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Tips for infertility practice and IVF program

Dr(Brig) R K Sharma VSM MD. Tips for infertility practice and IVF program. TIP OR THE GREAT MASS. As Ernest Hemingway once said, “The dignity of movement of an iceberg is due to only one-eighth of it being above water.” . GREAT MASS-FOUNDATION OF INFERTILTY PRACTICE.

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Tips for infertility practice and IVF program

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  1. Dr(Brig) R K Sharma VSM MD Tips for infertility practice and IVF program

  2. TIP OR THE GREAT MASS

  3. As Ernest Hemingway once said, “The dignity of movement of an iceberg is due to only one-eighth of it being above water.” 

  4. GREAT MASS-FOUNDATION OF INFERTILTY PRACTICE • INFERTILITY IS NOT THE DUMPING GROUND OF FAILED OBSTETRICIANS BUT ACME OF THEIR CARRIER

  5. ADEQUATE KNOWLEDGE OF PHYSIOLOGY,ANATOMY,ENDOCRINOLOGY, PATHOLOGY, PSYCHOLOGY,ULTRASONOGRAPHY, ENDOSCOPY,OBS &GYNE, ANDROLOGY,EMBRYOLOGY,

  6. ART SPECIALIST • LEADERSHIP WITH VISION,MISSION,COMMITMENT AND INTENSE PASSION • SELF EFFACEMENT • SPIRITUAL UNDERSTANDING OF ALL RELIGIONS • DEDICATION • DEVOTION • UNTIRING HARDWORK • EXCELLENT HUMAN RESOURCE DEVELOPMENT • INVENTORY MANAGEMENT • FINANCIAL MANAGEMENT

  7. ELEPHANT AND FOUR BLIND MEN

  8. HIPPOCRATES ARCHIE COCHRANE Primum non nocere First, do no harm Evidence Based Medicine

  9. WE MAKE HAPPY FAMILIESBABIES ARE JUST SMALL PARTS OF IT

  10. How do we measure the success

  11. Is it the number of research papers published? Is it the number of lectures delivered? Is it the position in the medical society? Is it the pregnancy rate?

  12. Pregnancy rate can be increased by denying treatment to all who are likely to have more failures like eldely , tb, severe endometriosis, etc No .none of these can be measured as success

  13. No, you can cut, paste and publish articles as many as you want. how many are path breaking.how many have got noble prize. Is it the number of research papers published?

  14. Well ,those who can do will do others will give lectures………….. like me. Is it the number of lectured delivered?

  15. Well …politics is bad every where? Who suffers ….the patient. Is it the position in the medical society?

  16. HISTORY TAKING • Couples with infertility problem should be interviewed separately as well as together, to bring out important facts that one partner might not wish to disclose to the other. Full history taking of both partners usually denotes the underlying problem

  17. COUNSELLING

  18. Clinical examination • Full clinical examination of both partners usually stands for the underlying physical problem. • By the end of this step, most of healthcare professionals will be able to sketch out their provisional diagnosis. • Investigations will be requested to prove the clinical diagnosis and to exclude other close possibilities.

  19. Many infertile couples have had some previous assessment for their infertility and this data should be cautiously reviewed. • Further investigations may be requested according to the clinical presentation and the results of preliminary tests. • Omitting unnecessary investigations, in particular couples, could reduce total cost of their infertility management without compromising their success rate.

  20. A woman who has no history suggestive of previous pelvic inflammatory disease or endometriosis, there is no justification to request a laparoscopy especially after normal hysterosalpingography study . • Similarly, there is no need for testing tubal patency for couples who will require IVF or ICSI procedure.

  21. TIPS FOR MANAGEMENT OF INFERTILE COUPLE:EVIDENCE BASED VIEW

  22. Sources of EB for The Topic • PubMed • Cochrane library  . • Evidence based recommendations RCOG • WHO • Journal of evidence based obstetrics and gynecology. • National Guideline Clearinghouse .

  23. Which Investigations?!

  24. 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.

  25. 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

  26. 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 Recommendation1999 ESHRE Capri workshop 2000

  27. 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

  28. 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

  29. 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

  30. Day 3 (FSH) And Estradiol D3 (FSH) and (E2)estradiol for patients >35 years. because of their reduced window of fertility potential. Bloomington: Institute for Clinical Systems Improvement (ICSI); 2000 The National Guideline Clearinghouse .Modified 2002

  31. Semen Analysis Serial semen samples (at least two) should be assessed in the same laboratory The lower limit of the normal semen testing is > 15 million/mL. >30% progressive motility >4% normal forms WHO,2010

  32. Semen Analysis In a RCT, the determination of motility characteristics as obtained bycomputer-assisted sperm analysis (CASA ) systems is of limited value .(Krause ,1995 ). CASA is not superior to conventional semen analysis. RCT= Randomized control trial

  33. Azoospermia:Testicular 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

  34. General Advice Weight loss if BMI > 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

  35. Treatment

  36. Male SubfertilityOligo/asthenospermia Gonadotrophin is effective for treatment for male hypogonadotrophichypogonadism. However, drug treatments are ineffective in the treatment of idiopathic male infertility. RCOG Guidelines : Grade B Recommendation

  37. 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 > 10 million). Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

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