1. Infertility Management: Practical Messages By Prof. Mohammad Emam Mansoura Faculty Of Medicine – OB &GYN Dept. Mansoura Integrated Fertility Center (MIFC). Egypt (2010 )

2. Rationale Recorded malpractices done by some general gynecologists (GG) in management of infertility.

3. Objective To highlight practical messages for GG regarding workup and management of infertility. To highlight practical messages for GG regarding workup and management of infertility. Are based on: Are based on:META-ANALYSISRCT GUIDELINES AND PROTOCOLS.

4. Malpractice regarding the workup? Negligence of history taking, Examination before starting workup: Negligence of history taking, Examination before starting workup: Many problems can be solved before proceeding to workup!!!!!!!! Many problems can be solved before proceeding to workup!!!!!!!!

5. When To start Workup ( investigations)? Three Era ) WHO) Three Era ) WHO) After one year ( Retrospective data ). After one year ( Retrospective data ). After two years ( Retrospective data ). After two years ( Retrospective data ). Recently After 6 months ( prospective data). Recently After 6 months ( prospective data). Provided That Absence of known reproductive pathology. Absence of known reproductive pathology. Regular and frequent marital relationship Regular and frequent marital relationship

6. Why duration becomes 6 month only ( WHO )? Reduction in both the time and cost of investigating an infertile couple.

7. WHAT IS AFTER WORKUP earlier than 6 month ? If workup normal…….leave couple till one year passed or become pregnant…… If any workup is abnormal……proceed the treatment

8. Message 1 :Workup earlier than 6 month Message 1 :Workup earlier than 6 month Female FactorFemale Factor Irregular mensesIrregular menses PIDPID Abdominal surgeryAbdominal surgery DyspareuniaDyspareunia Age > 35Age > 35 BMI >29BMI >29

9. Workup Before 6 months..cont Male factorsMale factors Impotence. Impotence. A partner known to be sub fertile. A partner known to be sub fertile. Testicular surgery/injury Testicular surgery/injury Outflow abnormalities (hypospadias). Outflow abnormalities (hypospadias). Traveling abroad for working leaving wife Traveling abroad for working leaving wife Social problemsSocial problems Second marriageSecond marriage

10. Workup which have an established correlation with pregnancy 1- Semen analysis. 2- ovulation Assessment (Mid luteal progesterone= MLP). 3-Tubal patency (HSG, sonohysterography or laparoscopy)

11. Messages regarding Semen Assessment

12. Message 2 Laboratories that perform semen analysis should follow WHO methodology.

13. Message 3 : CASA or Conventional Semen Analysis!!!? Message 3 : CASA or Conventional Semen Analysis!!!? CASA is not superior to conventional semen analysis (Grade A).

14. Message 4 :What To Do if Semen analysis Is Abnormal? Message 4 :What To Do if Semen analysis Is Abnormal? Repeat confirmatory test ( 3 months after the initial analysis & ttt). (Grade B ). Repeat confirmatory test ( 3 months after the initial analysis & ttt). (Grade B ). If azoospermia or severe oligozoospermia, repeat test as soon as possible. (GPP) If azoospermia or severe oligozoospermia, repeat test as soon as possible. (GPP) ) (GPP =Good practice point )

15. Message 5: Where & When Testicular Biopsy (TB) be done In Azoospermia? Message 5: Where & When Testicular Biopsy (TB) be done In Azoospermia? TB should be performed only in a tertiary service where there are facilities for sperm recovery,cryopreservation and ART( C ) TB should be performed only in a tertiary service where there are facilities for sperm recovery,cryopreservation and ART( C )

16. Messages regarding Ovulation Assessment

17. Message 6: Regular menstruation not indicate absolute ovulation Ovulation, should be confirmed by MLP Although regular menstruation is strongly suggestive of ovulation.

18. Message 7: Midluteal Progesterone Pulsatile release, thus single level may not be useful unless elevated. Pulsatile release, thus single level may not be useful unless elevated. Values of > or = 10ng/ml are suggestive of normal progesterone production. Values of > or = 10ng/ml are suggestive of normal progesterone production. In irregular cycles: In irregular cycles: the test may be performed later in the cycle and repeated weekly until the next menstruation. the test may be performed later in the cycle and repeated weekly until the next menstruation.

19. Messages regarding Tubal Patency tests

20. Message 8:No : Ranking of Tubal Patency tests The results of semen analysis and assessment of ovulation should be known before a test for Tubal Patency is performed.

21. Message 9 :p recautions Done Before Tubal Patency Tests? Prophylactic antibiotics should be considered before uterine instrumentation (including HSG), if screening for Chlamydia trachomatis has not been carried out. (GPP) Prophylactic antibiotics should be considered before uterine instrumentation (including HSG), if screening for Chlamydia trachomatis has not been carried out. (GPP)

22. Messages Regarding HSG Technique Messages Regarding HSG Technique

23. Message 10 : Message 10 : HSG should be performed Under Fluoroscopy ( Grade :d)..

24. Removal of the speculum before scanning Application of traction by the tenaculum during filling of the uterus often results in improved uterine visualization. Message 11:. A complete view of the endometrial cavity and cervical canal should be the aim. Grade D

25. Flushing of the tubes with oil-soluble media increases subsequent pregnancy rates (It may flush tubal "plugs" ). The Cochrane Library, Issue 2 2004. Message 12 : Oil-soluble # Water Soluble Media for HSG

26. Message 13 sonohysterography HSG? Message 13 : sonohysterography # HSG? The use of sonohysterography should be considered as an effective alternative to HSG (Grade A). TVS can add evaluation of pelvis. TVS can add evaluation of pelvis.

27. Hycosy using contrast agent (Infoson®) HYCOSY using contrast agent appears to be more efficient than saline solution in detecting tubal obstruction. (Grade A).

28. Messages regarding Doing Unnecessary Workup

29. Message 14: Unnecessary laparoscopy!!!  It is not cost effective to do diagnostic laparoscopy as part of the initial infertility evaluation when: (Grade B) history, and physical examination, TVS, HSG, and Midluteal progesterone are all normal (Grade B)

30. Message 15 :When To Do Laparoscopy For tubal evaluation? When associated pelvic co morbidities ( :evaluation of the pelvis is required. When associated pelvic co morbidities ( PID, previous Ectopic, endometriosis..etc ) : evaluation of the pelvis is required. (Grade B)

31. Message 16: Message 16: : Hysteroscopy has NO role in routine evaluation of infertility

32. Message 17: Indications of Hysteroscopy as workup of infertility? Abnormal HSG hen Laparoscopy is indicated as in Unexplained infertility ? When Laparoscopy is indicated as in Unexplained infertility ? Before IVF in cases of unexplained infertility ?!!!! Before IVF in cases of unexplained infertility ?!!!! After Failed IVF ? After Failed IVF ?

33. Message 18: No Role for... 1. Postcoital test. 2. Endometrial biopsy 3. Antisperm antibodies 4. Routine cervical cultures 5. Thyroid function ( in absence of symptoms suggestive of of thyroid disease) 6.Prolactin (in absence of galactorrhoea)

34. Why PCT Not Recommended? It has no predictive value on pregnancy rate. (Grade A)……… Why? It has no predictive value on pregnancy rate. (Grade A)……… Why?. PCT may be of value in the diagnosis of sexual dysfunction and ejaculatory problems.. Results of PCT may have little effect on treatment strategy in the light of the widespread use of IUI for fertility problems.. The lack of effective treatment for anti-sperm antibodies may render PCT unnecessary.

35. Why PEB Not Recommended? Controversies regarding the accuracy of diagnostic criteria.Controversies regarding the accuracy of diagnostic criteria. Controversies regarding the value of LPD, as a cause of infertility.Controversies regarding the value of LPD, as a cause of infertility. No evidence that medical treatment of LPD improves pregnancy rate. ( ASRM, 2004 &.No evidence that medical treatment of LPD improves pregnancy rate. ( ASRM, 2004 & Grade C NICE Guidelines 2004).

36. Message 19: The Role Of 3-D US In workup? Message 19: The Role Of 3-D US In workup? No role in routine infertility workup Is effective as two- dimensional US Is effective as two- dimensional US

37. Messages Regarding Management

38. General Rules Both partners should be considered as a one unit (couple) Timed intercourse to coincide with ovulation causes stress and not to be recommended ( e out COH). Smoking reduces both, women’s fertility as well as semen quality

39. 1. Anti E (cx & endometrium) 2. long lasting (till 14-22 day of cycle) 3.  sub clinical pregnancy loss 4.  LH sec > FSH   miscarriage 5. (LUF) syndrome (unexplained infertility) 6.  Ectopic ( Sluggish tubal transport) Message 20 : Disadvantages Ofempirical CC Message 20 : Disadvantages Of empirical CC

40. Conclusion It is more better to start workup of infertility earlier (6 month) and proceed…. than to waste time in empirical CC therapy, with its side effects.

41. Message 21: Pre requisites For Practicing IUI: The gynecologist should be aware of: 1.IUI workup. 2.Prevention of complication of super ovulation. 3.The optimal time for referral the case to ART centers ( not do IUI)

42. Optimum Time For Referral To ART Centers 1. Age > 35 Y. 2. Failed 3 IUI. 3. Severe male subfertility. 4. Number of mature follicles >4 (not give HCG). 5. Number of follicles (>12 mm) >8 (not give HCG). 6. Extensive endometriosis. 7. Need for cryopreservation of semen. 8. Non optimized office.

43. Male Subfertility Count Motility Morphology Million/ml (G1+G2%)(N%) Mild 15-20 40-50 30-40 Moderate 10-15 20-40 10-30 Severe <10 <20 <10 WHO

44. Message 22 Message 22 Targets For Treatment PCOS IR None IR ( Traditional) Causative ttt +or- Adjunctive Symptomatic ttt : Anovulation,Acne,Hirsutism, Insulin sensitizers : prevent Hyperandrogenemia – IR Vicious circle. Adjunctive PCOS

45. Message 23 :RCOG 2007 Guidelines All overweight PCOS should be provided with dietary and lifestyle advice.

46. Message 24: LOD Not rush towards LOD as first line of ttt PCOS.

47. Indications Of LOD In PCOS 1) IR PCOS (OBESE) Failure of : Change of life style. Insulin sensitizing agents. CC +/- HMG. 2) Non insulin R (Lean PCOS)

48. The Endless End

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