• 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..

• Minimum tests to be offered are

-Semen test

-TVS

20-30 Years 1 Year

30-35 Years 6 Months

35-40 Years Immediately

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, Hbelectrophoresis)

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 Mülleriananomalies (uterine septum)

• Age related decline in female fertility well recognised...

– Starts at 30,

– rapid decline after 37,

– virtually zero at 43.

• Ovarian reserve tests1. 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 for Ovarian Reserve

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

Recurrence AMH IVF-ICSI

Drainage Drainage and excision of cyst wall

Management depending upon hysteroscopic procedures..P

oly

p/S

ub

mu

cou

sfi

bro

ids • polypectomy

• Hysteroscopicmyomectomy

Intr

aute

rin

e a

dh

esio

ns • Adhesiolysis

• High dose estrogen

• Trial ET

• IVF-ET

Sep

tum • Minor

septum-DO NOT CUT

Abnormal Semen??

• M

• Minimum post-process Semen parameters for successful IUI -5 mill/ml motile sperms

Count Motility(G1+G2)

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 normalAge 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

Only 4 punctures with monoplorneedle using 4 watts for 4 seconds

WHO BENEFITS FROM PCO Drilling? CC resistant patients and those who are not responding to routine doses of gonadotrophins,Slim, raised S.LH

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…!!!

32www. blossomivfindia.com