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Dr(Brig) R K Sharma VSM MD TIP OR THE GREAT MASS.

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Presentation on theme: "Dr(Brig) R K Sharma VSM MD TIP OR THE GREAT MASS."— Presentation transcript:

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2 Dr(Brig) R K Sharma VSM MD

3 TIP OR THE GREAT MASS

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7  As Ernest Hemingway once said, “The dignity of movement of an iceberg is due to only one-eighth of it being above water.”

8  INFERTILITY IS NOT THE DUMPING GROUND OF FAILED OBSTETRICIANS BUT ACME OF THEIR CARRIER

9  ADEQUATE KNOWLEDGE OF PHYSIOLOGY,ANATOMY,ENDOCRINOLOGY, PATHOLOGY, PSYCHOLOGY,ULTRASONOGRAPHY, ENDOSCOPY,OBS &GYNE, ANDROLOGY,EMBRYOLOGY,

10  LEADERSHIP WITH VISION,MISSION,COMMITMENT AND INTENSE PASSION  SELF EFFACEMENT  SPIRITUAL UNDERSTANDING OF ALL RELIGIONS  DEDICATION  DEVOTION  UNTIRING HARDWORK  EXCELLENT HUMAN RESOURCE DEVELOPMENT  INVENTORY MANAGEMENT  FINANCIAL MANAGEMENT

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20 HIPPOCRATESARCHIE COCHRANE Primum non nocere First, do no harm Evidence Based Medicine

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23 Is it the number of research papers published? Is it the number of lectures delivered? Is it the position in the medical society?

24 Pregnancy rate can be increased by denying treatment to all who are likely to have more failures like eldely, tb, severe endometriosis, etc

25 No, you can cut, paste and publish articles as many as you want. how many are path breaking.how many have got noble prize.

26 Well,those who can do will do others will give lectures………….. like me.

27 Well …politics is bad every where? Who suffers ….the patient.

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30  Couples 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

31 COUNSELLING

32  Full 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.

33  Many 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.

34  A 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.

35 TIPS FOR MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW

36 o PubMed o Cochrane library. o Evidence based recommendations RCOG o WHO o Journal of evidence based obstetrics and gynecology. o National Guideline Clearinghouse.

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38 1-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. ESHRE Capri workshop 2000

39 Tests which have an established correlation with pregnancy are:  1- Semen analysis  2-Tubal patency by HSG or laparoscopy  3-Mid luteal progesterone for the diagnosis of ovulation National Guideline Clearinghouse 2000 RCOG Guidelines : Grade B Recommendation 1999

40 Testes which are not consistently correlated with pregnancy as.  Zona-free hamster egg penetration tests.  Post coital test.  Antisperm antibodies assays. ESHRE Capri workshop 2000 RCOG Guidelines : Grade B Recommendation 1999

41 Includes tests which seem not to correlate with pregnancy as:  Endometrial dating.  Varicocele assessment.  Chlamydial testing. May have a role in special situations ESHRE Capri workshop 2000

42 Hysteroscopy. U/S scan of the endomerium. Are not recommended in the routine. Investigation of the infertile couple. RCOG Guidelines : Grade C Recommendation

43 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

44 D3 (FSH) and (E2)estradiol for patients >35 years. because of their reduced window of fertility potential. Bloomington: Institute for Clinical Systems Improvement (ICSI); 2000 The National Guideline Clearinghouse.Modified 2002

45 Serial semen samples (at least two) should be assessed in the same laboratory The lower limit of the normal semen testing is > 15 million/mL. >30% progressive motility >4% normal forms WHO,2010

46 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

47 Testicular biopsy should be performed only in the context of a tertiary service where there are facilities for sperm recovery and cryostorage RCOG Guidelines :Grade C Recommendation

48 General Advice Weight loss if BMI > 30, Women should give up smoking (B). Men should give up smoking (C) RCOG Guidelines Regular intercourse throughout the cycle, rather than the use of temperature charts and LH detection (C)

49 Treatment

50 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

51 IUI 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. Oligo/asthenospermia

52 Intrauterine 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)(A) Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software. Oligo/asthenospermia

53 Varicocele treatment should be offered when all of the following are present: 1. A varicocele is palpable. 2. The couple has documented infertility. 3. The female has normal fertility or potentially correctable infertility. 4. 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

54 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

55 Intracytoplasmic sperm injection (ICSI) is indicated in  Severe deficits in semen quality  Obstructive azoospermia.  Non-obstructive azoospermia.  Previous IVF cycle with failed or very poor fertilisation. RCOG Guidelines : Grade A Recommendation

56 Clomiphene C. is an effective treatment for anovulation in appropriately selected women.(A) (Mild to moderate WHO type 1 T type 2 dysfunction) Up to 12 cycles of treatment should be considered (B). RCOG Guidelines

57 FSH and hMG are both effective for ovulation induction in women with clomiphene resistant polycystic ovarian syndrome. RCOG Guidelines : Grade A Recommendation

58 There is no advantage in routinely using GRh analogues in conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant PCOS RCOG Guidelines : Grade A Recommendation

59 Dopamine agonists are effective treatment for women with anovulation due to hyperprolactinaemia RCOG Guidelines : Grade A Recommendation

60 Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS RCOG Guidelines : Grade A

61 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.

62 Surgical ablation of minimal And mild endometriosis improves fertility in subfertile women RCOG Guidelines : Grade A Recommendation

63 Also, ovarian stimulation with IUI is more effective for them than either no treatment or IUI alone. RCOG Guidelines : Grade A Recommendation

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65 Surgical treatment may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required (B). RCOG Guidelines : Grade B Recommendation

66 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

67 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

68 Micro scissor Cutting fimbrial band Cutting fimbrio- omental band Dissection of fimbriae adherent to the uterus

69 Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted RCOG Guidelines : Grade B Recommendation

70 Bilateral Cornual Block Amorphous material R. Ovary R. fimbria Cornual catheterization

71 . IVF should be considered as the first line treatment for moderate to severe distal tubal disease RCOG Guidelines : Grade B Recommendation

72 Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment Johnson et al., March 2002 (Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.

73 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

74 The effective treatment for unexplained infertility is ovarian stimulation in conjunction with IUI. If failed IVF is recommended. RCOG Guidelines : Grade A Recommendation

75  LOOK 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 UPGRADATION  TROUBLE SHOOTING

76  pH  Osmolarity  Temperature  Infection  VOC  Air quality

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92 THANKS


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