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

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

HIPPOCRATES ARCHIE COCHRANEPrimum non nocereFirst, do no harm

Evidence Based Medicine

WE MAKE HAPPY FAMILIESBABIES 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 successPregnancy 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

o PubMedo Cochrane library .o Evidence based recommendations

RCOGo WHOo Journal of evidence based

obstetrics and gynecology.o National Guideline Clearinghouse .

Which Investigations?!

Diagnostic tests for infertility are categorized into 3 categories.

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


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

National Guideline Clearinghouse 2000

RCOG Guidelines : Grade B Recommendation 1999

The Second Category

Testes which are not consistently

correlated with pregnancy as. Zona-free hamster egg penetration

tests.Post coital test.Antisperm antibodies assays.



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


Hysteroscopy U/S ??

Hysteroscopy.U/S scan of the endomerium.

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.


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

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

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 cryostorageRCOG Guidelines :Grade C Recommendation

General AdviceWeight 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)

Treatment

Male SubfertilityOligo/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

Male Subfertility

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

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.

Oligo/asthenospermia

http://www.nelh.nhs.uk/guidelinesdb/html/Infertility-ft.htm

Varicocele 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

Obstructive Azoospermia

Vasectomy reversal and surgical correction of epididymal blockage (microsurgical)can be considered in cases of obstructive azoospermia .

It needs Expert hands.


ICSIIntracytoplasmic 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.


Ovulation Disorders

There is no advantage in routinely using GRh analogues in conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant PCOS


Hyperprolactinaemia

Dopamine agonists are effective treatment for women with anovulation due to hyperprolactinaemia


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


Endometriosis : Mild

Also , ovarian stimulation with IUI is more effective for them than either no treatment or IUI alone.


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).


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.


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.


Microsurgical Tubal SurgeryMild distal tubal disease

Micro scissor Cutting fimbrial band

Cutting fimbrio-omental band

Dissection of fimbriae adherent to the uterus

Tubal Catheterization

Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted


Tubal Catheterization

Bilateral Cornual Block

Amorphous material

R. Ovary

R. fimbria

Cornual catheterization

Moderate to Severe Distal tubal Disease

. IVF should be considered

as the first line treatment

for moderate to severe

distal tubal disease


Hydrosalpinges & 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 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.


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

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

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