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Infertility unexplained eb glines2019

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ABOUBAKR ELNASHAR

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Infertility unexplained eb glines2019

  1. 1. 12/14/2019 1 UNEXPLAINED INFERTILITY An Evidence Based Guidelines Canadian Fertility&Andrology Society 2019 Prof. Aboubakr Elnashar Benha university Hospital, EgyptABOUBAKR ELNASHAR CONTENTS 1.QUALITY OF EVIDENCE 2.INCIDENCE 3.DEFINITION 4.DIAGNOSIS 5.TREATMENT CONCLUSION ABOUBAKR ELNASHAR
  2. 2. 12/14/2019 2 1. QUALITY OF EVIDENCE & CLASSIFICATION OF RECOMMENDATIONS ABOUBAKR ELNASHAR 2. INCIDENCE  30–50% based on criteria (Collins and Crosignani, 1992; Esteves et al., 2015). ABOUBAKR ELNASHAR
  3. 3. 12/14/2019 3 3. DEFINITION  Unexplained infertility (UEI)  Absence of identifiable causes for the infertility (Moghissi and Wallach, 1983; Zegers-Hochschild et al., 2017). Inability to conceive After 1 year of unprotected intercourse With routine (standard, basic) investigations of infertility showing no abnormality. (RCOG guidelines,1998; Randolph,2000) ABOUBAKR ELNASHAR  Tests that have an established association with pregnancy: 1. Conventional semen analysis 2. Mid luteal P 3. HSG (ESHRE, 2000) ABOUBAKR ELNASHAR
  4. 4. 12/14/2019 4  Limitations of this definition.  Age: After 35 y: decrease LBR (Kamel, 2010).  Coital difficulties  Other male factors  Endometriosis  Ovarian reserve  Oocyte quality  Tubal dysfunction  Uterine factors  Cervical mucus factors  Immunological factors  Genetic factors ABOUBAKR ELNASHAR 4. DIAGNOSIS By exclusion Consider the following (Moghissi et al,2000) Was the infertility evaluation 1. Complete? 2. Performed correctly? 3.Interpreted appropriately? ABOUBAKR ELNASHAR
  5. 5. 12/14/2019 5  LAPAROSCOPY  In the absence of evidence for tubal or other pelvic pathology, laparoscopy is not necessary in UEI (Level II-2B). ABOUBAKR ELNASHAR 5. TREATMENT  Empirical  Dependent on:  Resources  Age  Duration of infertility.  Step-wise progression  The least invasive, least expensive  followed by a gradual progression to  ART if the initial treatments fail. ABOUBAKR ELNASHAR
  6. 6. 12/14/2019 6  Lines of treatment I. Expectant management (EM) II. Superovulation 1. Oral agents:  CC:  Let 2. GnT III. IUI 1. Alone 2. With oral agents 3. With GnT IV. IVF/ICSI ABOUBAKR ELNASHARABOUBAKR ELNASHAR I. EXPECTANT MANAGEMENT  What? Healthy lifestyle habits Maintain optimal weight Continue regular sexual intercourse Not always appealing Many couples prefer active medical treatment CC or IUI Vs EM: CC or IUI more acceptable (Bhattacharya et al, 2008) ABOUBAKR ELNASHARABOUBAKR ELNASHAR
  7. 7. 12/14/2019 7  Can you expect occurrence of pregnancy?  The synthesis model= Hunault model (Hunault et al, 2004, Hum Rep)  based on the patient data of 3 previous cohorts of Eimers, Collins and Snick, combined into one  Discriminate between couples  who will conceive naturally&  those who will not within 1 year  5 variables 1. Age 2. Duration of infertility 3. Type of infertility: primary or secondary, 4. Referral status: referred by  general practitioner or  another gynaecologist 5. Percentage motile sperm ABOUBAKR ELNASHAR (Hunault et al, 2004, Hum Rep) ABOUBAKR ELNASHAR
  8. 8. 12/14/2019 8 ABOUBAKR ELNASHAR  In couples with a good prognosis based on  Age  Duration of infertility expectant management (EM) can be offered (Level 1A). ABOUBAKR ELNASHAR
  9. 9. 12/14/2019 9  Good-prognosis: mean age 33 y, median duration of infertility 2 y  EM:  LBR after 6 months: 27%. (Steures et al., RCT, 2006)  Good prognosis: mean age 32 y median duration of infertility 2.5 y (Bhattacharya et al. 2008, RCT) ABOUBAKR ELNASHAR II. SUPEROVULATION 1. Oral Agents  CC alone  does not offer any benefit over EM  should not be offered to couples with UEI (Level 1A).  Aromatase inhibitors alone  do not offer any benefit in comparison to CC alone  should not be offered to couples with UEI (Level 1A). ABOUBAKR ELNASHAR
  10. 10. 12/14/2019 10 2. Gonadotropins There is insufficient evidence to recommend GnT-OS alone in the management of UEI (Level IIIL). ABOUBAKR ELNASHAR III. IUI 1. Alone (Natural-cycle IUI)  Natural-cycle IUI  does not offer any benefit over EM  should not be offered in UEI (Level 1A). ABOUBAKR ELNASHAR
  11. 11. 12/14/2019 11 2. Ovarian Stimulation With Oral Agents & IUI  IUI with oral agents is  an appropriate treatment in couples with UEI  more effective than EM (Level IA).  Either Let or CC can be used for IUI (Level 1A). ABOUBAKR ELNASHAR  Farquhar et al, 2018, lancet  RCT  UEI for 2-3 y  Oral OS IUI is an effective treatment in UEI ABOUBAKR ELNASHARABOUBAKR ELNASHAR
  12. 12. 12/14/2019 12 AMIGOS Trial Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (Diamond et al.,New Eng. J. of Med 2015) – 12 RCT – 900 couples – Age: 32y. – Infertility duration: 2.9y – 4 OS cycles with IUI • No sig difference • Given the ease, cost and lower rate of multiple pregnancy, IUI with oral agents is a standard first-line therapy in good-prognosis women with UEI. ABOUBAKR ELNASHAR 3. Ovarian Stimulation With GnT& IUI  GnT/IUI is associated with  Higher PR/cycle  Higher multiple PR/cycle than IUI with oral agents (Level IA). . ABOUBAKR ELNASHAR
  13. 13. 12/14/2019 13 IV. IVF/ICSI  IVF can be offered as an effective 1st -line treatment in UEI based on  Cost  Age  Duration of infertility (Level 1B).  IVF should be offered to couples with UEI after failure of 3 cycles of OS/IUI (Level 1A). ABOUBAKR ELNASHAR  GnT/ IUI Vs IVF for unexplained infertility. (Nandi et al, RCT, 2017) ABOUBAKR ELNASHARABOUBAKR ELNASHAR
  14. 14. 12/14/2019 14  There is insufficient evidence to recommend ICSI in UEI to increase LBR, although ICSI may reduce the incidence of TFF (Level 1B).  During IVF for UEI, TFF occurs in 5–10% (Bungum et al., 2004; Tournaye et al., 2002). ABOUBAKR ELNASHAR CONCLUSIONS  UEI, a common problem, remains a diagnosis of exclusion.  Counseling the couple with regard to  treatment in terms  Expected outcome  Adverse events  Age  duration of infertility. ABOUBAKR ELNASHAR
  15. 15. 12/14/2019 15  There is a role for less invasive treatment options  Expectant management and  IUI with ovarian stimulation.  Advancing therapy to IVF  Benefit:  improved LBR/cycle  reduced multiple pregnancy  Although  invasive  costly. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR You can get this lecture and 450 lectures from 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site 3.elnashar53@hotmail.com ABOUBAKR ELNASHAR

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