Septate uteri are the most prevalent congenital uterine anomaly in infertile women. Women with septate uteri have reduced conception rates and increased risks of first-trimester miscarriage, preterm birth and malpresentation at delivery. The prevalence of arcuate uteri in infertile women is almost identical to that of the general/fertile population. Acquired uterine abnormalities described in the chapter include endometrial polyps, intrauterine adhesions, and uterine fibroids. Hysteroscopic myomectomy is now considered the gold standard treatment for submucosal fibroids. Abdominal myomectomy remains the routine approach for most surgeons faced with multiple or large intramural fibroids. For appropriately trained surgeons, a laparoscopic approach may be adopted. Hysteroscopic resection of submucosal fibroids before IVF treatment is recommended. Although subfertile women who have otherwise asymptomatic fibroids may benefit from a myomectomy procedure, this approach should be individualised given the absence of any good randomised controlled trials (RCT) in this area.

This chapter examines the evidence and methods of uterine cavity evaluation and the structural abnormalities that may compromise in vitro fertilization (IVF) success. The gold standard method for the evaluation of the uterine cavity is direct visualization with hysteroscopy. One of the most commonly encountered uterine cavity abnormalities is endometrial polyps. Müllerian anomalies are structural developmental abnormalities of the female reproductive system. The American Society for Reproductive Medicine (ASRM) staging system classifies these abnormalities into hypoplastic/agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and DES-related. Uterine septae form from incomplete absorption of the intervening tissue as the two Müllerian ducts fuse. The arcuate uterus occurs when there is a mild extension from the uterine fundus caudally. Myomas are the most common benign tumor of the female reproductive system. Finally, the chapter describes a comprehensive diagnostic and treatment algorithm for patients with Asherman's syndrome (AS).

Power Doppler ultrasound (US), in combination with three-dimensional US and virtual organ computer-aided analysis (VOCAL), is a very good approach for investigating the global ovarian vascular network and its correlation with ovarian response in assisted reproductive technology (ART). An ovarian vascular map is easily obtained from a sagittal section of the ovary. Three-dimensional US has become a key tool for diagnosing uterine malformations. Leiomyomas and endometrial polyps are the most frequent benign uterine pathologies, and both can interfere with the reproductive process. The human endometrium undergoes intense angiogenesis during menstrual cycle, and angiogenesis is a key process for successful embryo implantation and development. In reproductive medicine, it is crucial to exclude ectopic pregnancy as early as possible. 3D US is a more accurate technique for evaluating the relationship between the gestational sac and uterine septum and for differentiating between a cornual pregnancy and a displaced intracavitary pregnancy.

This chapter reviews evidence on various investigative modalities and management planning for women presenting to the gynaecology clinic with post-menopausal bleeding. It discusses some of the issues to be considered when planning a cost-effective, clinic-based service for these women. Dilatation and curettage (D&C) was for many years the investigation of choice in women presenting with post-menopausal bleeding. The Pipelle de Cornier is a widely used system. The system is a narrow plastic catheter, which is passed through the cervical canal into the uterine cavity. Transvaginal ultrasound (TVS) is an accurate, non-invasive diagnostic modality that enables examination of the uterine cavity and endometrium in the outpatient setting. With the uterus visualised in a longitudinal plane, the thickness of the endometrial echo can be measured. Endometrial polyps are a common finding in post-menopausal women and when they occur in association with post-menopausal bleeding they should be removed for histopathological diagnosis.

In vitro fertilization (IVF) was initially developed to treat patients with damaged Fallopian tubes. IVF treatment has since been extended far beyond tubal infertility to treat a whole host of indications, including unexplained infertility, endometriosis, and male infertility. Infertility treatments include timed intercourse, ovulation induction, intrauterine insemination (IUI), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), IVF, and intracytoplasmic sperm injection (ICSI). Standard stimulation protocols require pituitary desensitization with a GnRH agonist, and this strategy has become almost a universal practise in assisted conception clinics with the induced hypogonadotropic hypogonadism enabling almost complete control over follicular development. The presence of endometrial polyps, submucous fibroids, and intrauterine adhesions may be associated with reduction in pregnancy rates and increase in risk of miscarriage with IVF. Cryopreservation of supernumerary good-quality embryos is vital to optimize pregnancy rates per cycle started without the need to superovulate the patient again.