Scribd
Upload
35 views

Common Algorithm of The Management of Infertility

This document profiles Dr. Rupal N Shah, an expert in reproductive medicine. It lists her qualifications and experience, which include being the medical director of Blossom IVF Centre and Rupal Hospital For Women in Surat, India for over 15 years. It also outlines her training in infertility treatment in Germany, USA and Europe. The rest of the document consists of a presentation by Dr. Shah on common algorithms for managing infertility, which discusses investigations, treatments and outcomes based on factors like age, duration of infertility and test results.

Uploaded by

eldarhobe91
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
35 views

Common Algorithm of The Management of Infertility

This document profiles Dr. Rupal N Shah, an expert in reproductive medicine. It lists her qualifications and experience, which include being the medical director of Blossom IVF Centre and Rupal Hospital For Women in Surat, India for over 15 years. It also outlines her training in infertility treatment in Germany, USA and Europe. The rest of the document consists of a presentation by Dr. Shah on common algorithms for managing infertility, which discusses investigations, treatments and outcomes based on factors like age, duration of infertility and test results.

Uploaded by

eldarhobe91
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 32

• 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
Dr Rupal N Shah associated with the leading cultural club of
Surat-Tarbatar.
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 and excision of


Drainage cyst wall

Recurrence AMH IVF-ICSI


Management depending upon hysteroscopic procedures..
fibroids
Polyp/Submucous

Intrauterine adhesions

Septum
• polypectomy • Adhesiolysis • Minor
• Hysteroscopic • High dose septum-DO
myomectomy estrogen NOT CUT

• Trial ET

• IVF-ET
Abnormal Semen??
Count Motility Morphology Treatment
(G1+G2)
• M
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

• Minimum post-process Semen parameters for successful IUI -


5 mill/ml motile sperms
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 Abnormal
>2ng/ml <2ng/ml

Diagnostic
CC+/- HMG+IUI ?DHEA
Laproscopy+ IVF
(3-4 Cycles) IVF+ICSI
Hysteroscopy
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 AMH<2
AFC >5 AFC<5

Diagnostic
CC+/- HMG+IUI ?DHEA
Laproscopy+ IVF
(3-4 Cycles) IVF+ICSI
Hysteroscopy
Age 35-40 years,ML >5 years ,Semen normal

AMH > 2 AMH 1 to 2 AMH < 1


AFC normal AFC less AFC less
• IVF with own • IVF-Own • IVF with donor
eggs eggs/donor eggs
eggs
• ?DHEA
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…!!!

www. blossomivfindia.com 32

You might also like