It is very important to refer proper patient at proper time for infertility treatment. This presentation explores briefly the different criteria to refer the patient and the follow-up after.
2. Infertility
โ Introduction to infertility
โ Background
โ General considerations
โ Unexplained infertility
โ Criteria for referral
3. Introduction
โIt is estimated that more than 15% of
couples living in developed countries
are infertile.
โNo major change in prevalence, but
there has been an increase in
demand for treatment during the past
decade
4. Introduction
โProbably because of the perception
that effective assisted reproductive
technology (ART) treatments are
now easily available at affordable
cost
5. Background
ART treatment also has disadvantages.
โ It involves greater expense, and potentially
serious complications such as OHSS and
multiple pregnancies can occur.
โ There are also fears that drugs that induce
ovulation may increase the risk of ovarian
cancer.
6. Background
โInfertility treatment should therefore
be individualized to avoid subjecting
couples to unnecessary risks due to
overtreatment,
โOr to inappropriate delay because of
under treatment.
8. Artificial
insemination
โStimulated / unstimulated cycle
โWomen who are ovulating regularly
& have patent tubes should have
minimum of 6 cycles of insemination
without ovarian stimulation to reduce
the risk of multiple pregnancy
9. Artificial
insemination
โCouples who do not conceive after 6
cycles despite all normal parameters
should be offered further 6 cycles of
unstimulated IUI before IVF is
considered
10. Chances of
conception
โOver 50% of women under 40 years
will conceive within 6 cycles of IUI
โOf those who do not conceive within
6 cycles of IUI about half will do so in
next 6 cycles
โCumulative pregnancy rate is over
75%
11. Success
with IUI
โIUI using fresh sperms is
associated with higher conception
rates than frozen thawed sperms
โIntrauterine insemination is
associated with higher conception
rates than intracervical insemination
even, even with frozen sperms
โDonor sperm should always be IUI
as it improves pregnancy rates
12. Unstimulated
IUI
General
โCouple who are unable to achieve
normal intercourse due to physical or
psychosexual problems
Specific conditions
โEx: HIV positive male partner
Insemination is timed around ovulation
13. General
considerations
In patients with:
โ Unexplained infertility
โ Mild endometriosis
โ Mild male factor infertility
โ Do not offer IUI!
โ Advice the couple to try to conceive
for at least 2 years before offering
IVF
14. Unexplained
infertility
โ Patients with unexplained infertility -
CC as stand alone treatment does
not increase the chances of
pregnancy
โ IVF has to be offered to these
women who do not conceive in 2
years of regular unprotected
intercourse
17. Criteria
for
referral
Inform the couple
One full cycle of IVF consists of:
โ 1 episode of ovarian stimulation with
or without ICSI
โ Transfer of fresh or frozen embryos
18. Women
<40 yrs
Women less than 40 years, who have
not conceived after
โ 2 years of unprotected intercourse or
โ 12 cycles of insemination (of which at least 6
IUI)
Then offer full 3 cycles of IVF
with/without ICSI
โ If the woman reaches 40 yrs age during
treatment, complete current full cycle but
donโt offer any further cycles
19. Women
40-42 yrs
Women aged 40-42 years, who have
not conceived after
โ 2 years of unprotected intercourse or
โ 12 cycles of insemination (of which at least 6
IUI)
Then offer 1 full cycle of IVF
with/without ICSI provided
โ They have never previously had IVF
โ No evidence of low ovarian reserve
โ Couple counseled about pregnancy at this
age
20. โ
โRefer directly to an IVF specialist,
when investigations show there is no
chance of pregnancy with expectant
management, irrespective of age
IVF is the only effective treatment in these patients
23. General
considerations
In IVF program,
โ Pretreatment with OCP or
progestogen does not affect the
chances of having a live birth
โ Can be considered in order to
schedule IVF treatment
28. Choice of
method
The choice of the procedure used, e.g.
IVF-ET, GIFT, ZIFT, or ICSI, is made
depending on:
โ Needs,
โ Resources,
โ Circumstances of the couple,
โ Availability of the facilities &
โ Experience and expertise of the
gynecologist / embryologist.
30. Husband
โ Physical examination: Systemic &
local
โ Detailed Semen Analysis: if
abnormal โ repeat after suitable
interval.
โ Screening for HIV, HBV, HCV.
โ Endocrinological report if needed
and therapy.
31. Wife
โ Physical examination: systemic &
local
โ Detection & Timing of Ovulation by
appropriate test
โ Assessment of Tubal Patency.
โ Screening for HIV, HBV, HCV .
โ Endocrinological report if needed
and therapy
32. Referring
the
patient
โ Any gynecologist not specifically
trained in the subspecialty of
infertility care can also complete
these investigations.
โ Based on the results of these
investigations, couples should be
referred.
