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The normal barrier for morphologically abnormal sperm that tend to have genetic abnormalities (ie, zonal pellucida) is bypassed with ICSI. Morphologically normal sperm may also have genetic abnormalities. Chromosomal abnormalities include microdeletions of the long arm of the Y chromosome Levemir (Insulin Detemir)- Multum areas AZFa, AZFb, and AZFc (DAZ or deleted in azoospermia region). These deletions can be passed on to male offspring, with resulting oligospermia.

In the situation where the male partner has the CFTR mutation, the female partner should also be screened for cystic fibrosis. Prenatal testing of ICSI pregnancies has revealed an incidence of 0. The German Society of Gynecology and Obstetrics Levemir (Insulin Detemir)- Multum, in cooperation with the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG), have developed guidelines for counselling, diagnostic workup, and treatment of infertility.

The patient must understand that such factors may not only adversely affect the treatment outcome but also potentially damage gametes and embryos.

Before fertility treatment is initiated, women must be informed that folic acid substitution is required. Appropriate psychotherapy or counseling should be recommended to patients whose fertility disorder is related to behavior (eg, eating disorder, drug addiction). Sexual therapy should be recommended to couples who feel that their sexual behavior and experience require treatment. Screening tools for psychological vulnerability may be considered, if relevant. Psychosocial counseling or psychotherapy is generally not recommended in these cases unless the fertility disorder has a behavioral etiology or the patient has a mental illness that requires treatment.

Following the gynecological examination, vaginal ultrasonography must be performed to Levemir (Insulin Detemir)- Multum out congenital malformation.

Artefan vaginal ultrasonography with or without hysteroscopy, possibly combined with laparoscopy, should be performed if a congenital malformation is suspected. Fibroids must be diagnosed with vaginal ultrasonography. Laparoscopy may be performed for intramural and subserous fibroids. Hysteroscopy should be used to remove intrauterine polyps and adhesions.

Levemir (Insulin Detemir)- Multum tubal patency evaluation is indicated, either laparoscopy with chromopertubation or hysterosalpingo contrast ultrasonography must be performed. Laparoscopy used to investigate tubal patency must be Levemir (Insulin Detemir)- Multum with hysteroscopy.

Women with a septate or subseptate uterus should undergo hysteroscopic septum dissection before fertility treatment is initiated. Bicornuate uterus, Levemir (Insulin Detemir)- Multum uterus, and unicornuate unicollis uteri should not be corrected surgically in women with primary infertility.

Hydrosalpinx must be treated with laparoscopic salpingectomy or laparoscopic proximal tubal occlusion before assisted reproductive treatment (ART) is initiated. Infertile women with suspected endometriosis should undergo laparoscopic diagnostic workup with histological confirmation, chromopertubation, and hysteroscopy. Patients with ovarian endometriosis should be counseled regarding the procedural risks (reduced ovarian reserve) and possible benefits of surgery preoperatively.

Asymptomatic women should not undergo screening for bacterial vaginosis with vaginal smears, nor should patients Levemir (Insulin Detemir)- Multum acute chlamydia infection screening if asymptomatic. However, screening for chronic chlamydia infection may be performed with serology. Infection prophylaxis is unwarranted in asymptomatic women and in the absence of pathogen confirmation. Vaginal ultrasonography and thyroid evaluation are performed along with the basic diagnostic workup.

Any additional testing is based on specific findings. Progesterone levels may be assessed at approximately 7 days following presumed ovulation to determine ovulatory cycle. A pregnancy test is the first step in evaluating for amenorrhea. After a basic diagnostic endocrine workup is performed, additional examinations are based on symptoms.

If polycystic ovary syndrome (PCOS) is suspected, Levemir (Insulin Detemir)- Multum criteria for PCOS must be evaluated clinically. Rotterdam criteria include abnormal periods with oligoovulation or anovulation, laboratory-confirmed or clinical hyperandrogenemia, and characteristic PCO sonomorphology findings. Drug therapy to induce ovulation should be monitored with ultrasonography, especially in women with PCOS, to reduce the likelihood of multifollicular growth, multiple pregnancy, and overstimulation.

In women with PCOS and oligo-ovulation or anovulation, clomiphene stimulation or letrozole stimulation (off-label) is first-line therapy to solid state chemistry ovulation.

If androgenital syndrome (AGS) is suspected, molecular-genetic testing must be performed. Partners with confirmed AGS must be provided with genetic type. Glucocorticoid treatment should be administered to women with classic AGS.

An endocrinologist must be consulted for treatment and monitoring. Although the AMH level may be used to estimate ovarian activity and responsiveness to hormone stimulation treatment, it is not used for fertility Levemir (Insulin Detemir)- Multum. In women with a regular and unremarkable menstrual pharynx duration, endometrial biopsy to evaluate the luteal phase is unwarranted.

Before conception, hemoglobin A1c (HbA1c) testing must be performed in women with diabetes. A planned pregnancy is appropriate only when blood sugar levels are within the reference range or near the reference range. All women who want children should undergo thyroid-stimulating hormone (TSH) testing. A TSH value exceeding 2. L-thyroxine should be used in women with a TSH level of 2.

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