MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW

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• MANAGEMENT OF INFERTILE COUPLE EVIDENCE BASED
  VIEW

Dr.Mohamed El Sherbiny MD ObstetricsGynecology
Senior Consultant Damietta General
Hospital Damietta Egypt
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Sources of EB for The Topic

• PubMed
• Cochrane library  .
• Evidence based recommendations RCOG
• WHO
• Journal of evidence based obstetrics and
  gynecology.
• National Guideline Clearinghouse .

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Which Investigations?!
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Diagnostic tests for infertility are categorized
into 3 categories.
ESHRE Capri workshop 2000

• 1-Testes which have an established correlation
  with pregnancy.
• 2- Testes which are not consistently correlated
  with pregnancy.
• 3-Testes which seem not to correlate with
  pregnancy.

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The First Category The Basic Routine
Infertility Investigation

• Tests which have an established correlation with
  pregnancy are
• 1- Semen analysis
• 2-Tubal patency by HSG or laparoscopy
• 3-Mid luteal progesterone for the diagnosis of
  ovulation

RCOG Guidelines Grade B Recommendation 1999
ESHRE Capri workshop 2000
National Guideline Clearinghouse 2000
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The Second Category

• Testes which are not consistently correlated with
  pregnancy as.
• Zona-free hamster egg penetration tests.
• Post coital test.
• Antisperm antibodies assays.

RCOG Guidelines Grade B Recommendation 1999
ESHRE Capri workshop 2000
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The Third Category

• Includes tests which seem not to correlate with
  pregnancy as
• Endometrial dating.
• Varicocele assessment.
• Chlamydial testing.
• May have a role in special situations

ESHRE Capri workshop 2000
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Hysteroscopy U/S ??

• Hysteroscopy.
• U/S scan of the endomerium.
• Are not recommended in the routine.
• Investigation of the infertile couple.

RCOG Guidelines Grade C Recommendation
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T3, T4, TSH PL??

• There is no value in measuring thyroid function
  or prolactin in women with a regular menstrual
  cycle, in the absence of galactorrhoea or
  symptoms of thyroid disease.

RCOG Guidelines Grade B Recommendation 2001
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Day 3 (FSH) And Estradiol

• D3 (FSH) and (E2)estradiol for patients gt35
  years. because of their reduced window of
  fertility potential.

Bloomington Institute for Clinical Systems
Improvement (ICSI) 2000 The National Guideline
Clearinghouse .Modified 2002
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Semen Analysis

• Serial semen samples (at least two) should be
  assessed in the same laboratory
• The lower limit of the normal semen testing is
• gt 20 million/mL.
• gt50 progressive motility
• gt30 normal forms
• WHO,1999

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Semen Analysis

• In a RCT, the determination of motility
  characteristics as obtained by computer-assisted
  sperm analysis (CASA ) systems is of limited
  value . (Krause ,1995 ).

CASA is not superior to conventional semen
analysis.
RCT Randomized control trial
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AzoospermiaTesticular biopsy

• Testicular biopsy should be performed only in
  the context of a tertiary service where there are
  facilities for sperm recovery and cryostorage

RCOG Guidelines Grade C Recommendation
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General Advice
Weight loss if BMI gt 30,
Women should give up smoking (B). Men should
give up smoking (C)
Regular intercourse throughout the cycle,rather
than the use of temperature charts and LH
detection (C)
RCOG Guidelines
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• Treatment

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Male SubfertilityOligo/asthenospermia

• Gonadotrophin is effective for treatment for
  male hypogonadotrophic hypogonadism.
• However, drug treatments are ineffective in the
  treatment of idiopathic male infertility.

RCOG Guidelines Grade B Recommendation
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Male Subfertility
Oligo/asthenospermia

• IUI offers couples with male subfertility benefit
  over timed intercourse, both in natural cycles
  and in cycles with COH.
• Mild ovarian hyperstimulation with gonadotrophins
  is advised in cases with less severe semen
  defects (motile sperm concentration gt 10
  million).

Cohlen et al., January 1999 (Cochrane Review).
In The Cochrane Library, Issue 2 2002. Oxford
Update Software.
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Male Subfertility
Oligo/asthenospermia

• Intrauterine insemination with or without ovarian
  stimulation is an effective treatment where the
  man has abnormalities of semen quality, but it
  has to be remembered that the pregnancy rates
  even after treatment remain very low (A)

Cohlen et al., January 1999 (Cochrane Review).
In The Cochrane Library, Issue 2 2002. Oxford
Update Software.
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Varicocele

• Varicocele treatment should be offered
• when all of the following are present
• A varicocele is palpable.
• The couple has documented infertility.
• The female has normal fertility or potentially
  correctable infertility.
• The male partner has one or more abnormal semen
  parameters .

Baltimore (MD) American Urological Association,
Inc. 2001 Apr. 9 p. 15 National Guideline
Clearinghouse modified 2002
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Obstructive Azoospermia

• Vasectomy reversal and surgical correction of
  epididymal blockage (microsurgical)can be
  considered in cases of obstructive azoospermia .
• It needs Expert hands.

RCOG Guidelines Grade B Recommendation
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ICSI

• Intracytoplasmic sperm injection (ICSI) is
  indicated in
• Severe deficits in semen quality
• Obstructive azoospermia .
• Non-obstructive azoospermia .
• Previous IVF cycle with failed or very poor
  fertilisation.

RCOG Guidelines Grade A Recommendation
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Ovulation Disorders

• Clomiphene C. is an effective treatment for
  anovulation in appropriately selected women.(A)
• (Mild to moderate WHO type 1
• T type 2 dysfunction)
• Up to 12 cycles of treatment should be considered
  (B).

RCOG Guidelines
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Ovulation Disorders

• FSH and hMG are both effective for ovulation
  induction in women with clomiphene resistant
  polycystic ovarian syndrome.

RCOG Guidelines Grade A Recommendation
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Ovulation Disorders

• There is no advantage in routinely using GRh
  analogues in conjunction with gonadotrophins for
  ovulation induction in women with
  clomiphene-resistant PCOS

RCOG Guidelines Grade A Recommendation
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Hyperprolactinaemia

• Dopamine agonists are effective treatment for
  women with anovulation due to hyperprolactinaemia

RCOG Guidelines Grade A Recommendation
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PCOLaparoscopic Drilling"

• Laparoscopic ovarian drilling with either
  diathermy or laser is an effective treatment for
  anovulation in women with clomiphene-resistant
  PCOS

RCOG Guidelines Grade A
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PCOLaparoscopic Drilling"

• There is insufficient evidence of a difference
• in pregnancy rates between
• Laparoscopic ovarian drilling after 6-12 m follow
  up
• Gonadotrophins 3-6 cycles .
• Multiple pregnancy are considerably reduced
• after laparoscopic drilling..

Farquhar et al., August 2001 (Cochrane Review).
In The Cochrane Library, Issue 2 2002. Oxford
Update Software.
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Endometriosis Minimal Mild

• Surgical ablation of minimal
• And mild endometriosis improves fertility in
  subfertile women

RCOG Guidelines Grade A Recommendation
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Endometriosis Mild

• . Also , ovarian stimulation with IUI is more
  effective for them than either no treatment or
  IUI alone.

RCOG Guidelines Grade A Recommendation
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Endometriosis Moderate to Severe
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Endometriosis Moderate to Severe

• Surgical treatment may improve fertility but
  controlled studies and comparisons with assisted
  reproduction techniques are required (B).

RCOG Guidelines Grade B Recommendation
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Endometriosis-associated infertility

• Hormonal therapy for ovulation suppression
  cannot be recommended as a standard therapy for
  endometriosis-associated infertility.
• So drug treatments dont improve conception
  rate.

Hughes et al., 1996 (Cochrane Review). In The
Cochrane Library, Issue 2 2002. Oxford Update
Software.
RCOG Guidelines Grade A Recommendation
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Microsurgical Tubal Surgery

• Microsurgical tubal surgery may be
  appropriate for
• Mild distal tubal disease ( Laparoscopy).
• Proximal tubal obstruction, or Reanastomosis
  to reverse sterilization .
• If pregnancy has not occurred within 12 m of
  surgery, IVF should be discussed.

RCOG Guidelines Grade B Recommendation
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Microsurgical Tubal SurgeryMild distal tubal
disease
Cutting fimbrio-omental band
Dissection of fimbriae adherent to the uterus
Micro scissor Cutting fimbrial band
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Tubal Catheterization

• Where proximal tubal obstruction is suspected,
  and there are no other tubal abnormalities, a
  tubal catheterisation procedure may be attempted

RCOG Guidelines Grade B Recommendation
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Tubal Catheterization
R. Ovary
Bilateral Cornual Block
R. fimbria
Cornual catheterization
Amorphous material
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Moderate to Severe Distal tubal Disease

• . IVF should be considered as the first line
  treatment for moderate to severe distal tubal
  disease

RCOG Guidelines Grade B Recommendation
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Hydrosalpinges IVF,

• Laparoscopic salpingectomy should be considered
  for all women with hydrosalpinges prior to IVF
  treatment

Johnson et al., March 2002(Cochrane Review). In
The Cochrane Library, Issue 2 2002. Oxford
Update Software.
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Unexplained Infertility

• Expectant management (no treatment) for up to
  three years of trying should be considered,
  taking into consideration the woman's age.

RCOG Guidelines GradeC Recommendation
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Unexplained Infertility

• The effective treatment for unexplained
  infertility is ovarian stimulation in conjunction
  with IUI . If failed IVF is recommended.

RCOG Guidelines Grade A Recommendation
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Thank You