Cover
About the Editor
Preface
Section One: Reproductive Science
1. 1 Sexual Differentiation, Gonadal Development, and Development of the External Genitalia
  1. Introduction
  2. The Bipotential Gonad
  3. Primordial Germ Cells
  4. The Internal Reproductive Tract
  5. The External Genitalia
  6. Testis Differentiation
  7. Ovarian Differentiation
  8. Conclusion
  9. References
2. 2 Male and Female Reproductive Anatomy
  1. Female Reproductive System (Figure 2.1)
  2. Male Reproductive System (Figure 2.2)
  3. Further Reading
3. 3 Fundamentals of Reproductive Endocrinology
  1. Introduction
  2. Female Reproductive Endocrinology
  3. Male Reproductive Endocrinology
  4. Further Reading
4. 4 The Ovaries, Oocytes, and Folliculogenesis
  1. Introduction
  2. Development of Ovaries
  3. Oogenesis or Gamete Production
  4. Loss of Follicles
  5. The Hormonal Changes
  6. Conclusion
  7. Further Reading
5. 5 The Human Spermatozoa
  1. Introduction
  2. Spermatogenesis
  3. Epididymal Maturation
  4. The Structure of Mature Sperm
  5. The Sperm Transcriptome and Proteome
  6. Ejaculation and Post‐Ejaculatory Changes to Sperm Physiology
  7. Capacitation and Hyperactivation
  8. Thermotaxis, Chemotaxis, and Rheotaxis
  9. Conclusion
  10. References
6. 6 The Biology of Fertilization
  1. A Brief History
  2. The Journey of the Sperm
  3. Finding the Oocyte
  4. Capacitation, Hyperactivation, and the Acrosome Reaction
  5. Sperm Meets Oocyte
  6. Sparks of Life – Oocyte Activation
  7. Conclusion
  8. References
7. 7 Human Embryo Development
  1. Human Embryo Cleavage
  2. Compaction and Morula
  3. Blastocyst
  4. Implantation
  5. Conclusion
  6. References
  7. Further Reading
8. 8 The Female Reproductive Tract and Early Embryo Development
  1. Introduction
  2. Nutrient Demand: Satisfying the Needs of the Embryo
  3. Nutrient Supply: The Formation and Composition of the Environments in the Oviduct and Uterus
  4. Recent Developments in Oviduct Physiology and Function
  5. Can Knowledge of the Maternal Environment Help Us Improve Culture Media?
  6. References
Section Two: Clinical Reproductive Science
1. 9 Disorders of Male Reproductive Endocrinology
  1. Introduction
  2. Diagnosis
  3. Primary Hypogonadism
  4. Secondary Hypogonadism
  5. Conclusion
  6. References
2. 10 Disorders of Female Reproductive Endocrinology
  1. Introduction
  2. Causes of Hormonal Infertility
  3. Treatment Principles
  4. Conclusion
  5. References
3. 11 Oocyte Aneuploidy and the Maternal Age Effect
  1. Introduction
  2. Ovarian Ageing Versus Chromosomal Ageing
  3. Maternally Transmitted Aneuploidy in Humans
  4. Assisted Reproductive Technologies to Reduce the Risk Of Oocyte Aneuploidy?
  5. Conclusion
  6. Acknowledgements
  7. References
4. 12 Female Reproductive Pathology
  1. Introduction
  2. Endometriosis
  3. Fallopian Tube Pathology
  4. Uterine Fibroids
  5. Intrauterine Adhesions (Asherman Syndrome)
  6. Conclusion
  7. References
5. 13 Pathologies of the Male Reproductive Tract
  1. Introduction
  2. Disorders of the Testes and Epididymis
  3. Disorders of the Scrotum
  4. Penile Pathologies
  5. Pathologies of the Prostate
  6. Conclusion
  7. References
6. 14 The Impact of Infections on Reproduction and Fertility
  1. Introduction
  2. Normal Flora of the Genital Tract
  3. Infection and Infertility
  4. Female Genital Infections
  5. Male Genital Tract Infections
  6. Sexually Transmitted infections
  7. Conclusion
  8. References
7. 15 Nutrition, Fetal Health, and Pregnancy
  1. Nutritional Demands
  2. Choline
  3. Docosahexaenoic Acid
  4. Alcohol
  5. Caffeine
  6. Conclusion
  7. References
8. 16 The Embryonic Environment and Developmental Origins of Health
  1. Introduction
  2. In Vivo Environmental Condition and Embryo Plasticity
  3. In vitro Environmental Condition and Embryo Plasticity
  4. Conclusion
  5. Acknowledgements
  6. References
9. 17 Lifestyle and Environmental Impacts on Fertility
  1. Introduction
  2. Reproductive Toxicology: Environmental and Occupational Exposures
  3. Environmental and Occupational Toxicants
  4. Radiation and Chemotherapy
  5. Impact of Lifestyle and Reproduction
  6. Sexually Transmitted Infections
  7. Conclusion
  8. References
Section Three: Clinical Reproductive Science In Practice
1. 18 Assessing the Infertile Couple
  1. Introduction
  2. History Taking: Female Partner
  3. History Taking: Male Partner
  4. Clinical Examination
  5. Investigations of an Infertile Couple
  6. Conclusion
  7. References
2. 19 Ovarian Stimulation Protocols
  1. Introduction
  2. Prevention of Premature LH Surge
  3. Follicular Growth in Controlled Ovarian Stimulation: Gonadotropins
  4. Oocyte Maturation
  5. Luteal Phase Support
  6. Conclusion
  7. References
3. 20 Oocyte Retrieval Techniques and Culture of Oocytes
  1. History of Human Oocyte Retrieval
  2. Timing of Oocyte Retrieval
  3. Planning Theatre
  4. Preparation for Oocyte Retrieval
  5. Transvaginal Oocyte Retrieval
  6. Preparing the Oocytes for Culture
  7. Assessing Oocyte Maturity
  8. Problem Solving
  9. Conclusion
  10. References
4. 21 Sperm Preparation
  1. Introduction
  2. Sperm Separation Techniques: Why Do We Need Them?
  3. What Separation Techniques Are Available?
  4. The Importance of Consideration of ‘Reprotoxicity’
  5. Direct Sperm Washing
  6. Sperm Challenge Separation (The ‘Swim‐Up’)
  7. Use of the Migration Sedimentation Chamber for Sperm Preparation
  8. Density Gradient Separation
  9. Which Technique is ‘Better’?
  10. Storage of Sperm Preinsemination
  11. Managing Sero‐Discordancy During ART
  12. Offering ART to Men with Severe Asthenozoospermia or Necrozoospermia
  13. Preparation of Surgically Retrieved Sperm
  14. Future Methodologies for Sperm Preparation and Selection
  15. Conclusion
  16. References
5. 22 Diagnostic Semen Analysis
  1. What is Semen Analysis?
  2. Standardization, Limitations, and Uncertainty in Routine Semen Analysis
  3. Sperm Concentration
  4. Sperm Motility
  5. Sperm Morphology
  6. Computer‐Assisted Semen Analysis (CASA)
  7. Optional Tests (Antisperm Antibodies and DNA Fragmentation)
  8. Conclusion: Clinical Value of Semen Analysis
  9. Conflict of Interest Declaration
  10. References
6. 23 Surgical Sperm Retrieval
  1. Introduction
  2. Azoospermia
  3. Preparation for SSR
  4. Methods of SSR
  5. SSR Aftercare
  6. Conclusion
  7. Acknowledgements
  8. References
7. 24 In Vitro Fertilization and Intracytoplasmic Sperm Injection
  1. Introduction
  2. IVF or ICSI: The Dilemma
  3. Timing of Insemination
  4. Conventional IVF Insemination
  5. ICSI Procedure
  6. Fertilization Assessment
  7. Conclusion
  8. References
8. 25 Morphological Assessment of Embryos in Culture
  1. Why Do We Select Embryos?
  2. Conventional Morphology Assessment
  3. Time Lapse Imaging (TLI)
  4. Conclusion
  5. References
9. 26 In Vitro Culture of Gametes and Embryos – The Culture Medium
  1. Introduction
  2. Salts and Osmolality
  3. Energy Sources and Metabolites
  4. Amino Acids
  5. Macromolecules and Growth Factors
  6. Single‐step and Sequential Culture Systems
  7. Conclusion
  8. References
10. 27 Incubators in the Assisted Reproductive Technology Laboratory
  1. Introduction
  2. Incubator Types
  3. Main Incubator Features to Consider When Selecting an Incubator
  4. Other Considerations When Selecting an Incubator
  5. Future Developments
  6. Conclusion
  7. References
11. 28 Embryo Transfer Techniques and Improving Embryo Implantation Rates
  1. Introduction
  2. Embryo Transfer Technique
  3. Endometrial Thickness and Pattern
  4. Endometrium Receptivity
  5. Embryo Transfer Media
  6. Blastocyst Transfer
  7. Endometrial Injury
  8. Luteal Support
  9. Postembryo Transfer Interventions
  10. Conclusion
  11. References
12. 29 Cryopreservation of Gametes and Embryos
  1. Introduction: A Brief History of Gamete Cryopreservation
  2. Principles of Cryopreservation
  3. Permeating and Nonpermeating Cryoprotectants in ART
  4. Freezing Media and Cryopreservation in ART
  5. Cryopreservation Media and Related Challenges
  6. Gamete and Embryo Cryopreservation
  7. Conclusion
  8. References
13. 30 Preimplantation Genetic Diagnosis and Screening
  1. Introduction
  2. Preimplantation Genetic Diagnosis
  3. Preimplantation Genetic Screening
  4. The Embryology Laboratory
  5. Approaches to Biopsy
  6. Adverse Outcomes and Misdiagnosis
  7. Conclusion
  8. References
14. 31 Long‐Term Follow‐Up of Children Conceived Through In Vitro Fertilization
  1. Introduction
  2. Perinatal Risks
  3. Congenital Defects
  4. Neurological Outcome
  5. Neurodevelopmental Outcome
  6. Use of Health Services and Physical Health
  7. Psychological Outcome
  8. Fertility
  9. Cancer Risk
  10. Conclusion and Future Directions
  11. References
Index
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List of Tables

Chapter 03
1. Table 3.1 Hormones involved in pregnancy.
Chapter 09
1. Table 9.1 Causes of hypogonadism in the male.
Chapter 15
1. Table 15.1 Increased nutritional demands in pregnancy.
2. Table 15.2 Dietary reference intake values for choline.
Chapter 17
1. Table 17.1 Lifestyle and environmental exposures factors affecting the fertility of men and women.
Chapter 18
1. Table 18.1 Causes of and influences on female subfertility (Saunders and Debuse 2003).
2. Table 18.2 Ovulatory Disorders (WHO 1973).
3. Table 18.3 Hormone Assays.
4. Table 18.4 Semen Analysis (WHO 2010).
5. Table 18.5 Abnormalities in sperm Production.
Chapter 21
1. Table 21.1 A summary of the four most commonly adopted sperm preparation techniques.
2. Table 21.2 Recommended final sperm concentrations for different assisted reproductive treatment techniques.
3. Table 21.3 The advantages and disadvantages of the most common sperm preparation methods.
Chapter 22
1. Table 22.1 Information provided by the semen analysis.
2. Table 22.2 Sperm concentration in consecutive samples in 625 men.^a
3. Table 22.3 Mean sperm count and motility parameters for 25 samples analysed first at room temperature (19–23 °C) and using a heated microscope stage (36–37 °C). Parameters were compared by Student’s t‐test after log transformation.
Chapter 23
1. Table 23.1 Comparison of characteristics of obstructive vs nonobstructive azoospermia.
2. Table 23.2 Types of azoospermia and appropriate sperm retrieval methods.
Chapter 24
1. Table 24.1 Insemination techniques used to cause fertilization in vitro.
2. Table 24.2 Reasons for failed fertilization after conventional IVF insemination where good sperm quality was observed pre‐ and post‐preparation.
3. Table 24.3 Equipment needed for conventional in vitro fertilization (IVF) insemination and intracytoplasmic sperm injection (ICSI).
Chapter 25
1. Table 25.1 Grading scheme for pronuclear stage embryo assessment (Alpha/ESHRE Istanbul Consensus 2011).
2. Table 25.2 Recommended timings for early cleavage stage (Day 1) embryo assessment (Alpha/ESHRE Istanbul Consensus 2011).
3. Table 25.3 Recommended timings for cleavage stage Day 2 and Day 3 embryo assessment (Alpha/ESHRE Istanbul Consensus 2011).
4. Table 25.4 UK National Grading Scheme for Day 2 and Day 3 cleavage stage embryo assessment.
5. Table 25.5 Amended UK National Grading Scheme for Day 2 and Day 3 cleavage stage embryo assessment (ACE 2017).
6. Table 25.6 Grading scheme for Day 2 and Day 3 cleavage stage embryo assessment (Alpha/ESHRE Istanbul Consensus 2011).
7. Table 25.7 UK National Grading Scheme for Day 5 blastocyst stage embryo assessment based on that originally developed by Gardner and Schoolcraft (1999) and developed further by Stephenson et al. (2007).
8. Table 25.8 Amended UK National Grading Scheme for blastocyst stage embryo assessment (ACE 2017).
9. Table 25.9 Grading scheme for Day 5 blastocyst stage embryo assessment (Alpha/ESHRE Istanbul Consensus 2011).
Chapter 26
1. Table 26.1 Back to nature: the refinement of embryo culture medium.
2. Table 26.2 The differing metabolic requirements of the embryo as it develops in the female tract based on the analysis of the oviductal and uterine fluids. As the embryo develops low glucose combined with high pyruvate and lactate is required during the cleavage stages in the oviduct, switching to high glucose and low pyruvate and lactate as the embryo undergoes compaction and blastulation prior to implantation in the uterus.
3. Table 26.3 Classification of essential nonessential and conditionally essential amino acids.
Chapter 27
1. Table 27.1 Comparison of commercially available time‐lapse systems.
Chapter 29
1. Table 29.1 Differences between slow freezing and vitrification methods of cryopreservation in assisted reproductive technology.

List of Illustrations

Chapter 01
1. Figure 1.1 Simplistic illustration of the molecular determinants for gonadal differentiation. In the presence of SRY, SOX9 is upregulated and is responsible for the regulation for testicular development. In the absence of SRY, pro‐ovarian factors regulate ovarian development (see text for more detail).
2. Figure 1.2 Migration of human primordial germ cells. Representation of human primordial germ cell (PGC) migration from the allantois to the gonadal ridge in the intact embryo (a) and through the gut mesentery within the dissected abdomen (b) at approximately 6 weeks after conception. The gonadal ridge (G) has developed on the medial surface of the mesonephros (M) adjacent to the adrenal gland (A) and superior to the kidney (K). (c) Human embryo section corresponding to (b) showing PGCs darkly stained for alkaline phosphatase activity in the gonad (G) and throughout the folds of the gut mesentery (arrow). Bar = 250 µm.
3. Figure 1.3 Development of gonadal and internal reproductive system in males and females.
4. Figure 1.4 Development of external genitalia in both males and females.
Chapter 02
1. Figure 2.1 Female reproductive organs (posterior view).
2. Figure 2.2 Male reproductive organs.
Chapter 03
1. Figure 3.1 Steroidogenesis. A simplified scheme of steroidogenesis showing the various pathways and associated enzymes involved in the synthesis of the adrenal and gonadal steroid hormones.
2. Figure 3.2 Female reproductive endocrinology. GnRH released from the hypothalamus stimulates the release of luteinizing hormone (LH) and follicle‐stimulating hormone (FSH) from the anterior pituitary. These gonadotropins stimulate the synthesis of the ovarian reproductive hormones. Oestrogen and progesterone are released into the circulation where they exert various hormonal responses including preparing the endometrium for implantation. They also have a negative effect, where increasing levels decrease gonadotropin release. Mid cycle, increasing oestrogen levels stimulates a surge of LH release. Inhibin, an ovarian peptide hormone, downregulates FSH release.
3. Figure 3.3 Ovarian and menstrual cycle. Changes in the ovarian follicle, endometrial thickness, and serum hormone levels during a typical 28‐day menstrual cycle.
4. Figure 3.4 Testosterone targets many parts of the male body.
5. Figure 3.5 Male reproductive endocrinology. The testis is controlled by classic positive feed‐forward and negative feedback mechanisms. As in the female, gonadotropin‐releasing hormone (GnRH) released from the hypothalamus stimulates the release of luteinizing hormone (LH) and follicle‐stimulating hormone (FSH) from the anterior pituitary. LH stimulates the testicular Leydig cells to produce testosterone. Testosterone is converted to dihydrotestosterone. Both testosterone and dihydrotestosterone are responsible for the induction and maintenance of secondary sexual characteristics. Testosterone and inhibin both control the hypothalamic–pituitary–testicular axis through negative feedback.
Chapter 04
1. Figure 4.1 Human ovary.
2. Figure 4.2 Primary follicle enlarged as if in transmission electron microscopy. From inside to outside: the primary oocyte with nucleus displaying prophase of meiosis I (chromosomal structures evident); the Balbiani body corresponds to the crescentic organization of organelles in the perikaryon. A blue belt‐like is the zona pellucida built by the interacting oocyte and the connected layer of granulosa or follicular cells (contacts with fine extensions of both cells with gap junctions).
3. Figure 4.3 Stages of follicular growth during oogenesis. (a) Primordial follicle. (b) Primary follicle. (c) Late primary follicle (more than two layers of granulosa cells). (d) Secondary follicle. (e) Tertiary, mature or Graafian follicle. Green: membrane granulosa; blue, zona pellucida; red, vascularization in theca interna layer. Scales are not respected, i.e. structure in (b) is approximately 20 µm and (e) is 1500–1800 µm.
Chapter 05
1. Figure 5.1 Cellular differentiation during spermatogenesis begins with Type A spermatogonia either committing to differentiate into Type B spermatogonia or self‐renewal. Type B spermatogonia then further differentiate into primary spermatocytes which are in prophase of meiosis I, consisting of a duplicated complement of DNA, 2n, 4c. In primary spermatocytes, homologous chromosomes line up along the metaphase plate, which allows for homologous recombination, before entering meiosis I and dividing into secondary spermatocytes, which have a haploid complement of chromosomes, with sister chromatids still bound together (1n, 2c). Meiosis I is known as a reductional division as the chromosomal complement has halved to haploid. Secondary spermatocytes then progress through meiosis II to form four round spermatids with one set of chromosomes (1n, 1c). During the final step, spermiogenesis, the round spermatids further differentiate into the specialized form that is required for a functional spermatozoa.
2. Figure 5.2 The structure of the human spermatozoa. The head contains the acrosome and the condensed male DNA in the nucleus. The head is connected to the tail via the mid (connecting) piece containing the centriole and the mitochondria, wrapped around the axial filament, which runs throughout the entire sperm tail.
3. Figure 5.3 The tail of the sperm contains a central skeleton, constructed of 11 microtubules collectively termed the axoneme, similar to the structure found in general cilia. Back and forth movement results from a rhythmical longitudinal sliding motion between the anterior and posterior tubules that make up the axoneme. The flagellar (tail) waveform is created by the motor activities of the axonemal dynein arms working against the stable microtubule doublets. This motion propels the sperm and ATP produced by mitochondria supplies energy for this process.
Chapter 06
1. Figure 6.1 The Venus of Willendorf is an 11.1 cm high figurine estimated to have been made between about 28,000 and 25,000 BCE. It was found in 1908 at a palaeolithic site near Willendorf, a village in Lower Austria near the town of Krems.
2. Figure 6.2 (a) Robert Hooke’s microscope and (b) Illustration of Robert Hooke.
3. Figure 6.3 (a) Replica of Leeuwenhoek’ microscope. (b) Illustration of sperm as observed by Leeuwenhoek. (c) Leeuwenhoek. (d) The Homunculus as described by Hartsoeker.
4. Figure 6.4 The journey of sperm in the human female reproductive tract.
5. Figure 6.5 Scanning electron micrograph of an explant of human oviduct taken 3 h after insemination with human spermatozoa. Note the spermatozoon (arrow) of normal morphology attached by its acrosomal region to several cilia. Ciliated epithelial cells predominate, but there are also some nonciliated epithelial cells (arrow head) covered by microvilli. Observe the mucous material (asterisk) near the spermatozoon tail. The scale bar represents 10 µm.
6. Figure 6.6 The sperm introduces several factors to the oocyte during fertilization. (a) The paternal haploid genome. (b) The sperm factor required for egg activation. (c) The centrioles. (d) Sperm‐derived mRNA. (e) Noncoding RNAs. (f) Sperm‐specific proteins. ER, endoplasmic reticulum; IP₃R, inositol 1,4,5‐ trisphosphate receptor; PAWP, postacrosomal WW‐domain binding protein; PIP₂, phosphatidylinositol 4,5, bisphosphate; PLCζ, phospholipase C ζ; ZP, zona pellucida.
7. Figure 6.7 The Ca²⁺ signalling pathway and DAG, diacyglycerol; IP₃, inositol 1,4,5‐ trisphosphate; IP₃R, inositol 1,4,5‐ trisphosphate receptor; PIP₂, phosphatidylinositol 4,5, bisphosphate; PLC, phospholipase C.
Chapter 07
1. Figure 7.1 Development of the preimplantation blastocyst in humans. A schematic diagram illustrating the temporal and spatial development of a human embryo during the first week from fertilization until the preimplantation phase. Fertilization occurs in the Fallopian tube: a spermatozoa must successfully penetrate the zona pellucida (ZP) of the oocyte and fuse to share the paternal genetic material. From 1 to 3–4 days after fertilization, the embryo cleavage takes place by successive mitotic divisions. Thus, the embryo develops itself through various stages: pronucleus (PN), two‐cell, four‐cell, eight‐cell and morula. After 5–6 days, the embryo becomes a blastocyst. A cavity, called a blastocoele, is formed and filled with fluid. Moreover, at the late blastocyst stage, two distinct cells types are visible: the monolayer of trophectoderm (TE) at the periphery and the inner cell mass (ICM, orange).
2. Figure 7.2 In vitro development of the human embryo. Representative phase contrast images of a human embryo during its early development. After fertilization, pronuclei are visible: originating from oocyte and spermatozoa they are easily identifiable inside the single cell (arrow). Moreover, at the surrounding of the cell, polar bodies resulting from successful oocyte meiosis are visible until their deterioration (red star). Human embryos are in‐vitro cultured and observed at each development stage: two‐cell (day 2), eight‐cell (day 3), morula/compaction (day 3–4), early blastocyst and late blastocyst stage (day 5–6)
3. Figure 7.3 Steps of human embryo implantation. A schematic diagram of the implantation process including embryo hatching, apposition, attachment, and invasion into the endometrium. The peri‐implantation stage embryo is a blastocyst composed of two differentiated cell types: trophectoderm (TE) and inner cell mass (ICM). Through hatching, the embryo breaks free from its zona pellucida (ZP) in the uterine lumen. The embryo apposes onto luminal epithelial cells (LE). Cell interactions between both epithelia are strengthened: adhesion. Then, the TE cell differentiation into syncytiotrophoblast (SCT) occurs, allowing the embryo to breach the epithelial endometrial monolayer and invade the endometrial stroma.
Chapter 08
1. Figure 8.1 Schematic representation of the oviduct and its suggested involvement in the reproductive process.
2. Figure 8.2 Environmental effects on embryogenesis. During progression from conception, through first cleavage to morula and blastocyst stages, a preimplantation embryo is vulnerable to perturbations in its nutritional, biochemical, and physical environment. Influences exerted in the oviduct in vivo, or the culture dish in vitro, operate via epigenetic pathways to program the embryo developmental trajectory, resulting in an altered adult phenotype. BMI, body mass index; PN, pronucleus; TE, trophoectoderm; ICM, inner cell mass; ZP, zona pellucida.
Chapter 09
1. Figure 9.1 Diagnosis of male hypogonadism. FSH, follicle‐stimulating hormone; LH, luteinizing hormone; SHBG, sex hormone binding globulin.
2. Figure 9.2 Testicular volume measurements by orchidometer. (a) The volume of each testis can be measured by comparing testicular size with those on the orchidometer. (b) Expected testis volume and Tanner scale of testis development. The beads are compared with the testicles of the patient, and the volume is read off the bead that matches most closely in size.
3. Figure 9.3 Characteristics of Klinefelter syndrome.
4. Figure 9.4 Karyotype for Klinefelter syndrome.
5. Figure 9.5 Y chromosome showing p and q arms with associated location of SRY and AZF genes.
6. Figure 9.6 Migration of gonadotropin‐releasing hormone (GnRH)‐releasing neurons along the olfactory bulb towards the hypothalamus during early brain development, and associated genes with Kallmann syndrome. FSH, follicle‐stimulating hormone; LH, luteinizing hormone.
Chapter 10
1. Figure 10.1 Causes of hypogonadotropic hypogonadal anovulation. FSH, follicle‐stimulating hormone; LH, luteinzing hormone.
2. Figure 10.2 (a) Schematic depiction of PCOS. (b) Laparascopic view of a normal ovary. (c) Laparascopic view of a polycystic ovary.
Chapter 11
1. Figure 11.1 Bivalent chromosomes are formed after premeiotic DNA replication. Each consists of four chromatids – a pair from each parental homologue. The bivalent chromosome structure is stabilized by cohesin rings distal to the site of crossover formation. During anaphase I, separase cleaves Rec8 (a subunit of cohesion) on arms but Sgol2 protects Rec8 at centromeres maintaining homologue attachment at the centromeres.
2. Figure 11.2 Premature separation of sister centromeres. Loss or gain of a single chromatid detected in metaphase‐II arrested oocytes, which is often referred to as unbalanced predivision, may be due to failure to protect centromeric cohesion and/or failure of monopolar attachment. Balanced predivision, could arise by the same pathways, but involving both sets of parental centromeres.
Chapter 12
1. Figure 12.1 Endometriosis explants located on various parts of the female reproductive system.
2. Figure 12.2 Endometriosis with adhesions.
3. Figure 12.3 Extended Fallopian tube due to hydrosalpinx.
4. Figure 12.4 Fibroid location. a, Subserosal fibroids; b, intramural fibroids; c, submucosal fibroid;, pedunculated submucosal fibroid; e, fibroid in statu nascendi; f, intraligamental fibroid.
5. Figure 12.5 Large subserosal leimyoma of the uterus.
6. Figure 12.6 Hysteroscopic view of Asherman syndrome. (a) Entrance to the cervix. (b) Adhesions in the uterine cavity.
Chapter 13
1. Figure 13.1 Cryptorchidism. The right undescended testis forms a swelling in the inguinal canal in a prepubescent male.
2. Figure 13.2 Testicular torsion. During testicular torsion a testis rotates, twisting the spermatic cord that supplies blood to the testis. The resultant reduced blood flow causes sudden and often severe pain and swelling.
3. Figure 13.3 Hydrocele. (a) Hydrocele depicted as presence of a fluid‐filled sack along the spermatic cord between tunica vaginalis and testes within the scrotum. (b) Presented at a large scrotal swelling.
4. Figure 13.4 Varicocele. (a) Varicocele showing abnormally dilated pampiniform venous plexus dilated and (b) presented as enlargement of the scrotal veins.
5. Figure 13.5 Hypospadias. Hypospadias is the malformation of the urethral groove and urethral canal resulting in an abnormal opening on the ventral surface of the penis. (a) Showing locations of hypospadias and (b) example of subcoronal hypospadias.
Chapter 14
1. Figure 14.1 (a) Candidia albicans in culture on agar showing hyphae (arrow). (b) Vaginal wet mount in candidal vulvovaginitis with hyphae visible (arrow).
2. Figure 14.2 Papanicolau stain (×400) showing infestation by Trichomonas vaginalis (circle).
3. Figure 14.3 (a) Chlamydia trachomatis infection in the male, showing penile discharge. (b) Infection in the female displaying purulent discharge from the endocervical canal.
4. Figure 14.4 Lymphogranuloma venereum is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. Symptoms can include acute onset of tender, enlarged lymph nodes in both groins.
Chapter 15
1. Figure 15.1 The role of nutrition and dietary components during pregnancy. DHA, docosahexaenoic acid.
2. Figure 15.2 The features and symptoms of fetal alcohol spectrum disorder.
Chapter 16
1. Figure 16.1 Summary of periconceptional developmental programming mediated through maternal and in vitro environmental cues that are sensed by embryos resulting in induction of programming and a series of responses or adaptations in embryonic and extra‐embryonic cell lineages. Collectively, through cellular, physiological and epigenetic mechanisms, the developmental programme is altered, leading to fetal and postnatal changes in growth and phenotype and ultimately, the origin of health and disease in offspring.
2. Figure 16.2 Extra‐embryonic lineages including the trophectoderm epithelium in the blastocyst (as here) respond to Emb‐LPD maternal nutrition by upregulation of cellular endocytosis. (a) Diagram showing both exogenous protein and branched‐chain amino acid (BCAA) levels may affect embryonic cell protein synthesis via mTORC1 signalling and endocytosis via mTORC2 signalling (see text for details). (b) Representative images of E3.5 blastocysts labelled to show trophectoderm endocytosis using LysoTracker (red, for lysosomes) and BSA‐BODIPY (green, for endocytosed ligand); blue = nuclei. (c) Blastocyst immunostained to show distribution of megalin endocytic receptor in trophectoderm; blue = nuclei. Scale bar = 20 µm.
Chapter 17
1. Figure 17.1 Mechanism of toxicity. To exert its toxic effect a chemical compound must reach the target cell/molecule. Cellular damage occurs when the toxin/toxicant results in perturbations in cell function and/or structure beyond any repair capacity. GI, gastrointestinal.
Chapter 18
1. Figure 18.1 Flow diagram outlining initial assessment of the female patient including clinical history, physical examination, and screening. AFC, antral follicle count; AMH, anti‐Müllerian hormone; FSH, follicle‐stimulating hormone; HSG, hysterosalpingogram; HyCoSy, hysterosalpingo‐contrast‐sonography; IVF, in vitro fertilization; Lap & Dye, laparoscopy and dye test; LH, luteinizing hormone; PRL, prolactin level; TFT, thyroid function test; TVUSS, transvaginal ultrasound scan.
2. Figure 18.2 Flow diagram outlining initial assessment of the male patient including semen analysis. FSH, follicle‐stimulating hormone; ICSI, intracytoplasmic sperm injection; LH, luteinizing hormone; PRL, prolactin level; SSR, surgical sperm retrieval.
Chapter 19
1. Figure 19.1 Controlled ovarian stimulation (COS) protocols.
2. Figure 19.2 Gonal‐F.
3. Figure 19.3 Menopur.
Chapter 20
1. Figure 20.1 (a) Single lumen aspiration needle and (b) double lumen aspiration needle.
2. Figure 20.2 Ultrasound‐guided transvaginal oocyte retrieval procedure
3. Figure 20.3 After each follicular aspiration, the theatre staff places the tube in a heated block. The embryologist collects the tube, recovers any oocytes present and places them in culture media.
Chapter 21
1. Figure 21.1 Sperm washing.
2. Figure 21.2 The swim‐up procedure.
3. Figure 21.3 The migration sedimentation chamber (MSC).
4. Figure 21.4 Density gradient centrifugation using density gradient medium (DGM).
5. Figure 21.5 Magnetic activated cell sorting. (a) Apoptotic or periapoptotic sperm bind to the Annexin V‐coated magnetic beads. No binding occurs in healthy sperm. (b) Separation of sperm is achieved by passing the sperm mix through a magnetic column. Apoptotic sperm are retained while healthy sperm pass though
6. Figure 21.6 (a) IMSI vs (b) ICSI assessment of sperm.
Chapter 22
1. Figure 22.1 Alternative methods used for assessing sperm concentration.
2. Figure 22.2 Sperm morphology fixed and stained using Papanicoloau.
3. Figure 22.3 Sperm defects which could be classified as ‘high risk’: (a) Globozoospermia. (b) ‘Stump’ tails. (c) Multiple tails. (d) Multiple head and tails (conjoined).
4. Figure 22.4 Editing using the SAMi system – nonsperm objects are normally excluded based on size. Objects detected in error and can be deleted at this stage (insert).
5. Figure 22.5 Schematic of sperm kinetic parameters permitted by CASA analysis. ALH, lateral head displacement; VAP, path velocity; VCL, curvilinear velocity; VSL, straight‐line velocity.
6. Figure 22.6 Tracked sample showing sperm swimming at speeds of up to 75–80 µm per second.
Chapter 23
1. Figure 23.1 PESA with a needle into the epididymis.
2. Figure 23.2 Unifocal open TESE. (a) Single incision on each testicle exposing tunica vaginalis. (b) Single incision on each testicle, exposing the spermatic tubule for biopsy. (c) Extraction of testicular tissue using surgical scissors.
3. Figure 23.3 Multifocal open TESE. (a) Midline scrotal incision for scrotal exploration. (b) Testicle after scrotal exploration. (c) Multiple incisions on tunica albuginea on the testicle showing spermatic tubules. (d) Scrotal septum held showing both testicles after TESE.
4. Figure 23.4 Scrotal support after TESE surgery.
Chapter 24
1. Figure 24.1 Assisted reproductive fertilization in vitro techniques. After oocyte retrieval, fertilization is accomplished by (a) insemination or (b) intracytoplasmic sperm injection. Source: Blausen Medical – Wikimedia
2. Figure 24.2 Insemination technique. Prepared sperm are added to the wells or droplets using a micropipette.
3. Figure 24.3 Setting up a dish for oocyte denudation. The denudation dish consists of one large droplet of hyaluronidase and several smaller droplets of buffered medium. The cumulus‐oocyte‐complexes are initially transferred to the hyaluronidase droplets using a sterile Pasteur pipette. Once the majority of the cumulus has been removed, each oocyte with its remaining layers of cumulus cells is transferred to a wash droplet.
4. Figure 24.4 The intracytoplasmic sperm injection (ICSI) station or rig. The ICSI rig is a microscope with micromanipulation station containing a holding micropipette and an injection micropipette. Image courtesy of Assisted Conception Suite, Glasgow Royal Infirmary, Glasgow, UK.
5. Figure 24.5 The intracytoplasmic sperm injection (ICSI) procedure. Sperm are firstly captured, immobilized, and aspirated slowly into the injection pipette (a). The micropipette containing the sperm is then moved towards the oocyte, which is secured by the holding pipette. The injection micropipette is inserted through the zona pellucida, where the sperm is positioned near the tip of the micropipette (b, circle). The injection pipette pierces the oolemma, and the sperm is injected in to the centre of the oocyte (c). The injection pipette is then gently withdrawn and the oocyte released. Schematic depiction of ICSI (d).
Chapter 25
1. Figure 25.1 Cell sizes in idealized embryos.
2. Figure 25.2 Amended UK National Grading Scheme for blastocyst stage embryo assessment (ACE 2017).
Chapter 27
1. Figure 27.1 Example of (a) a large volume single chamber incubator with (b) segmented inner door to reduce gas loss in a single chamber incubator.
2. Figure 27.2 Example of a benchtop incubator.
3. Figure 27.3 Embryoscope™ time‐lapse system.
Chapter 28
1. Figure 28.1 Guardia access catheter with inner and outer catheter.
2. Figure 28.2 The two‐part catheter.
3. Figure 28.3 Embryo transfer loading.
4. Figure 28.4 Uterine embryo transfer.
5. Figure 28.5 Catheter with echogenic tip.
6. Figure 28.6 A triple line endometrium.
Chapter 29
1. Figure 29.1 Cryopreservation. (1) Cells prepared for cryopreservation are placed in a cryomedium containing cryoprotectant. (2) As the temperature decreases, ice crystals form in the extracellular media, (3) which subsequently increase solute concentration causing osmotic dehydration. (4) Cells continue to shrink while losing intracellular water. (5) Successful cryopreservation is achieved with little or no ice crystal formation. (6) Vitrification of cells is carried out in medium with very high concentrations of cryoprotectant, thus minimizing any cryodamage. (7) In the absence of any cryoprotectant, the formation of intracellular ice crystals will damage cellular structures, ultimately killing the cells.
2. Figure 29.2 Slow freezing programme for sperm.
3. Figure 29.3 Loading the cryostraw for embryo freeze. Embryos are aspirated in to the cryostraw and heat sealed at both ends. Each straw contains the patient identification details, the stage of embryo development, and date of freeze. These straws can be then stored long‐term in liquid nitrogen.
4. Figure 29.4 Slow freezing programme for embryos. Labelled straws containing the embryos are loaded into the freezing chamber and cooled slowly from room temperature to ‐6 °C at a cooling rate of ‐0.3 °C per minute. Manual seeding (initiating of ice crystal formation) is induced at ‐6 °C. The straws are gradually cooled to –30 °C at a rate of ‐0.3 °C per minute, followed by another round of cooling to ‐150 °C at the rate of ‐50 °C per minute, after which the straws can be removed from the freezing chamber and plunged into liquid nitrogen prior to final storage in liquid nitrogen at ‐196 °C.
5. Figure 29.5 Vitrification of human metaphase II (MII) oocyte. (a) Human metaphase II (MII) oocyte prior to exposure to equilibration solution. (b) Oocyte gradually collapsing in equilibration solution after 1 min. (c) Oocyte fully collapsed in vitrification solution, prior to plunging in liquid nitrogen at ‐196 °C.
Chapter 30
1. Figure 30.1 Preimplantation genetic diagnosis for a reciprocal translocation between the long arm chromosome 9 and the short arm of chromosome 11. The top and bottom images show analysis of the same trophectoderm sample via array‐based comparative genomic hybridization and next generation sequencing respectively, revealing an unbalanced female karyotype.
2. Figure 30.2 Software analysis of karyomapping data (Illumina). Preimplantation genetic diagnosis for a genetic mutation at 16p13.3. In the case of a recessive genetic condition where the reference was an affected child, embryo 8 would be affected, embryos 1 and 4 would be paternal carriers, and embryo 10 would be a maternal carrier. In the case of a paternally inherited dominant condition, where the reference was an affected child, embryos 1, 4, and 8 would be affected and embryo 10 would be unaffected. The detailed haploblock chart shows the single nucleotide polymorphism calling along chromosome 16 for embryo 4.
3. Figure 30.3 Data collected by Cooper Genomics showing the percentage of aneuploid embryos by maternal age.
4. Figure 30.4 Preimplantation genetic screening for chromosome aneuploidy. The top and bottom images show analysis of the same trophectoderm sample via array‐based comparative genomic hybridization and next generation sequencing respectively, revealing a male karyotype with trisomy of chromosomes 11 and 20.
5. Figure 30.5 Typical embryology laboratory set up for biopsy including microscope, intracytoplasmic sperm injection holdings and syringes, laser, and PC with laser and biopsy software. Biopsy rig: A, video monitor; B, laser; C, video camera; D, laser fibre optic cable.
6. Figure 30.6 First polar body biopsy with polar body in 12 o’clock position and zona pellucida breach at 1–2 o’clock. With the oocyte and polar body on the same plane of focus, the biopsy needle can be inserted through the breach with light suction used to remove the polar body.
7. Figure 30.7 Blastomere biopsy with selected blastomere and zona pellucida breach at around 3 o’clock. With the zona pellucida and blastomere on the same plane of focus, the biopsy needle can be inserted through the breach with light suction used to remove the blastomere.
8. Figure 30.8 Trophectoderm biopsy with zona pellucida breach at around 3 o’clock. (a) Cells are aspirated into the biopsy pipette. (b) The laser is fired continually at different points on cell junctions as the biopsy pipette is drawn away, until the cells become detached. (c) The biopsy pipette is drawn sharply down across the holding pipette shearing the cells from the embryo. The laser can be used prior to this to create a weakness.

List of Contributors

Omar Abdel‐Mannan
Population Policy and Practice
Institute of Child Health
London
UK

Tope Adeniyi
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Muhammad A. Akhtar
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Ruth Arnesen
Reproductive Health Group,
Centre for Reproductive Health
Daresbury Park
Daresbury
UK

Brendan Ball
Bourn Hall Fertility Centre
Al Hudaiba Awards Building
Jumeirah
Dubai
UAE

Stéphane Berneau
School of Healthcare Science
Manchester Metropolitan University
John Dalton Building
Manchester
UK

Daniel R. Brison
Maternal and Fetal Health Research Centre
Division of Developmental Biology and Medicine
School of Medicine, Faculty of Biology, Medicine and Health
University of Manchester
Manchester
UK
and
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Michael Carroll
School of Healthcare Science
Manchester Metropolitan University
Manchester
UK

James Coey
Department of Anatomical Sciences
St Georges’ University School of Medicine
KBT Global Scholar’s Program
Newcastle upon Tyne
UK

J. Diane Critchlow
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Rachel Cutting
Jessop Fertility
The Jessop Wing
Sheffield
UK

Emma Derbyshire
Nutritional Insight Ltd
Surrey
UK

Derrick Ebot
Department of Anatomical Sciences
St Georges’ University School of Medicine
KBT Global Scholar’s Program
Newcastle upon Tyne
UK

Edmond Edi‐Osagie
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Val Edwards Jones
School of Healthcare Science
Manchester Metropolitan University
John Dalton Building
Manchester
UK

Cheryl T. Fitzgerald
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Tom P. Fleming
Biological Sciences
University of Southampton
Southampton General Hospital
Southampton
UK

Jacques Gilloteaux
Unité de Recherche en Physiologie Moléculaire (URPhyM)
Faculté de Médecine
Université de Namur
Namur
Belgium

Stephen Harbottle
Cambridge IVF
Cambridge University Hospitals, NHS Foundation Trust
Cambridge
UK

Mary Herbert
Newcastle Fertility Centre
Centre for Life, Times Square
Newcastle upon Tyne
UK

and

Wellcome Trust Centre for Mitochondrial Research
Institute of Genetic Medicine
Newcastle University
Newcastle upon Tyne
UK

Elizabeth Hester
Faculty of Biology, Medicine and Health
The University of Manchester
Manchester
UK

Haider Hilal
Department of Anatomical Sciences
St Georges’ University School of Medicine
KBT Global Scholar’s Program
Newcastle upon Tyne
UK

Louise Hyslop
Newcastle Fertility Centre
International Centre for Life
Newcastle upon Tyne
UK

Narmada Katakam
Reproductive Health Group
Centre for Reproductive Health
Daresbury Park
Daresbury
UK

Robbie Kerr
GCRM‐Belfast Ltd
Edgewater House
Belfast
UK

Henry J. Leese
Hull York Medical School
University of Hull
Hull
UK

Colleen Lynch
Cooper Genomics
MediCity Nottingham
Nottingham

Luciano G. Nardo
Reproductive Health Group
Centre for Reproductive Health
Daresbury Park
Daresbury
UK

Mahshid Nickkho‐Amiry
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Allan Pacey
Department of Oncology & Metabolism Academic
Unit of Reproductive and Developmental Medicine
The Jessop Wing
Sheffield
UK

Rebecca M. Perrett
Nuffield Department of Clinical Neurosciences
John Radcliffe Hospital
Oxford
UK

Aarush Sajjad
Sofia Medical University
Sofia
Bulgaria

Solmaz Gul Sajjad
Sofia Medical University
Sofia
Bulgaria

Yasmin Sajjad
Burjeel Center for Reproductive Medicine
Burjeel Hospital
Abu Dhabi
UAE

Bert Stewart
Reproductive Health Group
Centre for Reproductive Health
Daresbury Park
Daresbury
UK

Sara Sulaiman
Department of Anatomical Sciences
St Georges’ University School of Medicine
KBT Global Scholar’s Program
Newcastle upon Tyne
UK

Congshan Sun
Biological Sciences
University of Southampton
Southampton General Hospital
Southampton
UK

Alastair G. Sutcliffe
Population Policy and Practice
Institute of Child Health
London
UK

Mathew Tomlinson
Fertility Unit
Nottingham University Hospital
Nottingham
UK

Ana‐Maria Tomova
School of Healthcare Science
Manchester Metropolitan University
John Dalton Building
Manchester
UK

Rosa Trigas
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Nikolaos Tsampras
Department of Reproductive Medicine
Old St Mary’s Hospital
Manchester University NHS Foundation Trust
Manchester
UK

Caroline Watkins
Reproductive Health Group
Centre for Reproductive Health
Daresbury Park
Daresbury
UK

Katrina Williams
Department of Oncology and Metabolism
Academic Unit of Reproductive and Developmental Medicine
The Jessop Wing
Sheffield
UK

Bryan Woodward
X&Y Fertility
Leicester
UK

Dawn Yell
Complete Fertility Centre Southampton
Princess Anne Hospital
Southampton
UK

Kenneth Ma Kin Yue
Department of Gynaecology
Central Manchester University Hospitals NHS Trust
Manchester
UK