysterectomy 503 Vaginal malignancies 185
–– indications 503 Vaginitis 183
–– myomectomy 503–505 Varicocelectomy 275
–– treatment 499, 500 Vascularized composite allografts (VCAs) 615
–– aromatase inhibitors 502, 503 Vasectomy reversal 276
–– GnRH 500, 501 Vasomotor symptoms (VMS) 211, 212
–– SERMs 501 Vasopressin 445
–– SPRM 501, 502 Vecchietti procedure 580
–– UAE 505, 506 Venous thromboembolism (VTE) 167, 223, 559, 564,
–– ultrasound 498, 499 566
Uterine leiomyomata 616 Veress needle 462, 463
Uterine NK cells (uNK) 101 Vertebral fracture assessment (VFA) 247
Uterine septum 126, 130 Vertebral fractures 238, 248
–– classification systems 451 Vitamin D 285
–– diagnosis 452 Vitrification 379, 403
–– etiology 450, 451 Von Willebrand disease 180
–– hysterosalpingogram 452
–– incidence 451
–– magnetic resonance imaging 452 W
–– pathogenesis of pregnancy complications 451
–– surgical treatment Water-soluble media (WSM) 520
–– abdominal metroplasty 454 WHO BMD and T-score criteria 247
–– complications 454 Whole genome amplification (WGA) 414, 420
–– hysteroscopic technique 453, 454 Whole ovary cryopreservation 316
–– indication 453 Withdrawal method 563
–– outcomes 454, 455 Women’s Health Initiative (WHI) 219, 223
–– postoperative care 454
–– ultrasonography 452
Uterine septum at hysteroscopy 340 Z
Uterus didelphys 588 Zona pellucida 84, 85, 88, 89
Uterus transplantation (UTx) Z-plasty technique 595

Libro Medicina Reproductiva 2022

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Clinical Reproductive

ISBN 978-3-030-99595-9 ISBN 978-3-030-99596-6 (eBook)

1  ypothalamic-Pituitary-­Ovarian Axis and Control of the

2 Female and Male Gametogenesis..........................................................23

3 Normal Puberty and Pubertal Disorders...........................................55

4 Fertilization and Implantation.................................................................79

7 Polycystic Ovary Syndrome.......................................................................157

8 Abnormal Uterine Bleeding.......................................................................171

14 Ovarian Reserve Testing...............................................................................323

15 Recurrent Early Pregnancy Loss..............................................................335

17 Assisted Reproductive Technology: Clinical Aspects................367

18 ART: Laboratory Aspects..............................................................................393

19 Preimplantation Genetic Testing............................................................409

20  ysteroscopic Management of Intrauterine Disorders:

23 Tubal Disease and Ectopic Pregnancy.................................................515

25 Contraception: Evidence-­Based Practice Guidelines

26  urgical Techniques for Management of Anomalies of the

Ashok Agarwal, PhD American Center for Reproductive Medicine, Depart-

Paula Amato, MD, MCR Division of Reproductive Endocrinology and Infertil-

Raj Kumar Anirudh, BA University of Miami, College of Arts and Sciences,

Christopher K. Arkfeld, MD Department of Obstetrics and Gynecology, Yale

Marjan Attaran, MD Department of Obstetrics and Gynecology, Section of

Pelin Batur, MD Department of Obstetrics & Gynecology, Women’s Health

Mohamed A. Bedaiwy, MD, PhD Department of Obstetrics and Gynecology,

Charles L. Bormann, PhD, HCLD Department of Obstetrics, Gynecology, and

Ashley Brant, DO, MPH Department of Obstetrics & Gynecology, Women’s

Krystle Y. Chong, MBBS (Hons) Department of Obstetrics and Gynaecology,

Gregory M. Christman, MD Division of Reproductive Endocrinology and

Nina Desai, PhD, HCLD IVF Laboratory, Department of Obstetrics and

Laura Detti, MD Department of Obstetrics and Gynecology, Division of

Sonia Elguero, MD Boston IVF-The Albany Center, Albany, NY, USA

M. Blake Evans, DO Section of Reproductive Endocrinology and Infertility,

Tommaso Falcone, MD Cleveland Clinic London, London, UK

Rebecca Flyckt, MD Department of Obstetrics and Gynecology, Reproductive

Jason M. Franasiak, MD, HCLD/ALD (ABB) Reproductive Medicine Associates

Gary N. Frishman, MD Department of Obstetrics and Gynecology, Warren

Jeffrey M. Goldberg, MD Department of Obstetrics and Gynecology,

Eric Han, MD Section of Reproductive Endocrinology and Infertility,

Karl R. Hansen, MD, PhD Section of Reproductive Endocrinology and

Pardis Hosseinzadeh, MD Section of Reproductive Endocrinology and

William W. Hurd, MD, MSc, MPH Division of Reproductive Endocrinology

Keith B. Isaacson, MD Newton Wellesley Hospital, Harvard Medical School,

Tara K. Iyer, MD Center for Specialized Women’s Health, Department of

Anna V. Jones, BS University of Alabama School of Medicine, Birmingham,

Elizabeth J. Klein, MD Department of Obstetrics and Gynecology, Warren

Alexander M. Kotlyar, MD Section of Reproductive Endocrinology and Infertility,

Dan I. Lebovic, MD Department of Obstetrics and Gynecology, Division of

Mabel Lee, MD Department of Obstetrics and Gynecology, Reproductive

Jennifer Ludgin, BA OB/GYN/IVF Research Intern, Department of Obstetrics

Scott Lundy, MD, PhD Department of Urology, Glickman Urological and

Siddhi Mathur, MSc, MD Department of Obstetrics and Gynaecology, Mount

Ginevra Mills, MD Department of Obstetrics and Gynecology, McGill

Ben W. Mol, MD, PhD Department of Obstetrics and Gynaecology, Monash

Michelle G. Park, MD Southern California MIGS Collaborative, AAGL,

Bansari Patel, MD Atlanta Center for Reproductive Medicine, Atlanta, GA,

Pasquale Patrizio, MD Department of Obstetrics, Gynecology and Reproduc-

Alexander Quaas, MD, PhD Division of Reproductive Endocrinology and

Jenna M. Rehmer, MD Reproductive Endocrinology and Infertility Division,

1 ypothalamic-Pituitary-Ovarian Axis and Control of the

2 Female and Male Gametogenesis..........................................................23

3 Normal Puberty and Pubertal Disorders...........................................55

4 Fertilization and Implantation.................................................................79

7 Polycystic Ovary Syndrome.......................................................................157

8 Abnormal Uterine Bleeding.......................................................................171

14 Ovarian Reserve Testing...............................................................................323

15 Recurrent Early Pregnancy Loss..............................................................335

17 Assisted Reproductive Technology: Clinical Aspects................367

18 ART: Laboratory Aspects..............................................................................393

19 Preimplantation Genetic Testing............................................................409

20 ysteroscopic Management of Intrauterine Disorders:

23 Tubal Disease and Ectopic Pregnancy.................................................515

25 Contraception: Evidence-Based Practice Guidelines

26 urgical Techniques for Management of Anomalies of the

1.2 The Menstrual Cycle – 2

1.3 Anatomy of the Menstrual Cycle – 5

1.4 Endocrinology of the Menstrual Cycle – 10

1.5 Review Questions – 17

.. Table 1.1 Major hormones of the hypothalamic-pituitary-ovarian axisa

1.2.1 The Follicular Phase diol biosynthesis. Increased estradiol produc-

The central nervous system is the primary 1.3.2 Pituitary

Structure and substitutions at Half-life Relative Route of administration

??2. Which ligament provides the primary 6. Amsterdam A, Rotmensch S. Structure-function

2.2 Structure of the Ovary – 25

2.3 Overview of Oogenesis – 26

2.4 Additional Regulatory Mechanisms – 31

2.5 Advances, Future Directions, and Challenges – 34

2.6 Male Gametogenesis – 35

2.7 Organization of the Testis – 36

2.8 The Sertoli Cell – 37

2.10 Structure of the Spermatozoa – 44

2.11 Regulation of Spermatogenesis – 46

2.12 The Epididymis – 47

2.13 Sperm Entry into Cervical Mucus – 48

2.14 Capacitation and Acrosome Reaction – 48

2.15 Concluding Remarks – 49

2.16 Review Questions – 49

2.3.1 Oocyte Development First polar body

Formation c-KIT, SCF