6As Ernest Hemingway once said, “The dignity of movement of an iceberg is due to only one-eighth of it being above water.”
7GREAT MASS-FOUNDATION OF INFERTILTY PRACTICE INFERTILITY IS NOT THE DUMPING GROUND OF FAILED OBSTETRICIANS BUT ACME OF THEIR CARRIER
8ADEQUATE KNOWLEDGE OF PHYSIOLOGY,ANATOMY,ENDOCRINOLOGY, PATHOLOGY, PSYCHOLOGY,ULTRASONOGRAPHY, ENDOSCOPY,OBS &GYNE, ANDROLOGY,EMBRYOLOGY,
9ART SPECIALISTLEADERSHIP WITH VISION,MISSION,COMMITMENT AND INTENSE PASSIONSELF EFFACEMENTSPIRITUAL UNDERSTANDING OF ALL RELIGIONSDEDICATIONDEVOTIONUNTIRING HARDWORKEXCELLENT HUMAN RESOURCE DEVELOPMENTINVENTORY MANAGEMENTFINANCIAL MANAGEMENT
29HISTORY TAKINGCouples with infertility problem should be interviewed separately as well as together, to bring out important facts that one partner might not wish to disclose to the other. Full history taking of both partners usually denotes the underlying problem
31Clinical examinationFull clinical examination of both partners usually stands for the underlying physical problem.By the end of this step, most of healthcare professionals will be able to sketch out their provisional diagnosis.Investigations will be requested to prove the clinical diagnosis and to exclude other close possibilities.
32Many infertile couples have had some previous assessment for their infertility and this data should be cautiously reviewed.Further investigations may be requested according to the clinical presentation and the results of preliminary tests.Omitting unnecessary investigations, in particular couples, could reduce total cost of their infertility management without compromising their success rate.
33A woman who has no history suggestive of previous pelvic inflammatory disease or endometriosis, there is no justification to request a laparoscopy especially after normal hysterosalpingography study .Similarly, there is no need for testing tubal patency for couples who will require IVF or ICSI procedure.
34TIPS FOR MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW
35Sources of EB for The Topic PubMedCochrane library .Evidence based recommendations RCOGWHOJournal of evidence based obstetrics and gynecology.National Guideline Clearinghouse .
37Diagnostic tests for infertility are categorized into 3 categories. ESHRE Capri workshop 20001-Testes which have an established correlation with pregnancy.2- Testes which are not consistently correlated with pregnancy.3-Testes which seem not to correlate with pregnancy.
38The First Category The Basic Routine Infertility Investigation Tests which have an established correlation with pregnancy are:1- Semen analysis2-Tubal patency by HSG or laparoscopy3-Mid luteal progesterone for the diagnosis of ovulationRCOG Guidelines : Grade B Recommendation 1999ESHRE Capri workshop 2000National Guideline Clearinghouse 2000
39The Second CategoryTestes which are not consistently correlated with pregnancy as.Zona-free hamster egg penetration tests.Post coital test.Antisperm antibodies assays.RCOG Guidelines : Grade B Recommendation 1999ESHRE Capri workshop 2000
40Includes tests which seem not to correlate with pregnancy as: The Third CategoryIncludes tests which seem not to correlate with pregnancy as:Endometrial dating.Varicocele assessment.Chlamydial testing.May have a role in special situationsESHRE Capri workshop 2000
41Hysteroscopy U/S ?? U/S scan of the endomerium. Hysteroscopy. Are not recommended in the routine.Investigation of the infertile couple.RCOG Guidelines : Grade C Recommendation
42T3, T4, TSH & PL??There is no value in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhoea or symptoms of thyroid disease.RCOG Guidelines : Grade B Recommendation 2001
43Day 3 (FSH) And Estradiol D3 (FSH) and (E2)estradiol for patients >35 years. because of their reduced window of fertility potential.Bloomington: Institute for Clinical Systems Improvement (ICSI); The National Guideline Clearinghouse .Modified 2002
44Semen Analysis The lower limit of the normal semen testing is Serial semen samples (at least two) should be assessed in the same laboratoryThe lower limit of the normal semen testing is> 15 million/mL.>30% progressive motility>4% normal formsWHO,2010
45Semen Analysis CASA is not superior to conventional semen analysis. In a RCT, the determination of motility characteristics as obtained by computer-assisted sperm analysis (CASA ) systems is of limited value . (Krause ,1995 ).CASA is not superior to conventional semen analysis.RCT= Randomized control trial
46Azoospermia:Testicular biopsy Testicular biopsy should be performed only in the context of a tertiary service where there are facilities for sperm recovery and cryostorageRCOG Guidelines :Grade C Recommendation
47General Advice Weight loss if BMI > 30, Women should give up smoking (B).Men should give up smoking (C)Regular intercourse throughout the cycle,rather than the use of temperature charts and LH detection (C)RCOG Guidelines
49Male Subfertility Oligo/asthenospermia Gonadotrophin is effective for treatment for male hypogonadotrophic hypogonadism. However, drug treatments are ineffective in the treatment of idiopathic male infertility.RCOG Guidelines : Grade B Recommendation
50Oligo/asthenospermia Male SubfertilityOligo/asthenospermiaIUI offers couples with male subfertility benefit over timed intercourse, both in natural cycles and in cycles with COH. Mild ovarian hyperstimulation with gonadotrophins is advised in cases with less severe semen defects (motile sperm concentration > 10 million).Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.
51Oligo/asthenospermia Male SubfertilityOligo/asthenospermiaIntrauterine insemination with or without ovarian stimulation is an effective treatment where the man has abnormalities of semen quality, but it has to be remembered that the pregnancy rates even after treatment remain very low (A)Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.
52Varicocele Varicocele treatment should be offered when all of the following are present:A varicocele is palpable.The couple has documented infertility.The female has normal fertility or potentially correctable infertility.The male partner has one or more abnormal semen parameters .Baltimore (MD): American Urological Association, Inc.; 2001 Apr. 9 p. [15 :National Guideline Clearinghouse modified 2002
53Obstructive Azoospermia Vasectomy reversal and surgical correction of epididymal blockage (microsurgical)can be considered in cases of obstructive azoospermia . It needs Expert hands.RCOG Guidelines : Grade B Recommendation
54ICSI Intracytoplasmic sperm injection (ICSI) is indicated in Severe deficits in semen qualityObstructive azoospermia .Non-obstructive azoospermia .Previous IVF cycle with failed or very poor fertilisation.RCOG Guidelines : Grade A Recommendation
55Ovulation DisordersClomiphene C. is an effective treatment for anovulation in appropriately selected women.(A)(Mild to moderate WHO type 1T type 2 dysfunction)Up to 12 cycles of treatment should be considered (B).RCOG Guidelines
56Ovulation DisordersFSH and hMG are both effective for ovulation induction in women with clomiphene resistant polycystic ovarian syndrome.RCOG Guidelines : Grade A Recommendation
57Ovulation DisordersThere is no advantage in routinely using GRh analogues in conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant PCOSRCOG Guidelines : Grade A Recommendation
58HyperprolactinaemiaDopamine agonists are effective treatment for women with anovulation due to hyperprolactinaemiaRCOG Guidelines : Grade A Recommendation
59PCO:Laparoscopic “Drilling" Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOSRCOG Guidelines : Grade A
60PCO:Laparoscopic “Drilling" There is insufficient evidence of a difference in pregnancy rates between : Laparoscopic ovarian drilling after 6-12 m follow up & Gonadotrophins 3-6 cycles . Multiple pregnancy are considerably reduced after laparoscopic drilling. .Farquhar et al., August 2001 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.
61Endometriosis :Minimal &Mild Surgical ablation of minimalAnd mild endometriosis improves fertility in subfertile womenRCOG Guidelines : Grade A Recommendation
62Endometriosis : MildAlso , ovarian stimulation with IUI is more effective for them than either no treatment or IUI alone.RCOG Guidelines : Grade A Recommendation
64Endometriosis :Moderate to Severe Surgical treatment may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required (B).RCOG Guidelines : Grade B Recommendation
65Endometriosis-associated infertility Hormonal therapy for ovulation suppression cannot be recommended as a standard therapy for endometriosis-associated infertility. So drug treatments don’t improve conception rate.Hughes et al., 1996 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.RCOG Guidelines : Grade A Recommendation
66Microsurgical Tubal Surgery Microsurgical tubal surgery may be appropriate for : Mild distal tubal disease ( Laparoscopy). Proximal tubal obstruction, or Re-anastomosis to reverse sterilization . If pregnancy has not occurred within 12 m of surgery, IVF should be discussed.RCOG Guidelines : Grade B Recommendation
67Microsurgical Tubal Surgery Mild distal tubal disease Dissection of fimbriae adherent to the uterusCutting fimbrio-omental bandMicro scissor Cutting fimbrial band
68Tubal Catheterization Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attemptedRCOG Guidelines : Grade B Recommendation
69Tubal Catheterization R. OvaryBilateral Cornual BlockR. fimbriaCornual catheterizationAmorphous material
70Moderate to Severe Distal tubal Disease . IVF should be considered as the first line treatment for moderate to severe distal tubal diseaseRCOG Guidelines : Grade B Recommendation
71Hydrosalpinges & IVF,Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatmentJohnson et al., March 2002(Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.
72Unexplained Infertility Expectant management (no treatment) for up to three years of trying should be considered, taking into consideration the woman's age.RCOG Guidelines : GradeC Recommendation
73Unexplained Infertility The effective treatment for unexplained infertility is ovarian stimulation in conjunction with IUI . If failed IVF is recommended.RCOG Guidelines : Grade A Recommendation
74TIPS FOR IVFLOOK AT ALL PREVIOUS RECORDS TO GET ALL THE RELEVANT CRUCIAL INFORMATION.NEVER CRITICIZE YOUR COLLEGUES IN FRONT OF PATIENTS.MUST UNDERSTAND ALL THE PROTOCOLS,IVF LAB MANAGEMENT,MANAGEMENT OF COMPLICATIONS.REGULAR KNOWLEDGE UPGRADATIONTROUBLE SHOOTING