1. Tips for infertility practice and IVF program
Dr(Brig) R K Sharma VSM MD

2. TIP OR THE GREAT MASS

6. As Ernest Hemingway once said, “The dignity of movement of an iceberg is due to only one-eighth of it being above water.” 

7. GREAT MASS-FOUNDATION OF INFERTILTY PRACTICE
INFERTILITY IS NOT THE DUMPING GROUND OF FAILED OBSTETRICIANS BUT ACME OF THEIR CARRIER

8. ADEQUATE KNOWLEDGE OF PHYSIOLOGY,ANATOMY,ENDOCRINOLOGY,
PATHOLOGY, PSYCHOLOGY,ULTRASONOGRAPHY, ENDOSCOPY,OBS &GYNE, ANDROLOGY,EMBRYOLOGY,

9. 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

10. ELEPHANT AND FOUR BLIND MEN

19. Evidence Based Medicine
HIPPOCRATES
ARCHIE COCHRANE
Primum non nocere
First, do no harm
Evidence Based Medicine

20. WE MAKE HAPPY FAMILIES BABIES ARE JUST SMALL PARTS OF IT

21. How do we measure the success

22. 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?

23. No .none of these can be measured as success
Pregnancy rate can be increased by denying treatment to all who are likely to have more failures like eldely , tb, severe endometriosis, etc

24. 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.

25. Is it the number of lectured delivered?
Well ,those who can do will do
others will give lectures………….. like me.

26. Is it the position in the medical society?
Well …politics is bad every where?
Who suffers ….the patient.

29. 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

30. COUNSELLING

31. 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.

32. 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.

33. 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.

34. TIPS FOR MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW

35. Sources of EB for The Topic
PubMed
Cochrane library  .
Evidence based recommendations RCOG
WHO
Journal of evidence based obstetrics and gynecology.
National Guideline Clearinghouse .

36. Which Investigations?!

37. Diagnostic tests for infertility are categorized into 3 categories.
ESHRE Capri workshop 2000
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.

38. 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
RCOG Guidelines : Grade B Recommendation 1999
ESHRE Capri workshop 2000
National Guideline Clearinghouse 2000

39. The Second Category
Testes which are not consistently correlated with pregnancy as.
Zona-free hamster egg penetration tests.
Post coital test.
Antisperm antibodies assays.
RCOG Guidelines : Grade B Recommendation 1999
ESHRE Capri workshop 2000

40. Includes tests which seem not to correlate with pregnancy as:
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
ESHRE Capri workshop 2000

41. Hysteroscopy U/S ?? U/S scan of the endomerium. Hysteroscopy.
Are not recommended in the routine.
Investigation of the infertile couple.
RCOG Guidelines : Grade C Recommendation

42. 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.
RCOG Guidelines : Grade B Recommendation 2001

43. 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); The National Guideline Clearinghouse .Modified 2002

44. Semen Analysis The lower limit of the normal semen testing is
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

45. Semen Analysis CASA is not superior to conventional 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

46. Azoospermia:Testicular biopsy
Testicular biopsy should be performed only in the context of a tertiary service where there are facilities for sperm recovery and cryostorage
RCOG Guidelines :Grade C Recommendation

47. General Advice Weight loss if BMI > 30,
Women should give up smoking (B).
Men should give up smoking (C)
Regular intercourse throughout the cycle,rather than the use of temperature charts and LH detection (C)
RCOG Guidelines

48. Treatment

49. Male Subfertility Oligo/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

50. Oligo/asthenospermia
Male Subfertility
Oligo/asthenospermia
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 Oxford: Update Software.

51. Oligo/asthenospermia
Male Subfertility
Oligo/asthenospermia
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 Oxford: Update Software.

52. Varicocele Varicocele treatment should be offered
when all of the following are present:
A varicocele is palpable.
The couple has documented infertility.
The female has normal fertility or potentially correctable infertility.
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

53. Obstructive Azoospermia
Vasectomy reversal and surgical correction of epididymal blockage (microsurgical)can be considered in cases of obstructive azoospermia . It needs Expert hands.
RCOG Guidelines : Grade B Recommendation

54. ICSI Intracytoplasmic 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

55. 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

56. Ovulation Disorders
FSH and hMG are both effective for ovulation induction in women with clomiphene resistant polycystic ovarian syndrome.
RCOG Guidelines : Grade A Recommendation

57. Ovulation Disorders
There is no advantage in routinely using GRh analogues in conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant PCOS
RCOG Guidelines : Grade A Recommendation

58. Hyperprolactinaemia
Dopamine agonists are effective treatment for women with anovulation due to hyperprolactinaemia
RCOG Guidelines : Grade A Recommendation

59. 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

60. 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 Oxford: Update Software.

61. Endometriosis :Minimal &Mild
Surgical ablation of minimal
And mild endometriosis improves fertility in subfertile women
RCOG Guidelines : Grade A Recommendation

62. Endometriosis : Mild
Also , ovarian stimulation with IUI is more effective for them than either no treatment or IUI alone.
RCOG Guidelines : Grade A Recommendation

63. Endometriosis : Moderate to Severe

64. Endometriosis :Moderate to Severe
Surgical treatment may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required (B).
RCOG Guidelines : Grade B Recommendation

65. 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 Oxford: Update Software.
RCOG Guidelines : Grade A Recommendation

66. 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.
RCOG Guidelines : Grade B Recommendation

67. Microsurgical Tubal Surgery Mild distal tubal disease
Dissection of fimbriae adherent to the uterus
Cutting fimbrio-omental band
Micro scissor Cutting fimbrial band

68. Tubal Catheterization
Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted
RCOG Guidelines : Grade B Recommendation

69. Tubal Catheterization
R. Ovary
Bilateral Cornual Block
R. fimbria
Cornual catheterization
Amorphous material

70. Moderate to Severe Distal tubal Disease
. IVF should be considered as the first line treatment for moderate to severe distal tubal disease
RCOG Guidelines : Grade B Recommendation

71. Hydrosalpinges & IVF,
Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment
Johnson et al., March 2002(Cochrane Review). In: The Cochrane Library, Issue Oxford: Update Software.

72. 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

73. Unexplained Infertility
The effective treatment for unexplained infertility is ovarian stimulation in conjunction with IUI . If failed IVF is recommended.
RCOG Guidelines : Grade A Recommendation

74. 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

75. pH
Osmolarity
Temperature
Infection
VOC
Air quality

87. ONCE AT PEAK ..LEARN TO BALANCE

91. THANKS