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Active management of infertility - a guide for gynecologists
This document discusses best practices for actively managing infertility. It outlines some common mistakes made in traditional approaches, such as taking a "wait and watch" approach and not fully investigating the causes of infertility. The document recommends seeing couples together, completing the full testing protocol within 2 months, and having a clear treatment plan that progresses to more aggressive options if needed. It provides guidance on effective testing strategies and interpreting test results to determine the appropriate course of treatment, with the goal of helping patients conceive. The document also discusses advanced fertility treatments like IVF and stresses the importance of a good patient-doctor relationship.
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Introduction to infertility management presented by Dr. Aniruddha Malpani, highlighting the clinic and its services.
Infertility is common but often treated with a wait-and-watch approach, leading to patient frustration.
A call for change in infertility treatment as marriage age increases and biological clocks run out, emphasizing available technology.Errors include couples not seen together, uncoordinated tests, and unnecessary procedures leading to patient dissatisfaction.
Identification of unnecessary tests like TORCH and the breakdown of trust between doctors and patients due to ineffective treatments.
Emphasis on couples being treated together and the importance of clear communication regarding the infertility workup.
A cost-effective testing approach focusing on the essential tests needed to determine fertility issues without unnecessary procedures.
Post-workup treatment planning emphasized; recommended treatments based on a stepped-care approach including timed intercourse and IVF.
Details about semen analysis, its importance, and the conditions necessary for accurate testing.
Importance of determining causes of azoospermia and clarifying potential treatments, including testicular biopsy.
Addressing the management of low sperm counts, treatment options, and the need for effective counseling of couples.
Mistakes in treating female infertility including inappropriate treatment repetitions and lack of monitoring.
Guidelines for handling different causes of tubal infertility recommending IVF for severe cases.
PCOD as a common cause of infertility, highlighting treatment options including ovulation induction.
Description of ART and IVF as highly successful methods of assisting fertility despite cost concerns.
Discussion on IVF clinic quality, patient expectations of success rates, and factors impacting pregnancy rates.
Detailed steps of the IVF cycle, including superovulation and embryo transfer techniques.
Potential risks of IVF treatments including failure to conceive and complications like OHSS.
Introduction to advanced techniques like ICSI and genetic diagnostics in enhancing fertility outcomes.
Methods of cryopreservation for sperm, eggs, and embryos to facilitate future fertility treatments.ART's potential to help couples with various infertility problems and the ethical implications of regulation.
Emphasis on the importance of a good doctor-patient relationship, discussing options and empowering patients.
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Active management of infertility - a guide for gynecologists
- 2. Active management of infertility DrAniruddha Malpani, MD Malpani Infertility Clinic www.DrMalpani.com
- 3. Traditional approach • Infertilityis a common problem • Important and urgent for the patient • However, most doctors take a “wait and watch “ approach • Often , patients get fed up and frustrated and drop out of treatment • This is a shame !
- 5. Need to change! • Patients are getting married at an older age – time is running out as the biological clock ticks on • We now have technology to help them !
- 6. Common mistakes –what not to do ! • The couple is not seen together. • Husband’s semen analysis not performed. • Investigations are performed in a piecemeal fashion rather than as part of an overall strategy. • These are often done in a slow, time- consuming manner and patients get fed up
- 7. Common mistakes –what not to do ! • When the patient changes doctors, the doctor insists on repeating all the tests again, wasting the patient’s time and money • Doctors are keen to “do something” and repeated curettages and laparoscopies are often done unnecessarily
- 8. Common mistakes –what not to do ! • Also, myomectomies may be performed for small fibroids; ovarian cystectomy and wedge resections done for simple ovarian cysts which should have been left well alone; as well as “uterine ventrisuspension” when all else fails. • These create more damage and often cause infertility !
- 9. Wasteful tests • TORCHtest • TB PCR • Hysteroscopic “ metroplasty” • NK cell testing for failed implantation
- 10. The harm done •Trust between the doctor and patient breaks down. • The temptation to try many empirical, possibly useless medical treatments is considerable • Patients often end up spending large sums of monies at the hands of quacks and “spiritual healers”.
- 11. What to do •The couple must be seen together and treated as a unit. • First, find out the reason for the infertility. • The workup ( testing protocol) must be explained to the patient and should be completed in 2 months.
- 12. Egg plus sperm= baby !
- 14. A cost-effective testingstrategy Need only 4 things to make a baby ! Test for • Eggs • Sperms • Uterus • Tubes !
- 15. A cost-effective testingstrategy Semen analysis (during the wife’s menstrual period) Blood tests ( AMH, Prolactin, LH, FSH, TSH) – Day 3-5; Hysterosalpingogram-Day 5-7; Ultrasound for ovulation monitoring – Day 11-16.
- 16. A cost-effective testingstrategy • Laparoscopy NOT needed to complete the workup • Low yield when HSG is normal
- 17. A cost-effective testingstrategy • The testing should not stop when a problem is discovered. Complete the testing. Couples may have multiple problem. • A single abnormal result does not necessarily mean that a problem exists – re-test to confirm.
- 18. Plan of action •After the workup, plan course of action. • Treatment should not be on an ad-hoc single cycle basis
- 19. Plan of action •You need to keep on progressing to more aggressive treatment! • Similar to the stepped-care approach to treating hypertension !
- 20. Unexplained infertility • Timedintercourse, 6 cycles, for young couples • Intrauterine insemination (IUI)- 3 cycles; • Superovulation with HMG plus IUI-3 cycles; • then IVF. • Don’t waste time!
- 21. Treatment plan • Asa rule of thumb, if a treatment is going to work, it should work in 4 cycles. • Don’t repeat IUI again and again • Need to tailor treatment according to patient’s age, medical diagnosis, and budget
- 22. Semen analysis • Easytest to do - easy to do badly ! • Must be performed at a reliable lab • 3-day abstinence • No lubricant • Clean wide-mouthed jar
- 23. Semen analysis • Often,men are forced to produce a semen sample in a dirty bathroom, and this can be hard ! • Patient may need help to produce a sample – discuss this with him • Can use a vibrator for assistance
- 24. Semen analysis Interpreting thereport • Volume • Sperm count – million per ml • Motility • Total motile sperm count in ejaculate
- 25. Semen analysis Tips ininterpreting the report • Fructose and pH of importance only in men with azoospermia • A few pus cells are normal – treatment with antibiotics is not usually helpful !
- 26. Azoospermia Determine the reason Obstructive? Non-obstructive ? Clinical examination ( vas, epididymis, testis size) Volume, pH, fructose FSH level
- 27. Testis biopsy 1. Diagnostic– need multiple microbiopsies to sample many areas ! 2. Send in Bouin’s fluid to reliable lab 3. Spermatogenesis is not uniform, and some patients with testicular failure ( non- obstructive azoospermia) will have isolated foci of sperm production which can be used for TESA-ICSI
- 28. Low sperm count Reasonoften unknown Maybe because of a microdeletion on the Y- chromosome. Not worth doing this test – does not change treatment options Empiric medical therapy – wastes time and money Varicocele surgery not helpful
- 29. Low sperm count •Knee-jerk response – refer to urologist. Usually, not helpful • Patients get fed up • The end-point is not an increase in the sperm count – it is a baby ! • Better to refer to IVF clinic before wife becomes old
- 30. Low sperm count 1.If total motile sperm count more than 20 million, then IUI ( with HMG superovulation) 2. If TMSC less than 5 million, then ICSI
- 31. Low sperm count IUIis not sensible treatment for low sperm counts, though it is often misused for this ! If the sperm are not functionally competent, then washing them will not help !
- 32. Interpreting a lowsperm count is difficult Patient does not want to know what the count or motility is – he wants to know if his sperm can make a baby Not possible to answer this – no test for sperm function
- 33. Low sperm count Wehave all seen men with low sperm counts who have fathered a baby This is why counselling these couples is difficult IVF is the definitive test of sperm function !
- 34. Low sperm count 2key concepts • “ Trying time” • Fertility potential of couple
- 35. Common mistakes intreating female infertility 1. Repeating clomiphene again and again 2. Not monitoring ovulation induction therapy 3. Using danazol to treat mild endometriosis
- 36. Tubal infertility 1. TB. Advise IVF 2. Hydrosalpinx . Advise IVF. Results with surgery very poor. 3. Cornual block. Advise FTR ( fluoroscopic tubal recanalisation)
- 37. PCOD – polycysticovarian disease • Commonest cause of anovulation • Irregular cycles • Patients often are obese and hirsute • Vaginal scan for antral follicle count • LH, FSH ratio • AMH levels
- 38. PCOD – polycysticovarian disease • Induce ovulation • Metformin, 1500 mg daily • Myoinositol, 2 g daily • Clomiphene/ Letrozole • HMG • Laparoscopic ovarian cauterisation
- 39. ART – AssistedReproductive Technology Simple principle - increase the chances of the egg and sperm meeting What is not happening in the bedroom, we do in the lab ! IVF is the final common pathway – bypasses all hurdles ! Not artificial – we are just assisting nature ! No increased risk of birth defects
- 40. But IVF istoo expensive ! Maybe. But just because the right treatment is expensive, does not mean that you do the wrong treatment, just because it is cheap ! Often, IVF is more cost-effective !
- 41. Where should Irefer my patients for IVF • Good clinic vs Bad clinic • Embryo photos !
- 42. What is yoursuccess rate ? • For the patient, success means a baby ! Success rate is either 100% - or 0% • For the clinician, it’s a little more complicated , since you are dealing with groups of patients. • Success rates have improved dramatically in the last few years !
- 43. Factors affecting pregnancyrates • Patient ( age, cause of infertility) • Clinic 1. Laboratory ( the IVF lab is the heart of the IVF clinic !) 2. Physician
- 45. IVF cycle 4 basicsteps • 1. Superovulation • 2. Egg collection • 3. In vitro fertilisation • 4. Embryo transfer
- 46. IVF cycle 1. Superovulation 1.With HMG ( gonadotropins) Natural hormones. Urinary products Newer recombinant preparations much more expensive, but no better 2. Downregulation with Buserelin ( GnRH) or antagonists. Both work as well 3. Low cost – clomiphene plus HMG
- 47. IVF cycle Superovulation Monitor folliculargrowth ( ovarian response) Vaginal ultrasound scans – Day 3, 10, 12, 14 Rarely need to measure E2 levels !
- 49. IVF cycle 2. Eggcollection Vaginal ultrasound guidance Non-surgical
- 52. In vitro fertilisation 100000sperm added to egg Kept in CO2 incubator ( 37 C) – heart of an IVF lab !
- 53. IVF cycle 4. Embryotransfer Number of embryos ? When to transfer ? Day 2 or 3 or 5 ?
- 56. IVF cycle No needfor bed rest – you cannot cough the embryo out ! Still a matter of luck ! Not the patient’s “fault” if she doesn’t conceive She cannot “reject” the embryo !
- 58. Risks of IVF 1.No pregnancy 2. Multiple pregnancy 3. Ectopic pregnancy 4. OHSS – ovarian hyperstimulation syndrome. Managed conservatively
- 59. Advanced fertilisation techniques • IntracytoplasmicSperm Injection(ICSI) • Assisted Hatching • Blastocyst transfer • Preimplantation Genetic Diagnosis (PGD)
- 60. ICSI • Microinjection (Intracytoplasmic sperm injection) • One egg + one sperm = one embryo ! • Can use testicular sperm even from men with testicular failure ( with high FSH levels and small testes)
- 62. Indications for assistedhatching • Advanced maternal age • Thick zona • Repeated implantation failure
- 63. Blastocyst transfer • Higherimplantation rate ?
- 64. • The numberof embryos transferred can be reduced without risking a decline in pregnancy rates . This helps to reduce the risk of multiple pregnancy .
- 65.
- 66. Vitrification • Can storeand preserve –Sperm –Embryos –Eggs –Ovarian tissue
- 67. The promise ofART We can help any couple to have a baby, no matter what their medical problem ! Third party reproduction Embryo adoption Donor eggs Surrogate uterus
- 74. ART is amedical success story ! • However, advances in IVF have come with government guidelines and laws • The purpose of these guidelines is to ensure that these technologies are used safely and responsibly • How well do they work ? What purpose do really serve ?
- 75. Useful regulation • Mostdoctors would agree that there is a need to regulate the practice of IVF, so that all IVF clinics meet certain basic standards. • Need to protect infertile patients, who are emotionally vulnerable, and can get cheated easily by unscrupulous doctors
- 76. In real life •Bureaucrats only understand paperwork • Overburdened doctors end up spending more time filling up forms rather than talking to patients ! • Good doctors don’t need to be monitored; and monitoring bad doctors does not help !
- 77. Real life problem- How many embryos to transfer ? • Ideal would be one. However, the technology is still not perfect • The law is blind – limit of 2 for everyone ! • Why ? Makes sense for the NHS ! • Does this make sense for a 43 year old woman doing her 5th IVF cycle ? • Let the couple decide for themselves – weigh the pros and cons
- 78. The doctor-patient relationship •Guide your patient – help them to become an expert on their problem • Discuss all their options with them, including Child-free living Adoption Medical treatment
- 82. The ideal doctor •Doesn’t tell the couple what to do • Let’s them decide for themselves, so they have peace of mind they did their best !