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 !
4.
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.
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 !
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 !
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
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
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
53. IVF cycle
4. Embryo transfer
Number of embryos ?
When to transfer ? Day 2 or 3 or 5 ?
54.
55.
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 !
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)
61.
62. Indications for assisted hatching
• Advanced maternal age
• Thick zona
• Repeated implantation failure
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 .
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
68.
69.
70.
71.
72.
73.
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
79.
80.
81.
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 !