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MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW

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Oxford: Update Software. Oligo/asthenospermia. Varicocele. Varicocele ... Oxford: Update Software. RCOG Guidelines : Grade A Recommendation ... Oxford: ... – PowerPoint PPT presentation

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Title: MANAGEMENT OF INFERTILE COUPLE: EVIDENCE BASED VIEW


1
  • MANAGEMENT OF INFERTILE COUPLE EVIDENCE BASED
    VIEW

Dr.Mohamed El Sherbiny MD ObstetricsGynecology
Senior Consultant Damietta General
Hospital Damietta Egypt
2
Sources of EB for The Topic
  • PubMed
  • Cochrane library  .
  • Evidence based recommendations RCOG
  • WHO
  • Journal of evidence based obstetrics and
    gynecology.
  • National Guideline Clearinghouse .

3
Which Investigations?!
4
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.

5
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
6
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
7
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
8
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
9
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
10
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
11
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

12
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
13
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
14
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
15
  • Treatment


16
Male Subfertility Oligo/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
17
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.
18
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.
19
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
20
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
21
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
22
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
23
Ovulation Disorders
  • FSH and hMG are both effective for ovulation
    induction in women with clomiphene resistant
    polycystic ovarian syndrome.

RCOG Guidelines Grade A Recommendation
24
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
25
Hyperprolactinaemia
  • Dopamine agonists are effective treatment for
    women with anovulation due to hyperprolactinaemia

RCOG Guidelines Grade A Recommendation
26
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
27
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.
28
Endometriosis Minimal Mild
  • Surgical ablation of minimal
  • And mild endometriosis improves fertility in
    subfertile women

RCOG Guidelines Grade A Recommendation
29
Endometriosis Mild
  • . Also , ovarian stimulation with IUI is more
    effective for them than either no treatment or
    IUI alone.

RCOG Guidelines Grade A Recommendation
30
Endometriosis Moderate to Severe
31
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
32
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
33
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
34
Microsurgical Tubal Surgery Mild distal tubal
disease
Cutting fimbrio-omental band
Dissection of fimbriae adherent to the uterus
Micro scissor Cutting fimbrial band
35
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
36
Tubal Catheterization
R. Ovary
Bilateral Cornual Block
R. fimbria
Cornual catheterization
Amorphous material
37
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
38
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.
39
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
40
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
41
Thank You
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