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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
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)
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
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
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
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
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
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.
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.
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.
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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
I have made certain algorithms to simplify treatment of infertile couples ,mainly based on age and duration of infertility..
So when patient is young and duration of infertility is only 1-2 years,I proceed with…..READ
Now ,with the same patient,If duration of infertility is 3 to 5 years,after 2-3 cycles…..READ
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.
If age is between 30-35 years with less duration of infertility,you can go in routine sequence,which we discussed before.
But ,in this age group when duration of infertility is more than 3 years ,again I skip some steps depending upon AMH
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
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
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.
Similarly READ
Patients will require surrogacy straight away.
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
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”
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.