Infertility evidence that matters
Nov 22, 2014
Infertility evidence that matters
Not here to say
• Infertility is inability of a couple to conceive after one year of sexual intercourse without contraception
RCOG,1999
Conception rates for fertile couples
0102030405060708090
100
0 6 12 18 24
Months of intercourse (cycles)
Perc
ent o
f Cou
ples
Con
ceiv
ing
© 2008, March of Dimes Foundation
Not here to say (Continued)
(Speroff & Fritz, 2005)
Not here to say (Continued)
Best care not usual care
here to say
Integrate
Clinical Expertise
Research Evidence
Patient Preferences
The Best Example
Men should not be offered surgery for varicocele as a form of fertility treatment because it does not improve pregnancy rates. (Evers & Collins, 2003)
Post-coital test
The routine use of post-coital testing of cervical mucus in the investigation of fertility problems is not recommended because it has no predictive value on pregnancy rate (Oei et al, 1998).
AimTo provide the most recent available Patient oriented evidence in infertility Management based on :-
Cochrane Library, 2013 issue IV
NICE guideline 2013.
Investigations
How to proceed?
Concept to keep in mind A simplified approach will lead to a
significant reduction in both the time and cost of investigating an infertile couple.
(Strandell 2000)
Basic fertility work up referral gyn
HistoryPhysical examination
Ovulation evaluation Semen analysisTubalpatency:CATHSGDLS
Diagnostic studies to confirm Ovulation
BBTInexpensive Accurate
Endometrial biopsy
ExpensiveStatic information
Serum progesterone
Urinary ovulation-detection kits
Serum Progesterone
Progesterone starts rising with the LH surge
drawn between day 21-24
Mid-luteal phase>10 ng/ml suggests ovulation
Tubal Factor
hysterosalpingography (HSG) is a reliable test for ruling out tubal occlusion, and it is less invasive and cheaper than laparoscopy
When to do DL
Unless there is history of pelvic inflammatory disease, previous ectopic pregnancy or endometriosis, then, D.L is justified.
Hormonal Assay
Women with irregular menstrual cycles should be offered a blood test to measure serum (FSH, LH)
TSH
the routine measurement of thyroid function should not be offered.
Prolactin assay
This test should only be offered to women who have an ovulatory disorder, galactorrhoea or a pituitary tumour But not on routine basis
Tests of ovarian reserve
AMH Any day of cycleReliableexpensive
Hysteroscopy
Women should not be offered hysteroscopy on its own as part of the initial investigation
Semen analysis
Serial semen samples (at least two) should be assessed in the same laboratory
Semen analysis
CASA vs. conventional analysisIn a randomized controlled trial, the determination of motility characteristics as obtained by CASA systems is of limited value to optimizing the evaluation of male fertility status
(Krause ,1995 )
What to do?
Gonadotrophins Nutritional supplements ?
ICSI
Moderate or Severe male factor•Obstructive azoospermia
•non-obstructive azoospermia.
hypogonadotrophic hypogonadism
hMG is a must because these are effective in improving fertility
PCOS
treatment with clomifene citrate (or tamoxifen) as the first line of treatment for up to 12 months (not only 6) VanderVeen, 2014)
Monitoring
ultrasound monitoring during at least the first cycle of treatment to ensure that they receive an adequate dose
Metformin
In CC resistant casesFor at least 45 days
IUI
Its use is questionable (Reindollar et al, 2010)
IUI
If done, offer up to 3 cycles
Tubal surgery
For women with mild tubal disease, tubal surgery may be more effective than no treatment in centres where appropriate expertise is available.
IVF
Couples in which IVF is justified should be offered up to three stimulated cycles of in vitro fertilisation treatment.
recFSH vs hMG
hMG, u FSH and recombinant FSH are equally effective in achieving a live birth when used following pituitary down-regulation as part of in vitro fertilisation treatment.
GnRHa in IVF/ICSI
Long protocol is the standard .
IUA
should be offered hysteroscopic adhesiolysis because this may restore menstruation and improve the chance of pregnancy.
Endometriosis
Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women and should not be offered
Laparoscopic Ablation
Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis
Endometrioma
Women with ovarian endometriomas should be offered laparoscopic drainage because this improves the chance of pregnancy.
Endometriosis III / IV
Women with moderate or severe endometriosis can be offered surgical treatment because it improves the chance of pregnancy
Endometriosis III / IV
Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended.
Hydrosalpinx
Women with ultrasound visible hydrosalpinges should be offered salpingectomy before in vitro fertilisation treatment because this improves the chance of a live birth
BMI female body mass index should ideally be in the range 19–30 before commencing assisted reproduction, and that a female body mass index outside this range is likely to reduce the success of assisted reproduction procedures.
ET
Women undergoing in vitro fertilisation treatment should be offered ultrasound-guided embryo transfer because this improves pregnancy rates.
Day 2 vs day 5
Embryo transfers on day 2 or 3 and day 5 or 6 appear to be equally effective in terms of increased pregnancy and live birth rates per cycle started
ET
Replacement of embryos into a uterine cavity with an endometrium of less than 6 mm thickness is unlikely to result in a pregnancy and is therefore not recommended
ET
Bed rest of more than 20 minutes’ duration following embryo transfer does not improve the outcome of in vitro fertilisation treatment
Luteal Phase Support
luteal support using progesterone improves pregnancy rates
ICSI vs IVF
ICSI improves fertilisation rates compared to IVF, but once fertilisation is achieved the pregnancy rate is no better than with in vitro fertilisation
Karyotype
Where the indication for intracytoplasmic sperm injection is a severe deficit of semen quality or non-obstructive azoospermia, the man’s karyotype should be established
Children
Current research is broadly reassuring about the health and welfare of children born as a result of assisted reproduction
BreakThrough