What every gynecologist needs to know about the modern management of the infertile couple

2. Active management of
infertility
Dr Aniruddha Malpani, MD
Malpani Infertility Clinic
www.DrMalpani.com

3. Traditional approach
• Infertility is 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
• TORCH test
• 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 testing strategy
Need only 4 things to make a baby !
Test for
• Eggs
• Sperms
• Uterus
• Tubes !

15. A cost-effective testing strategy
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 testing strategy
• Laparoscopy NOT needed to
complete the workup
• Low yield when HSG is normal

17. A cost-effective testing strategy
• 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
• Timed intercourse, 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
• As a 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
• Easy test 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 the report
• Volume
• Sperm count – million per ml
• Motility
• Total motile sperm count in ejaculate

25. Semen analysis
Tips in interpreting 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
Reason often 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
IUI is 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 low sperm 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
We have 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
2 key concepts
• “ Trying time”
• Fertility potential of couple

35. Common mistakes in treating
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 – polycystic ovarian
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 – polycystic ovarian
disease
• Induce ovulation
• Metformin, 1500 mg daily
• Myoinositol, 2 g daily
• Clomiphene/ Letrozole
• HMG
• Laparoscopic ovarian cauterisation

39. ART – Assisted Reproductive
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 is too 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 I refer my patients
for IVF
• Good clinic vs Bad clinic
• Embryo photos !

42. What is your success 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 pregnancy rates
• Patient ( age, cause of infertility)
• Clinic
1. Laboratory ( the IVF lab is the heart of
the IVF clinic !)
2. Physician

45. IVF cycle
4 basic steps
• 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 follicular growth ( ovarian response)
Vaginal ultrasound scans
– Day 3, 10, 12, 14
Rarely need to measure E2 levels !

49. IVF cycle
2. Egg collection
Vaginal ultrasound guidance
Non-surgical

52. In vitro fertilisation
100000 sperm added to egg
Kept in CO2 incubator ( 37 C) –
heart of an IVF lab !

53. IVF cycle
4. Embryo transfer
Number of embryos ?
When to transfer ? Day 2 or 3 or 5 ?

56. IVF cycle
No need for 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
• Intracytoplasmic Sperm
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 assisted hatching
• Advanced maternal age
• Thick zona
• Repeated implantation failure

63. Blastocyst transfer
• Higher implantation rate ?

64. • The number of embryos transferred
can be reduced without risking a
decline in pregnancy rates .
This helps to reduce the risk of
multiple pregnancy .

65. Freezing - cryopreservation

66. Vitrification
• Can store and preserve
–Sperm
–Embryos
–Eggs
–Ovarian tissue

67. The promise of ART
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 a medical 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
• Most doctors 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 !