Tips for infertility practice and IVF program Dr(Brig) R K Sharma VSM MD

TIP OR THE GREAT MASS

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

GREAT MASS-FOUNDATION OF INFERTILTY PRACTICE INFERTILITY IS NOT THE DUMPING GROUND OF FAILED OBSTETRICIANS BUT ACME OF THEIR CARRIER

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

ART SPECIALIST 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

ELEPHANT AND FOUR BLIND MEN

Evidence Based Medicine HIPPOCRATES ARCHIE COCHRANE Primum non nocere First, do no harm Evidence Based Medicine

WE MAKE HAPPY FAMILIES BABIES ARE JUST SMALL PARTS OF IT

How do we measure the success

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

No .none of these can be measured as success Pregnancy rate can be increased by denying treatment to all who are likely to have more failures like eldely , tb, severe endometriosis, etc

Is it the number of research papers published? No, you can cut, paste and publish articles as many as you want. how many are path breaking.how many have got noble prize.

Is it the number of lectured delivered? Well ,those who can do will do others will give lectures………….. like me.

Is it the position in the medical society? Well …politics is bad every where? Who suffers ….the patient.

HISTORY TAKING 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

COUNSELLING

Clinical examination 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.

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.

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.

TIPS FOR MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW

Sources of EB for The Topic PubMed Cochrane library  . Evidence based recommendations RCOG WHO Journal of evidence based obstetrics and gynecology. National Guideline Clearinghouse .

Which Investigations?!

Diagnostic tests for infertility are categorized into 3 categories. ESHRE Capri workshop 2000 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.

The First Category The Basic Routine Infertility Investigation 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 RCOG Guidelines : Grade B Recommendation 1999 ESHRE Capri workshop 2000 National Guideline Clearinghouse 2000

The Second Category Testes 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 1999 ESHRE Capri workshop 2000

Includes tests which seem not to correlate with pregnancy as: The Third Category 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

Hysteroscopy 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

T3, 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

Day 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); 2000 The National Guideline Clearinghouse .Modified 2002

Semen Analysis The lower limit of the normal semen testing is 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

Semen 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

Azoospermia:Testicular biopsy 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

General 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

Treatment

Male 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

Oligo/asthenospermia Male Subfertility Oligo/asthenospermia 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 2 2002. Oxford: Update Software.

Oligo/asthenospermia Male Subfertility Oligo/asthenospermia 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) Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

Varicocele 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

Obstructive 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

ICSI 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

Ovulation Disorders 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

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

Ovulation Disorders 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

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

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

PCO: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 2 2002. Oxford: Update Software.

Endometriosis :Minimal &Mild Surgical ablation of minimal And mild endometriosis improves fertility in subfertile women RCOG Guidelines : Grade A Recommendation

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

Endometriosis : Moderate to Severe

Endometriosis :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

Endometriosis-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 2 2002. Oxford: Update Software. RCOG Guidelines : Grade A Recommendation

Microsurgical 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

Microsurgical Tubal Surgery Mild distal tubal disease Dissection of fimbriae adherent to the uterus Cutting fimbrio-omental band Micro scissor Cutting fimbrial band

Tubal Catheterization 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

Tubal Catheterization R. Ovary Bilateral Cornual Block R. fimbria Cornual catheterization Amorphous material

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

Hydrosalpinges & IVF, 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 2 2002. Oxford: Update Software.

Unexplained 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

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

TIPS FOR IVF 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

pH Osmolarity Temperature Infection VOC Air quality

ONCE AT PEAK ..LEARN TO BALANCE

THANKS