In vitro fertilisation is a process by which an egg is fertilised by sperm outside the body: "in vitro". IVF is a major treatment for infertility when other methods of assisted reproductive technology have failed. The process involves monitoring a woman's ovulatory process, removing ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a fluid medium in a laboratory. When a woman's natural cycle is monitored to collect a naturally selected ovum (egg) for fertilisation, it is known as natural cycle IVF. The fertilised egg (zygote) is then transferred to the patient's uterus with the intention of establishing a successful pregnancy.

While IVF therapy has largely replaced tubal surgery in the treatment of infertility, the presence of hydrosalpinx is a detriment to IVF success. It has been recommended that prior to IVF, laparoscopic surgery should be done to either block or remove hydrosalpinges.

For fallopian tube obstruction, alternative medicine has been used as a form of fertility treatment. A study of the use of alternative methods showed that only a minority of infertile couples utilize such treatments. It also showed that alternative methods are more often chosen by couples who were wealthier, have not yet achieved pregnancy, or had a belief in the effectiveness of such treatments. Of the study participants, 29% used a CAM modality for treatment, 22% used acupuncture, 17% used herbal therapies like Fuyan Pill, and 1% using meditation.

With the advent of IVF which bypasses the need for tubal function a more successful treatment approach has become available for women who want to conceive. IVF has now become the major treatment for women with hydrosalpinx to achieve a pregnancy.

Several studies have shown that IVF patients with untreated hydrosalpinx have lower conception rates than controls and it has been speculated that the tubal fluid that enters the endometrial cavity alters the local environment or affects the embryo in a detrimental way. Thus, many specialists advocate that prior to an IVF attempt, the hydrosalpinx should be removed.

For most of the past century patients with tubal infertility due to hydrosalpinx underwent tubal corrective surgery to open up the distally occluded end of the tubes (salpingostomy) and remove adhesions (adhesiolysis). Unfortunately, pregnancy rates tended to be low as the infection process often had permanently damaged the tubes, and in many cases hydrosalpinges and adhesions formed again. Further, ectopic pregnancy is a typical complication. Surgical interventions can be done by laparotomy or laparoscopy.

Non-infertile patients who suffer from severe chronic pain due to hydrosalpinx formation that is not relieved by pain management may consider surgical removal of the affected tube(s) (salpingectomy) or even a hysterectomy with removal of the tubes, possibly ovaries.

Patients with a unicornuate uterus may need special attention during pregnancy as pregnancy loss, fetal demise, premature birth, and malpresentation are more common. It is unproven that cerclage procedures are helpful.

A pregnancy in a rudimentary horn cannot be saved and needs to be removed with the horn to prevent a potentially fatal rupture of the horn and uterus.

Although it is unclear whether interventions before conception or early in pregnancy such as resection of the rudimentary horn and prophylactic cervical cerclage decidedly improve obstetrical outcomes, current practice suggests that such interventions may be helpful.

If tubal factor infertility is suspected to be the cause of the infertility treatment begins with or without confirmation of infection because of complications that may result from delayed treatment. Appropriate treatment depends on the infectious agent and utilizes antibiotic therapy. Treating the sexual partner for possible STIs helps in treatment and prevents reinfection.

Antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease.

For women with infections of mild to moderate severity, parenteral and oral therapies are prescribed . Typical antibiotics used are cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin. An alternative parenteral regimen is ampicillin/sulbactam plus doxycycline. Once infection has been eliminated, surgery may be successful in opening the lumen of the fallopian tubes to allow a successful pregnancy and birth.

A number of twin gestations have occurred where each uterus carried its pregnancy separately. A recent example occurred on February 26, 2009, when Sarah Reinfelder of Sault Ste. Marie, Michigan delivered two healthy, although seven weeks premature, infants by cesarean section at Marquette General Hospital. It is possible that the deliveries occur at different times, thus the delivery interval could be days or even weeks.

In the United States, uterus didelphys is reported to occur in 0.1–0.5% of women. It is difficult to know the exact occurrence of this anomaly, as it may go undetected in the absence of medical and reproductive complications.

Ovarian pregnancies are dangerous and prone to internal bleeding. Thus, when suspected, intervention is called for.

Traditionally, an explorative laparotomy was performed, and once the ovarian pregnancy was identified, an oophorectomy or salpingo-oophorectomy was performed, including the removal of the pregnancy. Today, the surgery can often be performed via laparoscopy. The extent of surgery varies according to the amount of tissue destruction that has

occurred. Patients with an ovarian pregnancy have a good prognosis for future fertility and therefore conservative surgical management is advocated. Further, in attempts to preserve ovarian tissue, surgery may involve just the removal of the pregnancy with only a part of the ovary. This can be accomplished by an ovarian wedge resection.

Ovarian pregnancies have been successfully treated with methotrexate since it was introduced in the management of ectopic pregnancy in 1988.

An ovarian pregnancy can develop together with a normal intrauterine pregnancy; such a heterotopic pregnancy will call for expert management as not to endanger the intrauterine pregnancy.

Tubal factor infertility (TFI) is female infertility caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the Fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases. Tubal factor is one complication of Chlamydia trachomatis infection in women.

Sexually transmitted Chlamydia and genital mycoplasma infections are preventable causes of infertility and negative pregnancy outcomes. When the infections progress and ascend, they can result in TFI. Infertility can have multiple possible causes and may not be recognized for years after a gonorrhea, Chlamydia or Mycoplasma infection has caused tubal damage, as the affected woman may not have attempted to become pregnant until years later.

Surgical treatment of ovarian torsion includes laparoscopy to uncoil the torsed ovary and possibly oophoropexy to fixate the ovary which is likely to twist again. In severe cases, where blood flow is cut off to the ovary for an extended period of time, necrosis of the ovary can occur. In these cases the ovary must be surgically removed.

Ovarian pregnancies are rare: the vast majority of ectopic pregnancies occur in the fallopian tube; only about 0.15-3% of ectopics occur in the ovary. The incidence has been reported to be about 1:3,000 to 1:7,000 deliveries.

A simple cruciate incision followed by excision of tags of hymen allows drainage of the retained menstrual blood. A thicker transverse vaginal septum can be treated with Z-plasty. A blind vagina will require a partial or complete vaginoplasty. Hematosalpinx may require laprotomy or laparoscopy for removal and reconstruction of affected tube.

Infertility may require assisted reproductive techniques.

Patients with an ectopic pregnancy are generally at higher risk for a recurrence, however, there are no specific data for patients with an interstitial pregnancy. When a new pregnancy is diagnosed it is important to monitor the pregnancy by transvaginal sonography to assure that is it properly located, and that the surgically repaired area remains intact. Cesarean delivery is recommended to avoid uterine rupture during labor.

A unicornuate uterus may be associated with a rudimentary horn on the opposite site. This horn may be communicating with the uterus, and linked to the ispilateral tube. Occasionally a pregnancy may implant into such a horn setting up a dangerous situation as such pregnancy can lead to a potentially fatal uterine rupture. Surgical resection of the horn is indicated.

Over one million cases of acute salpingitis are reported every year in the US, but the number of incidents is probably larger, due to incomplete and untimely reporting methods and that many cases are reported first when the illness has gone so far that it has developed chronic complications. For women age 16–25, salpingitis is the most common serious infection. It affects approximately 11% of females of reproductive age.

Salpingitis has a higher incidence among members of lower socioeconomic classes. However, this is thought of being an effect of earlier sex debut, multiple partners, and decreased ability to receive proper health care rather than any independent risk factor for salpingitis.

As an effect of an increased risk due to multiple partners, the prevalence of salpingitis is highest for people age 15–24 years. Decreased awareness of symptoms and less will to use contraceptives are also common in this group, raising the occurrence of salpingitis.

For the affected, 20% need hospitalization.

Regarding patients age 15–44 years, 0.29 per 100,000 dies from salpingitis.

However, salpingitis can also lead to infertility because the eggs released in ovulation can't get contact with the sperm. Approximately 75,000-225,000 cases of infertility in the US are caused by salpingitis. The more times one has the infection, the greater the risk of infertility. With one episode of salpingitis, the risk of infertility is 8-17%. With 3 episodes of salpingitis, the risk is 40-60%, although the exact risk depends on the severity of each episode.

In addition, damaged oviducts increase the risk of ectopic pregnancy. Thus, if one has had salpingitis, the risk of a pregnancy to become ectopic is 7 to 10-fold as large. Half of ectopic pregnancies are due to a salpingitis infection.

Other complications are:

- Infection of ovaries and uterus

- Infection of sex partners

- An abscess on the ovary

Potential methods in unexplained infertility include oral ovarian stimulation agents (such as clomifene citrate, anastrozole or letrozole) as well as intrauterine insemination (IUI), intracervical insemination (ICI) and in vitro fertilization (IVF).

In women who have not had previous treatment, ovarian stimulation combined with IUI achieves approximately the same live birth rate as IVF. On the other hand, in women who have had previous unsuccessful treatment, IVF achieves a live birth rate approximately 2-3 times greater than ovarian stimulation combined with IUI.

IUI and ICI has higher pregnancy rates when combined with ovarian stimulation in couples with unexplained infertility, for IUI being 13% unstimulated and 15% stimulated, and for ICI being 8% unstimulated and 15% stimulated. However, the rate of twin birth increases substantially with IUI or ICI combined with ovarian stimulation, for IUI being 6% unstimulated and 23% stimulated, and for ICI being 6% unstimulated and 23% stimulated.

According to NICE guidelines, oral ovarian stimulation agents should not be given to women with unexplained infertility. Rather, it is recommended that in vitro fertilization should be offered to women with unexplained infertility when they have not conceived after 2 years of regular unprotected sexual intercourse. IVF avails for embryo transfer of the appropriate number of embryos to give good chances of pregnancy with minimal risk of multiple birth.

A review of randomized studies came to the result that IVF in couples with a high chance of natural conception, as compared to IUI/ICI with or without ovarian stimulation, was "more" effective in three studies and "less" effective in two studies.

There is no evidence for an increased risk of ovarian hyperstimulation syndrome (OHSS) with IVF when compared with ovarian stimulation combined with IUI.

Choice of treatment is largely dictated by the clinical situation. A ruptured interstitial pregnancy is a medical emergency that requires an immediate surgical intervention either by laparoscopy or laparotomy to stop the bleeding and remove the pregnancy.

Surgical methods to remove the pregnancy include cornual evacuation, incision of the cornua with removal of the pregnancy (cornuostomy), resection of the cornual area or a cornual wedge resection, typically combined with an ipsilateral salpingectomy, and hysterectomy. Because of the vascularity of the interstitial region particularly during pregnancy, blood loss during surgery may be substantial. Postoperatively, patients with conservative surgical therapy are at risk for development of a persistent ectopic pregnancy due to the presence of deeply embedded surviving trophoblastic tissue; thus, monitoring of hCG levels is indicated until they become undetectable.

In patients with an asymptomatic interstitial pregnancy methotrexate has been successfully used, however, this approach may fail and result in cornual rupture of the pregnancy. Selective uterine artery embolization has been successfully performed to treat interstial pregnancies.

Ovarian torsion accounts for about 3% of gynecologic emergencies. The incidence of ovarian torsion among women of all ages is 5.9 per 100,000 women, and the incidence among women of reproductive age (15–45 years) is 9.9 per 100,000 women. In 70% of cases, it is diagnosed in women between 20 and 39 years of age. The risk is greater during pregnancy and in menopause. Risk factors include increased length of the ovarian ligaments, pathologically enlarged ovaries (more than 6 cm), ovarian masses or cysts, and enlarged corpus luteum in pregnancy.

The epidemiology of TOA is closely related to that of pelvic inflammatory disease which is estimated to one million people yearly.

Prognosis in unexplained infertility depends on many factors, but can roughly be estimated by e.g. the

Hunault model, which takes into account female age, duration of infertility/subfertility, infertility/subfertility being primary or secondary, percentage of motile sperm and being referred by a general practitioner or gynecologist.

As endosalpingiosis, generally, is not considered a pathology, treatment is not always necessary. However the treatment of other problems caused by this condition, such as ovarian cysts, chocolate cysts, fertility, pelvic pain, adhesions, dyspareunia may need to be addressed depending on the case.

Similar to Endometriosis, cases of endosalpingiosis that cause significant amounts of pain can be treated with excision surgery by a specialist, though this is not a cure. Removal of the tissues, cysts, and adhesions can help to greatly reduce symptoms. Some surgeons believe add-back therapy with progesterone to also be helpful in reducing symptoms. Taking progesterone continuously keeps a woman at a specific time in her menstrual cycle. This prevents the body from reaching high levels of estrogen found in ovulation and further aggravating the condition. Dietary estrogen can wreak havoc in highly sensitive cases, and similar to endometriosis women are encouraged to eat diets low in estrogens. This means avoiding foods like soy, black liquorice, and tofu, to name a few.

Treatment for TOA differs from PID in that some clinicians recommend patients with tubo-ovarian abscesses have at least 24 hours of inpatient parenteral treatment with antibiotics, and that they may require surgery. If surgery becomes necessary, pre-operative administration of broad-spectrum antibiotics is started and removal of the abscess, the affected ovary and fallopian tube is done. After discharge from the hospital, oral antibiotics are continued for the length of time prescribed by the physician.

Treatment is different if the TOA is discovered before it ruptures and can be treated with IV antibiotics. During this treatment, IV antibiotics are usually replaced with oral antibiotics on an outpatient basis. Patients are usually seen three days after hospital discharge and then again one to two weeks later to confirm that the infection has cleared. Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. Parenteral Regimens described by the Centers for Disease Control and prevention are Ampicillin/Sulbactam 3 g IV every 6 hours and Doxycycline 200 mg orally or IV every 24 hours, though other regiemes that are used for pelvic inflammatory disease have been effective.

Pain associated with ovarian cysts may be treated in several ways:

- Pain relievers such as acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

- While hormonal birth control prevents the development of new cysts in those who frequently get them, it is not useful for the treatment of current cysts.