Background: This thesis is based on a randomised controlled trial comparing the effectiveness of intrauterine insemination (IUI) plus Controlled Ovarian Hyperstimulation (COH) versus in vitro fertilisation (IVF) as the first line treatment option for couples with unexplained subfertility. Subfertility of a couple is classed as unexplained when they fail to conceive after one year of regular unprotected intercourse and when all the standard investigations for ovulation, tubal patency and semen analysis have been found to be normal. It affects 30-40% of couples. The age-old methods of treating these couples have included the empirical use of clomiphene or gonadotrophins to correct any possible subtle defects in ovulation with or without IUI (to overcome any existing cervical barrier to natural conception) or IVF. However, the best treatment options for these couples have yet to be determined. The matter has been made even more controversial by the issue of NICE (National Institute for Health and Care Excellence) guidelines in the UK that suggest IUI be abandoned completely for these women in favour of IVF after 2 years of expectant management. A systematic review of the available literature comparing IUI + COH versus IVF for unexplained subfertility revealed limited numbers of available studies and high clinical and statistical heterogeneity among them. An online survey was also conducted among fertility specialists to establish the general consensus regarding management of such couples. The results revealed a lack of agreement among fertility specialists with regards to the first line treatment of couples with unexplained subfertility. The mixed 8 response to this survey demonstrated the ongoing dilemma among practitioners, much of which was due to the lack of robust evidence. A randomised controlled trial was then designed to examine the effectiveness of COH with gonadotrophins + IUI versus IVF as the first line approach to the treatment of unexplained subfertility (Figure 1). This was the first UK-based randomised controlled trial comparing these two first-line management options for unexplained subfertility.

Philosophiae Doctor - PhD / Infertility is currently a serious problem that is escalating, not only in South Africa, but also worldwide. In Cape Town, a culturally diverse, urban community of approximately 1000 couples are referred to the Groote Schuur Hospital Infertility Clinic annually. Although infertility is primarily regarded as a medical condition, the treatments have emotional effects on infertile couples due to the recurring highs and lows that often accompany treatments. This study aimed to qualitatively explore and understand the emotional and psychological experiences of infertility and its treatments (specifically In Vitro Fertilisation and Embryo Transfer). Social constructionism is based on the premise that realities are not constructed in a vacuum but rather undergo a process whereby the subjective and inter-subjective experiences over time and through cultural processes come to be regarded as truths. These truths become internalised and function as lenses through which we see ourselves, compose and invent ourselves accordingly, making sense of what would otherwise have been chaotic and meaningless experiences. Additional aims were to examine women's experiences of infertility care whilst undergoing treatment and describe their experiences of coping with infertility and In Vitro Fertilisation and Embryo Transfer (IVF-ET). Semi-structured, in-depth individual interviews were conducted with 21 women presenting with primary infertility at a fertility clinic. This study utilised an ethnographic case study design. The results of the study suggested that women perceived themselves as not conforming to a dominant belief system that promotes motherhood as the most important role for women. The women described their 'failure' to fulfill socio-cultural expectations as emotionally turbulent. Some of the psychological responses to infertility included feelings of disappointment, shock, denial, devastation, anger, frustration, sadness, inadequacy, poor self-image and self-esteem. The women's personal accounts of their experiences of In Vitro Fertilisation and Embryo Transfer (IVF-ET) revealed that they found the treatment to be highly stressful, with emotional bouts of anxiety, nervousness, excitement and optimism. A psychological synopsis of infertility and IVF-ET is infertility and IVF-ET presents. The fmdings in this study suggest the need for the incorporation of presented. This diagrammatic representation shows the intensity of the emotional rollercoaster that psychosocial intervention into infertility management. Greater attention to the psychological and emotional repercussions of infertility treatment could lead to a more personalised approach which, in turn, would optimise patient satisfaction and also prepare couples for the demands of the program by informing them about better ways of coping.

The role oxygen plays in the developing ovarian follicle is of interest not only to the field of developmental biology but also to in-vitro fertilisation (IVF) technologists, as oxygenation of the oocyte is considered to be a potential determinant of oocyte competence. Oxygen transport through the developing ovarian follicle, and practical aspects of the analysis of oxygen in human follicular fluid were investigated in this work. Mathematical modelling of oxygen transport in the pre-antral, and antrallpreovulatory follicle revealed a number of interesting findings, Contrary to previous conclusions (Gosden & Byatt-Smith, 1986), oxygen can reach the oocyte in the small pre-antral follicle. Improved estimates of diffusion coefficients through the granulosa cell layer and the inclusion of fluid voidage in this layer showed that oxygen can also reach the oocyte in large pre-antral follicles. The amount of oxygen that reaches the oocyte in the pre-antral follicle is a function of its size and degree of vascularisation. Symmetrically distributed vascularisation is superior in achieving a well oxygenated follicle. However, the large pre-antral follicle will eventually reach a size beyond which it cannot grow without anoxic regions developing. The size at which this occurs is consistent with the size at which antrum formation is observed in human follicles. The model predicts that the follicle can avoid an anoxic state through antrum formation, and shows that the follicle develops in a way that is consistent with overcoming mass transport limitations. The oxygen status of the follicle during the antrallpre-ovulatory phase of growth requires that the volume of granulosa cells be balanced by the volume of follicular fluid. Further predictions suggest that oocyte respiration becomes sub-maximal at follicular fluid volumes below approximately 4m1, vascularisation levels below 38%, or fluid i dissolved oxygen levels below 5.1 ~01%. These values are consistent with observations in the literature. It was also shown that the measurement of follicular fluid dissolved oxygen levels could provide a simple measure of the respiratory status of the oocyte, and this may be superior to the measurement of follicular vascularisation which requires knowledge of more parameters. Methodology for the analysis of follicular fluid oxygen solubility and diffusivity was developed using a Clark oxygen electrode. Analysis of these parameters showed that they are similar to human plasma, and allowed the predictive uncertainty of the model to be reduced. Experimental studies into the effects of IVF aspiration on follicular fluid were carried out. Aspiration results in significant changes in the properties of follicular fluid. Dissolved oxygen levels rose 5 * 2 vol%, pH increased by 0.04 * 0.01 pH units, and temperature dropped by 7.7 * 1.3 "C. Mathematical modelling of blood contaminated follicular fluid also showed that contamination results in significant changes in the dissolved oxygen of the fluid. This suggests that if the composition of follicular fluid is to be determined (particularly dissolved oxygen), sampling andlor measurement of fluid must take place before the collection vial of the aspiration kit, and blood contamination must be eliminated. Based on this result, the design and testing of devices capable of reliable sampling andlor rneasurement of oxygen levels of follicular fluid was considered. This presents a continuing challenge, including the integration of routine follicular fluid oxygen measurement into clinical practice.

Gamete donors are actively searched by companies dedicated to assisted reproduction in the Spanish State, and advertising is not only legal but rather common. This thesis provides an overview of the main themes that arise from the analysis of mostly visual materials used to promote ovum donation in public spaces in Barcelona, and critically links them to current debates in intersectional feminist cultural studies of technoscience, bodily theory and visual studies. Conceptual and affective tensions between characterisations of women’s bodies, reproductive function and desires are identified and brought forward in terms that imply tropes of sacralisation, reification of cells/organs/tissues, and fragmentation of the bodily reality. It is argued that egg donation advertisements use an imagery that deeply connects with practices well rooted in Western biomedical traditions when it comes to female bodies, physiology and reproductive function, and that such practices are to be understood against the backdrop of neoliberalism. The analysis supports the idea that the publicity discourse of the assisted reproduction industry in Spain actively engages in a legitimation of the desire of biological parenthood as a right, in ways that value lives conceived in different circumstances and geopolitical contexts in radically different ways, and that can be interpreted as paving the way to prosurrogacy and/or eugenic positions. Future research is encouraged and directed towards exploring issues of agency, particularly in vulnerable groups such as migrant, poor, uneducated or racialised women. Further research is needed in order to build the foundations of a feminist ethical reflection on reproductive technologies and particularly of ovum donation.