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• The young, enthusiastic and energetic chief 
consultant at Rupal Hospital For Women, Surat, 
India (for last 15 years) 
• Medical director and IVF consultant at Blossom 
IVF Centre, Surat, India (for last 2 years) 
• Diploma in Reproductive Medicine from Kiel, 
Germany 
• Intense training in Advanced infertility 
treatment at numerous workshops and 
conferences in USA and Europe. 
• Specialized in all kind of gynec endoscopic 
surgeries. 
• Promotes health awareness by conducting 
Seminars and writing articles and specialty 
related books 
• In addition of being techno-savvy person, she 
loves making friends, and keenly interested in 
music and Guajarati literature. She is actively 
associated with the leading cultural club of 
Surat-Tarbatar. 
Dr Rupal N Shah 
M.D.(OBGYN) 
Diploma in Reproductive Medicine 
(Germany)
Common algorithm of the management of 
Infertility 
Dr Rupal N Shah 
M.D;D.G.O 
Diploma In Reproductive Medicine (Germany) 
Blossom IVF Centre 
& 
Rupal Hospital For Women 
Surat,India
Objectives: 
1. To present the practical concepts in the management of 
infertility 
2. To discuss the best possible clinical management options 
with local perspective.
When to start investigations and treatment? 
• Whenever couple feels like having to be investigated and 
treated.. 
20-30 Years 1 Year 
30-35 Years 6 Months 
35-40 Years Immediately 
• Minimum tests to be offered are 
-Semen test 
-TVS
BACKGROUND INFORMATION 
The single most important determinant of a couple’s 
fertility is the age of the female partner 
20-25 yrs 2.8% infertile 
30-34 yrs 10% infertile 
35-39 yrs 33% infertile 
40-45yrs 86% infertile 
5
CURRENT GUIDELINES 
The current clinical approach to the investigations and the 
management of infertility is backed by the evidence-based 
guidelines issued by: 
Royal College of Obstetricians and Gynecologists (RCOG) 
American Society of Reproductive Medicine (ASRM) 
European Society of Human Reproduction and Embryology (ESHRE)
INVESTIGATIONS 
1st Visit 
 Trans vaginal USG 
 TSH and prolactin (apart from CBC, RBS, HIV, HbsAg, Hb 
electrophoresis) 
 Semen analysis 
 AMH(ML>5 years,patient’s age >35 years)
Trans vaginal USG 
• D2 USG : AFC 
• 1st visit: 
• >10 to 12 follicles per ovary (PCOS), 
• Persistent hemorrhagic cysts with low-level echoes 
(endometriosis) 
• Anatomical conditions: fibroids, polyps, and Müllerian 
anomalies (uterine septum)
Investigations for Ovarian Reserve 
• Age related decline in female fertility well recognised... 
– Starts at 30, 
– rapid decline after 37, 
– virtually zero at 43. 
• Ovarian reserve tests 
1. Total D2 antral follicle count.(<5 ,Poor outcome) 
2. AMH of 2 to 6 (<2 Poor ovarian reserve,>6 PCO) 
3. D2 FSH > 10 IU/l poor response to ART 
No evidence for ovarian volume,- ovarian blood flow 
- inhibin B, -estradiol (E2)
Investigations to be required subsequently 
Screening test for Tubal patency 
• HSG 
• Diagnostic laparoscopy + Hysteroscopy
Laproscopy findings 
• Uterus Fibroids, Uterine Anomaly 
• Tubes Patency ,Hydrosalpinx 
• Ovaries PCOS ,Chocolate Cyst 
• POD Endometriosis ,Adhesions
Tubal Block 
Hydrosalpinx 
• Clipping IVF+ICSI 
Mid-tubal or fimbrial block 
• IVF-ICSI 
Cornual tubal block 
• Hysteroscopic cornual catheterisation 
• Most rewarding procedure
Endometriosis and Chocolate cyst 
Medical Management-Ineffective 
Surgical 
Drainage Drainage and excision of 
cyst wall 
Recurrence AMH IVF-ICSI
Management depending upon hysteroscopic procedures.. 
Polyp/Submucous 
fibroids 
• polypectomy 
• Hysteroscopic 
myomectomy 
Intrauterine adhesions 
• Adhesiolysis 
• High dose 
estrogen 
• Trial ET 
• IVF-ET 
Septum 
• Minor 
septum-DO 
NOT CUT
Abnormal Semen?? 
• M 
Count Motility 
(G1+G2) 
• Minimum post-process Semen parameters for successful IUI - 
5 mill/ml motile sperms 
Morphology Treatment 
Mild 15-20 mill/ml 40-50% 30-40% IUI 
Moderate 10-15mill/ml 20-40% 10-30% IUI 
severe <10mill/ml <10% <10% IVF-ICSI
MALE INFERTILITY 
• Medical Management Anti-oestrogens, androgens, 
bromocriptine and kinin-enhancing drugs , Antioxidants, mast 
cell blockers and alpha blockers, systemic corticosteroids for 
treatment of antisperm antibodies have not been shown to be 
effective in the treatment of Male infertility 
• Surgical Management The benefits of the treatment of a 
varicocele in oligozoospermic men is less certain
ICSI for male infertility 
• IVF and ICSI are effective treatments for men with moderate 
to severe semen abnormalities 
• ICSI has made it possible for men with only few sperms to 
become fathers 
• Even in very severe oligospermia and azoospermia ,Sperms 
for ICSI can be obtained are directly from( testicular biopsy by 
TESA )as well as aspiration from epididymis (PESA)
Common algorithms… 
Based on 
• Patient’s age 
• Duration of INFERTILITY 
• AMH
Age 20-30 years,ML 1-2 years, Semen and TVS NORMAL 
1-2 cycles fertile period 
2-3 cycles OI+Follicular study 
Diagnostic laparoscopy+Hysteroscopy 
4 cycles IUI(Tab CC-/+ HMG) 
IVF-ICSI
Age 20-30 years,ML 3-5 years, Semen and TVS NORMAL 
2-3 cycles OI+Follicular study 
Diagnostic 
laparoscopy+Hysteroscopy 
4 cycles IUI(Tab CC-/+ HMG) 
IVF-ICSI
Age 20-30 years,ML 5-10 years, Semen and TVS normal 
AMH 
Normal 
>2ng/ml 
Diagnostic 
Laproscopy+ 
Hysteroscopy 
CC+/- HMG+IUI 
(3-4 Cycles) 
IVF 
Abnormal 
<2ng/ml 
?DHEA 
IVF+ICSI
Age 30-35 years,ML 1-2 years,Semen and TVS normal 
2 cycles OI+Follicular study 
Diagnostic laparoscopy+Hysteroscopy 
4 cycles IUI(Tab CC+ HMG) 
IVF-ICSI
Age 30-35 years,ML >3 years ,Semen normal 
Age 35-40 years,ML >1 years ,Semen normal 
AMH/AFC 
AMH>2 
AFC >5 
Diagnostic 
Laproscopy+ 
Hysteroscopy 
CC+/- HMG+IUI 
(3-4 Cycles) 
IVF 
AMH<2 
AFC<5 
?DHEA 
IVF+ICSI
Age 35-40 years,ML >5 years ,Semen normal 
AMH > 2 
AFC normal 
• IVF with own 
eggs 
AMH 1 to 2 
AFC less 
• IVF-Own 
eggs/donor 
eggs 
• ?DHEA 
AMH < 1 
AFC less 
• IVF with donor 
eggs
Age 40-45 years 
IVF-ICSI 
Own eggs 
20% Donor eggs 
80%
Direct IVF treatment-Indications 
Bilateral Tubal Block 
Severe oligoAsthenospermia/Azoospermia 
(TESA) 
Premature ovarian failure 
Age over 40 years 
Genetic diseases(Donor gametes)
Surrogacy-Straight away…. 
After hysterectomy 
Congenital absence of the uterus 
Repeated failure of IVF or Recurrent 
abortion 
Severe intra-uterine adhesions 
Severe medical conditions incompatible with pregnancy
PCOS 
• Weight reduction 
• Ovulation Induction 
• Metformin 
• Ovarian drilling
PCO drilling 
WHO BENEFITS FROM PCO Drilling? 
CC resistant patients and those who 
are not responding to routine doses 
of gonadotrophins, 
Slim, raised S.LH 
Only 4 punctures with monoplor 
needle using 4 watts for 4 seconds
PCO drilling 
Very damaging procedure 
Please,please,please... 
Don’t over do it.
Take Home Massages 
• Infertility treatment protocols are highly dependent 
on ovarian age and duration of infertility. 
• Hurry UP…Most treatments have higher rates of 
success in younger women. 
• AMH can be a good guide to form a plan. 
• ART should be resorted to after 6 months of 
traditional treatment by infertility expert . ..(After 
treating the respective cause) 
8/29/2014
ONE SATISFIED PATIENT IS WORTH THOUSANDS OF 
GUIDELINES AND PROTOCOLS…!!! 
32 
www. blossomivfindia.com

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Common algorithm of the management of Infertility

  • 1. • The young, enthusiastic and energetic chief consultant at Rupal Hospital For Women, Surat, India (for last 15 years) • Medical director and IVF consultant at Blossom IVF Centre, Surat, India (for last 2 years) • Diploma in Reproductive Medicine from Kiel, Germany • Intense training in Advanced infertility treatment at numerous workshops and conferences in USA and Europe. • Specialized in all kind of gynec endoscopic surgeries. • Promotes health awareness by conducting Seminars and writing articles and specialty related books • In addition of being techno-savvy person, she loves making friends, and keenly interested in music and Guajarati literature. She is actively associated with the leading cultural club of Surat-Tarbatar. Dr Rupal N Shah M.D.(OBGYN) Diploma in Reproductive Medicine (Germany)
  • 2. Common algorithm of the management of Infertility Dr Rupal N Shah M.D;D.G.O Diploma In Reproductive Medicine (Germany) Blossom IVF Centre & Rupal Hospital For Women Surat,India
  • 3. Objectives: 1. To present the practical concepts in the management of infertility 2. To discuss the best possible clinical management options with local perspective.
  • 4. When to start investigations and treatment? • Whenever couple feels like having to be investigated and treated.. 20-30 Years 1 Year 30-35 Years 6 Months 35-40 Years Immediately • Minimum tests to be offered are -Semen test -TVS
  • 5. BACKGROUND INFORMATION The single most important determinant of a couple’s fertility is the age of the female partner 20-25 yrs 2.8% infertile 30-34 yrs 10% infertile 35-39 yrs 33% infertile 40-45yrs 86% infertile 5
  • 6. CURRENT GUIDELINES The current clinical approach to the investigations and the management of infertility is backed by the evidence-based guidelines issued by: Royal College of Obstetricians and Gynecologists (RCOG) American Society of Reproductive Medicine (ASRM) European Society of Human Reproduction and Embryology (ESHRE)
  • 7. INVESTIGATIONS 1st Visit  Trans vaginal USG  TSH and prolactin (apart from CBC, RBS, HIV, HbsAg, Hb electrophoresis)  Semen analysis  AMH(ML>5 years,patient’s age >35 years)
  • 8. Trans vaginal USG • D2 USG : AFC • 1st visit: • >10 to 12 follicles per ovary (PCOS), • Persistent hemorrhagic cysts with low-level echoes (endometriosis) • Anatomical conditions: fibroids, polyps, and Müllerian anomalies (uterine septum)
  • 9. Investigations for Ovarian Reserve • Age related decline in female fertility well recognised... – Starts at 30, – rapid decline after 37, – virtually zero at 43. • Ovarian reserve tests 1. Total D2 antral follicle count.(<5 ,Poor outcome) 2. AMH of 2 to 6 (<2 Poor ovarian reserve,>6 PCO) 3. D2 FSH > 10 IU/l poor response to ART No evidence for ovarian volume,- ovarian blood flow - inhibin B, -estradiol (E2)
  • 10. Investigations to be required subsequently Screening test for Tubal patency • HSG • Diagnostic laparoscopy + Hysteroscopy
  • 11. Laproscopy findings • Uterus Fibroids, Uterine Anomaly • Tubes Patency ,Hydrosalpinx • Ovaries PCOS ,Chocolate Cyst • POD Endometriosis ,Adhesions
  • 12. Tubal Block Hydrosalpinx • Clipping IVF+ICSI Mid-tubal or fimbrial block • IVF-ICSI Cornual tubal block • Hysteroscopic cornual catheterisation • Most rewarding procedure
  • 13. Endometriosis and Chocolate cyst Medical Management-Ineffective Surgical Drainage Drainage and excision of cyst wall Recurrence AMH IVF-ICSI
  • 14. Management depending upon hysteroscopic procedures.. Polyp/Submucous fibroids • polypectomy • Hysteroscopic myomectomy Intrauterine adhesions • Adhesiolysis • High dose estrogen • Trial ET • IVF-ET Septum • Minor septum-DO NOT CUT
  • 15. Abnormal Semen?? • M Count Motility (G1+G2) • Minimum post-process Semen parameters for successful IUI - 5 mill/ml motile sperms Morphology Treatment Mild 15-20 mill/ml 40-50% 30-40% IUI Moderate 10-15mill/ml 20-40% 10-30% IUI severe <10mill/ml <10% <10% IVF-ICSI
  • 16. MALE INFERTILITY • Medical Management Anti-oestrogens, androgens, bromocriptine and kinin-enhancing drugs , Antioxidants, mast cell blockers and alpha blockers, systemic corticosteroids for treatment of antisperm antibodies have not been shown to be effective in the treatment of Male infertility • Surgical Management The benefits of the treatment of a varicocele in oligozoospermic men is less certain
  • 17. ICSI for male infertility • IVF and ICSI are effective treatments for men with moderate to severe semen abnormalities • ICSI has made it possible for men with only few sperms to become fathers • Even in very severe oligospermia and azoospermia ,Sperms for ICSI can be obtained are directly from( testicular biopsy by TESA )as well as aspiration from epididymis (PESA)
  • 18. Common algorithms… Based on • Patient’s age • Duration of INFERTILITY • AMH
  • 19. Age 20-30 years,ML 1-2 years, Semen and TVS NORMAL 1-2 cycles fertile period 2-3 cycles OI+Follicular study Diagnostic laparoscopy+Hysteroscopy 4 cycles IUI(Tab CC-/+ HMG) IVF-ICSI
  • 20. Age 20-30 years,ML 3-5 years, Semen and TVS NORMAL 2-3 cycles OI+Follicular study Diagnostic laparoscopy+Hysteroscopy 4 cycles IUI(Tab CC-/+ HMG) IVF-ICSI
  • 21. Age 20-30 years,ML 5-10 years, Semen and TVS normal AMH Normal >2ng/ml Diagnostic Laproscopy+ Hysteroscopy CC+/- HMG+IUI (3-4 Cycles) IVF Abnormal <2ng/ml ?DHEA IVF+ICSI
  • 22. Age 30-35 years,ML 1-2 years,Semen and TVS normal 2 cycles OI+Follicular study Diagnostic laparoscopy+Hysteroscopy 4 cycles IUI(Tab CC+ HMG) IVF-ICSI
  • 23. Age 30-35 years,ML >3 years ,Semen normal Age 35-40 years,ML >1 years ,Semen normal AMH/AFC AMH>2 AFC >5 Diagnostic Laproscopy+ Hysteroscopy CC+/- HMG+IUI (3-4 Cycles) IVF AMH<2 AFC<5 ?DHEA IVF+ICSI
  • 24. Age 35-40 years,ML >5 years ,Semen normal AMH > 2 AFC normal • IVF with own eggs AMH 1 to 2 AFC less • IVF-Own eggs/donor eggs • ?DHEA AMH < 1 AFC less • IVF with donor eggs
  • 25. Age 40-45 years IVF-ICSI Own eggs 20% Donor eggs 80%
  • 26. Direct IVF treatment-Indications Bilateral Tubal Block Severe oligoAsthenospermia/Azoospermia (TESA) Premature ovarian failure Age over 40 years Genetic diseases(Donor gametes)
  • 27. Surrogacy-Straight away…. After hysterectomy Congenital absence of the uterus Repeated failure of IVF or Recurrent abortion Severe intra-uterine adhesions Severe medical conditions incompatible with pregnancy
  • 28. PCOS • Weight reduction • Ovulation Induction • Metformin • Ovarian drilling
  • 29. PCO drilling WHO BENEFITS FROM PCO Drilling? CC resistant patients and those who are not responding to routine doses of gonadotrophins, Slim, raised S.LH Only 4 punctures with monoplor needle using 4 watts for 4 seconds
  • 30. PCO drilling Very damaging procedure Please,please,please... Don’t over do it.
  • 31. Take Home Massages • Infertility treatment protocols are highly dependent on ovarian age and duration of infertility. • Hurry UP…Most treatments have higher rates of success in younger women. • AMH can be a good guide to form a plan. • ART should be resorted to after 6 months of traditional treatment by infertility expert . ..(After treating the respective cause) 8/29/2014
  • 32. ONE SATISFIED PATIENT IS WORTH THOUSANDS OF GUIDELINES AND PROTOCOLS…!!! 32 www. blossomivfindia.com

Editor's Notes

  1. Coming to my today’s topic.. Infertility has dominated gynec practice recently. I will share with you ,how in my practice ,I proceed with infertility work up. Primary and secondary infertility I treat equally .Only in secondary infertility, I stress on early laparoscopy and AMH
  2. Again ,the old concepts have to change..One has to be aggressive, because patients don’t stick to you forever if you go very conservative. Modern girls do not have time, so if you go by fixed guidelines ,you are sure to lose the patient. When patient is young ,you should start treating the couple after 1 year of their infertility. If patient is of more than 30 years ,start treating her within 6 months and if patient comes to you after 35 years of age ,I start treating her for her infertility problem immediately. Minimum tests to be done are.. Semen test,, TVS,and -Ovulation test(Mid-luteal Progesterone)-which are non-invasive simple tests. So, no patient should be sent back without these basic tests, if they are anxious to conceive
  3. I cannot overstress the fact that.. The single most important determinant of a couple’s fertility is the age of the female partner. Although, you cannot induce the couple to marry or reproduce early ,depending on age you can explain the urgency for child bearing to them.
  4. So ,these are the most respected guidelines…RCOG,ASRM and ESHRE I will add Dr Rupal’s guidelines..That is my own experience to these and summarize.
  5. It goes without saying, the importance of history, specially coital history. Apart from Semen analysis and TVS,I also advise for TSH and prolactin levels AMH has come up as very important tool, even in younger patients to estimate the urgency of the treatment, especially if the infertility is for more than 5 years or patients age is more than 35 years.
  6. We will see how it helps? TVS on 1st visit will show us PCO,Fibroids,endometriosis ,uterine septum etc.And on day 2 will show us AFCs.
  7. With Modern trend of conceiving late we have become acutely aware of importance of ovarian reserve, and it should be the essential part of all infertility investigations As you do TVS, an day 2, you will instantly asses the ovaries and combined with AMH,it gives very good idea regarding ovarian reserve. I don’t measure ovarian volume,ovarian blood flow,,inhibin B,oestradiol (E2)  
  8. There are two choices for tubal patency. I personally prefer diagnostic laparoscopy and hysteroscopy, because it is comprehensive diagnostic as well as treatment modality.HSG on the other side, though cheaper, is very uncomfortable, painful,gives less information and does not provide treatment option.So I do HSG only in short duration secondary infertility.
  9. Depending upon abnormal findings in laparoscopy, you can do fertility enhancing treatment procedures at the same time.. Myoma of more than 3 cms should be removed, we can clip hydrosalpinx in the same procedure to increase our IVF success,PCO drilling ,or chocolate cyst excision and adhesiolysis can be done.You can do uterine septum removal or endometrial polyp removal or submucous myomectomy through hysteroscope.
  10. When we come across tubal block,treatment depends upon the type of block.. If it is due to hydrosalpinx,we should always clip the tubes at the same time after consent of relatives ,which is followed by IVF. If we come across mid –tubal or fimbrial block,go for IVF straight-away Only cornual block itreatment s really rewarding procedure as we can offer them successful hysteroscopiuc cornual catheterization followed by our traditional treatment approach.      
  11. Always a debat,whether to drain or to drain and excise the wall?I always excise the wall of the cyst to prevent early recurrence. Excision of cyst is associated with a reduced rate of recurrence; reduced symptom recurrence and increased spontaneous pregnancy rates compared with ablative surgery If recurrence,better to avoid surgery for the fear of ovarian failure and better to go for IVF.
  12. Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyoma,, intrauterine adhesions, and tuberculous endometritis are the infertility causes ,which can be taken care of by operative hysteroscopy procedures. We routinely perform diagnostic hysteroscopy with laparoscopy and before starting the IVF treatment too. At time of routine hysteroscopy,EB for TB PCR is also included in our protocol as in our countries ,the proportion of tuberculous endometritis in varies from 1.5% to 11.8% .Involvement of endometrium can lead to destruction of implantation surface and poor fertility treatment outcome.
  13. Common myth amongst gynecologist is that IUI is the first line of treatment of all types of abnormal seemen parameters.It is to be understood that IUI works only in mild to moderately abnormal parameters. In severe oligoasthenospermia,trying IUI is waste of time and money.,IVF-ICSI is preferable.
  14. Medical management is generally found to be useless and wasteful,so I don’t give. READ Emperical gonadotropins in male infertility should never be used.It is useful only in hypogonadotropic hypogonadism,which makes only small portion of male infertile patients.
  15. IVF and ICSI has revolutionized treatment for moderate and severe semen abnormalities.It has become treatment of choice, Even for azoospermia.,TESA can produce pregnancy with own sperms.
  16. I have made certain algorithms to simplify treatment of infertile couples ,mainly based on age and duration of infertility..
  17. So when patient is young and duration of infertility is only 1-2 years,I proceed with…..READ
  18. Now ,with the same patient,If duration of infertility is 3 to 5 years,after 2-3 cycles…..READ
  19. Even in younger patient,if duration of infertility is more than 5 years,I routinely do AMH and than proceed as shown here….READ If AMH turns out to be less than 2 ,patient can be offered direct IVF or few cycles of IUI with pre-treatment of DHEA.
  20. If age is between 30-35 years with less duration of infertility,you can go in routine sequence,which we discussed before.
  21. But ,in this age group when duration of infertility is more than 3 years ,again I skip some steps depending upon AMH
  22. After 35 years of age,I routinely do AMH and If it is low, patient can be given an option of early IVF. Donor egg cycle counseling may be required as failure rate of IVF, is very high if AMH is very low
  23. After 40-45 years, they can directly go for IVF-ICSI and most of the patients require donor eggs. If patient wants IVF cycle with her own eggs,than thourough counseling regarding low success rate due to poor response to stimulation and pre-implantation genetic screening may be offered
  24. In all these age-wise algorithms,there are certain patients,who should directly be advised for straight away IVF treatment without wasting time and these patients are…READ   To this list,we can add recurrent or severe endometriosis and unexplained infertility also.
  25. Similarly READ   Patients will require surrogacy straight away.
  26. Although we must advise weight reduction,..Weight reduction is easy to advise but,difficult to achieve..It is frustrating for the patient to achieve magical result,So it is unfair to deny the patient any treatment unless she reduces the weight. Clomiphene citrate should be first-line pharmacological therapy to improve fertility outcomes in women with PCOS. 70% to 90 % will ovulate , 40 % will become pregnant and The multiple pregnancy rate is 5 %. Patients with 2-3 cycles of Clomiphene failed or resistant cases ,will require use of gonadotrophins,but you have to be cautious to avoid OHSS.Gonadotrophins are more efficient and may result in higher pregnancy rate. If one is considering using metformin alone to treat women with PCOS who are anovulatory, have a BMI ≥30kg/m2 (obese), and are infertile with no other infertility factors, clomiphene citrate should be added to improve fertility outcomes. The optimal duration for metformin treatment before initiation of CC is unknown as in cochrane review they could not find any data over short term Vs long term metformin pretreatment  
  27. CC resistant patients and those who are not responding to routine doses of gonadotrophins, Slim, and with raised S.LH Rule of thumb is that “Only 4 punctures with monopolor needle using 4 watts for 4 seconds”
  28. PCO drilling although claimed to be very effective , in my IVF practice ,I have seen so much of its abuse leading to low AMH level and premature ovarian failure.So I am scarred to advice PCO drilling as a primary treatment in severe PCO cases. Neo-laparoscopists and non-IVF gynecologists quite frequently overdo it.And these PCO patients,in which we are suppose to get more than enough eggs ,by the time they reach to us 20-25 % are having low AMH and less AFC.