management of infertility current guidelines. objectives to present the recent concepts in the...

MANAGEMENT OFMANAGEMENT OF INFERTILITYINFERTILITY

CURRENT GUIDELINESCURRENT GUIDELINES

OBJECTIVESOBJECTIVES

To present the recent concepts in the To present the recent concepts in the management of infertilitymanagement of infertility

To draw clinically relevant conclusions based To draw clinically relevant conclusions based on:on:

META-ANALYSISMETA-ANALYSIS

RANDOMISED CONTROLLED TRIALSRANDOMISED CONTROLLED TRIALS

GUIDELINES AND PROTOCOLSGUIDELINES AND PROTOCOLS To discuss the best possible clinical To discuss the best possible clinical

management options with local perspectivemanagement options with local perspective

BACKGROUND INFORMATIONBACKGROUND INFORMATION

At puberty there are 300,000 primordial At puberty there are 300,000 primordial folliclesfollicles

Dominant follicle produces oestradiol Dominant follicle produces oestradiol which leads to LH surgewhich leads to LH surge

Ovulation occurs 24-36 hours laterOvulation occurs 24-36 hours later The fertilization life span of the ovum is The fertilization life span of the ovum is

24-36 hours24-36 hours The receptivity of the endometrium is days The receptivity of the endometrium is days

16-19 of a 28 day cycle16-19 of a 28 day cycle


Infertility is rarely absolute so the term Infertility is rarely absolute so the term sub-fertility may be more appropriatesub-fertility may be more appropriate

About 84% of couples would conceive About 84% of couples would conceive within one year of trying for a pregnancywithin one year of trying for a pregnancy

Another 8% would conceive in the next Another 8% would conceive in the next year giving a cumulative pregnancy rate of year giving a cumulative pregnancy rate of 92% at the end of two years92% at the end of two years

Subfertility is defined as the inability to Subfertility is defined as the inability to conceive within 12-24 months of tryingconceive within 12-24 months of trying


The single most important determinant of a The single most important determinant of a couple’s fertility is the age of the female couple’s fertility is the age of the female partner:partner:

At the age of up to 25 years CCR is 60% At the age of up to 25 years CCR is 60% at at six months and 85% at one year six months and 85% at one year

At the age of 35 years or more the CCR At the age of 35 years or more the CCR is is 60% at one year and 85% at two years60% at one year and 85% at two years


The other factors influencing the likelihood of a The other factors influencing the likelihood of a spontaneous pregnancy are:spontaneous pregnancy are:

Duration of subfertilityDuration of subfertility

Occurrence of a previous pregnancy Occurrence of a previous pregnancy The effect of age on male fertility, however is The effect of age on male fertility, however is

less clearless clear Any change in the prevalence of subfertility in Any change in the prevalence of subfertility in

recent years is a difficult question to answer but recent years is a difficult question to answer but the male fertility is declining the male fertility is declining

CURRENT GUIDELINESCURRENT GUIDELINES

The current clinical approach to the The current clinical approach to the investigations and the management of investigations and the management of infertility is backed by the evidence-based infertility is backed by the evidence-based guidelines issued by:guidelines issued by:

Royal College of Obstetricians and Royal College of Obstetricians and Gynaecologists (RCOG)Gynaecologists (RCOG)

American Society of Reproductive American Society of Reproductive Medicine Medicine (ASRM)(ASRM)

European Society of Human European Society of Human Reproduction and Embryology (ESHRE)Reproduction and Embryology (ESHRE)

INVESTIGATIONSINVESTIGATIONS

The male partner should normally have The male partner should normally have two semen analyses performed during the two semen analyses performed during the initial investigation.initial investigation.

Laboratories that perform semen analysis Laboratories that perform semen analysis should undertake this according to should undertake this according to recognised WHO methodology.recognised WHO methodology.

Laboratories should also practice internal Laboratories should also practice internal quality control and belong to an external quality control and belong to an external quality control scheme .quality control scheme .


While regular menstruation is strongly While regular menstruation is strongly suggestive of ovulation, this should be confirmed suggestive of ovulation, this should be confirmed by the measurement of serum progesterone in by the measurement of serum progesterone in the mid-luteal phase the mid-luteal phase

There is no value in measuring thyroid function There is no value in measuring thyroid function

or prolactin in women with a regular menstrual or prolactin in women with a regular menstrual cycle, in the absence of galactorrhoea or cycle, in the absence of galactorrhoea or symptoms of thyroid disease symptoms of thyroid disease


Early follicular phase estimation of Early follicular phase estimation of FSH and LH is only performed if FSH and LH is only performed if clinically indicated clinically indicated

The female partner should normally The female partner should normally have a test of tubal patency during the have a test of tubal patency during the initial investigation of infertilityinitial investigation of infertility


A hysterosalpingogram may be used as a A hysterosalpingogram may be used as a screening test for tubal patency in low risk screening test for tubal patency in low risk couplescouples

When an evaluation of the pelvis is required, When an evaluation of the pelvis is required, however, a diagnostic laparoscopy with dye however, a diagnostic laparoscopy with dye transit is the procedure of choice transit is the procedure of choice


Ultrasound scan and hydrotubation has Ultrasound scan and hydrotubation has not been widely adopted.not been widely adopted.

The images obtained by falloposcopy are The images obtained by falloposcopy are not yet of sufficiently good quality to not yet of sufficiently good quality to provide useful clinical information. provide useful clinical information.


Before any uterine instrumentation, Before any uterine instrumentation, consideration should be given either to consideration should be given either to screening women for Chlamydia screening women for Chlamydia trachomatis, using an appropriately trachomatis, using an appropriately sensitive technique, or using sensitive technique, or using appropriate antibiotic prophylaxis .appropriate antibiotic prophylaxis .


Endometrial biopsy to evaluate the luteal phase Endometrial biopsy to evaluate the luteal phase should not be performed as part of the routine should not be performed as part of the routine investigation of the infertile coupleinvestigation of the infertile couple

The postcoital test is not recommended in the The postcoital test is not recommended in the

routine investigation of the infertile couple routine investigation of the infertile couple Sperm function tests are specialised tests and Sperm function tests are specialised tests and

should not be used in the routine investigation of should not be used in the routine investigation of the infertile couple . the infertile couple .


Routine testing for antisperm antibodies in semen Routine testing for antisperm antibodies in semen is not recommended is not recommended

Hysteroscopy should not be considered as a Hysteroscopy should not be considered as a

routine investigation in the infertile couple as routine investigation in the infertile couple as there is no evidence linking the treatment of there is no evidence linking the treatment of uterine abnormalities with enhanced fertility uterine abnormalities with enhanced fertility

An ultrasound examination of the endometrium is An ultrasound examination of the endometrium is

unnecessary in the initial investigation of infertility. unnecessary in the initial investigation of infertility. However, ultrasound evaluation of the ovaries may However, ultrasound evaluation of the ovaries may be useful be useful

DIAGNOSIS OF PCOSDIAGNOSIS OF PCOS

The debate was resolved in Rotterdam The debate was resolved in Rotterdam in May 2003 At PCOS consensus in May 2003 At PCOS consensus workshopworkshop

It was agreed that two of the following It was agreed that two of the following three criteria were essential to establish three criteria were essential to establish diagnosis:diagnosis:1.1. OVARIAN DYSFUNCTIONOVARIAN DYSFUNCTION2.2. CLINICAL OR BIOCHEMICAL EVIDENCE OF CLINICAL OR BIOCHEMICAL EVIDENCE OF

HYPERANDROGENISMHYPERANDROGENISM3.3. POLYCYSTIC OVARIAN MORPHOLOGY ON POLYCYSTIC OVARIAN MORPHOLOGY ON

ULTRASOUNDULTRASOUND

DIAGNOSIS OF PCOSDIAGNOSIS OF PCOS

Ultrasound is the gold standard Ultrasound is the gold standard for the diagnosis of PCO.for the diagnosis of PCO.

The diagnostic criteria is of 10 The diagnostic criteria is of 10 discrete follicles of <10mm discrete follicles of <10mm usually peripherally arranged usually peripherally arranged

around an enlarged, around an enlarged, hyperechogenic central stomahyperechogenic central stoma

WHICH INVESTIGATIONS?WHICH INVESTIGATIONS? Diagnostic tests for infertility were classified Diagnostic tests for infertility were classified

into following three categories by ESHRE into following three categories by ESHRE Capri workshop in 2000Capri workshop in 2000

Tests which have an established Tests which have an established correlation with pregnancycorrelation with pregnancy

Tests which are not consistently Tests which are not consistently correlated with pregnancycorrelated with pregnancy

Tests which seem NOT to correlate Tests which seem NOT to correlate with with pregnancypregnancy

Tests which have an established Tests which have an established correlation with pregnancycorrelation with pregnancy

Semen analysisSemen analysis

Tubal patency test by HSG or Tubal patency test by HSG or LaparoscopyLaparoscopy

Mid luteal serum progesterone for Mid luteal serum progesterone for the diagnosis of ovulationthe diagnosis of ovulation

Tests which are not consistently Tests which are not consistently correlated with pregnancycorrelated with pregnancy

Zona free hamster egg penetration Zona free hamster egg penetration teststests

Post-coital testPost-coital test

Antisperm antibodies assaysAntisperm antibodies assays

Tests which seem NOT to correlate Tests which seem NOT to correlate with pregnancywith pregnancy

Endometrial datingEndometrial dating

Varicocoel assessmentVaricocoel assessment

Chlamydial testingChlamydial testing

MAY HAVE A ROLE IN SPECIAL SITUATIONSMAY HAVE A ROLE IN SPECIAL SITUATIONS

MANAGEMENTMANAGEMENT

The management of infertility should The management of infertility should take place in a dedicated infertility take place in a dedicated infertility clinic staffed by an appropriately clinic staffed by an appropriately trained professional team with trained professional team with facilities for investigating and facilities for investigating and managing problems in both partners.managing problems in both partners.


Both partners should be seen togetherBoth partners should be seen together Privacy and sufficient clinical timePrivacy and sufficient clinical time Classical history taking with emphasis on Classical history taking with emphasis on

exploring a couple’s anxietiesexploring a couple’s anxieties Counseling is very important and essentialCounseling is very important and essential Routine examination is not necessary Routine examination is not necessary

unless indicated by the historyunless indicated by the history


Each stage in the investigation and Each stage in the investigation and treatment of infertility should be fully treatment of infertility should be fully explained to the couple.explained to the couple.

Written information in a range of languages Written information in a range of languages should be available where appropriate.should be available where appropriate.

Environmental factors can affect fertility and Environmental factors can affect fertility and therefore an occupational history should be therefore an occupational history should be taken. taken.


The management of the individual couple The management of the individual couple should always be discussed in the context should always be discussed in the context of their particular clinical situation. of their particular clinical situation.

Patients should be fully involved in Patients should be fully involved in decisions regarding their treatment. decisions regarding their treatment.

Couples should also have access to Couples should also have access to infertility counselors outside the clinical infertility counselors outside the clinical team, and to patient support groups team, and to patient support groups

GENERAL ADVICE TO THE COUPLEGENERAL ADVICE TO THE COUPLE

Sexual intercourse every 2-3 daysSexual intercourse every 2-3 days Timed intercourse to coincide with ovulation Timed intercourse to coincide with ovulation

causes stress and not to be recommendedcauses stress and not to be recommended Smoking reduces both, women’s fertility as Smoking reduces both, women’s fertility as

well as semen qualitywell as semen quality Excessive alcohol is detrimental to semen Excessive alcohol is detrimental to semen

quality and may cause erectile dysfunctionquality and may cause erectile dysfunction

GENERAL ADVICE TO THE COUPLEGENERAL ADVICE TO THE COUPLE

A body mass index of more than 29 is A body mass index of more than 29 is associated with reduced fertility in both associated with reduced fertility in both men and womenmen and women

Folic acid supplement prior to conception Folic acid supplement prior to conception and up to 12 weeks of conceptionand up to 12 weeks of conception

Rubella immunity should be checkedRubella immunity should be checked If vaccinated then advise to avoid If vaccinated then advise to avoid

pregnancy for at least one month after pregnancy for at least one month after vaccinationvaccination

MALE INFERTILITYMALE INFERTILITY

In considering the results of semen analysis for In considering the results of semen analysis for the individual couple, it is important to take into the individual couple, it is important to take into account the duration of infertility, the woman’s account the duration of infertility, the woman’s age and the previous pregnancy history .age and the previous pregnancy history .

Further investigations of the male partner should Further investigations of the male partner should be preceded by a clinical examination including be preceded by a clinical examination including an assessment of secondary sexual an assessment of secondary sexual characteristics and testicular size .characteristics and testicular size .


Further investigations of the male partner may Further investigations of the male partner may include endocrine tests, microbiological include endocrine tests, microbiological assessment of the semen and imaging of the assessment of the semen and imaging of the genital tract but should be initiated in the context genital tract but should be initiated in the context of a specialist infertility clinic.of a specialist infertility clinic.

Laboratories reporting semen analysis results Laboratories reporting semen analysis results should establish normal ranges for their own should establish normal ranges for their own populations and indicate these on report sheets .populations and indicate these on report sheets .


Certain in vitro tests of sperm function can Certain in vitro tests of sperm function can be of use in predicting fertility . However, be of use in predicting fertility . However, at this stage, their use and interpretation at this stage, their use and interpretation should be restricted to those few centres should be restricted to those few centres with relevant expertise.with relevant expertise.

Surgery on the male genital tract should Surgery on the male genital tract should be carried out only in centres where there be carried out only in centres where there are appropriate facilities and trained staff.are appropriate facilities and trained staff.


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

Vasectomy reversal is an effective treatment for Vasectomy reversal is an effective treatment for men who want to reverse their sterilisation.men who want to reverse their sterilisation.

Surgical correction of epididymal blockage can be Surgical correction of epididymal blockage can be considered in cases of obstructive azoospermia.considered in cases of obstructive azoospermia.

Where a diagnosis of hypogonadotrophic Where a diagnosis of hypogonadotrophic hypogonadism is made in the male partner the use hypogonadism is made in the male partner the use of gonadotrophin drugs is an effective fertility of gonadotrophin drugs is an effective fertility treatment.treatment.


Bromocriptine is an effective treatment for Bromocriptine is an effective treatment for sexual dysfunction in men with sexual dysfunction in men with hyperprolactinaemia.hyperprolactinaemia.

Intrauterine insemination is an effective Intrauterine insemination is an effective treatment where the man has mild abnormalities treatment where the man has mild abnormalities of semen quality.of semen quality.

Infection of the male genital tract should be Infection of the male genital tract should be treated if present, but there is no evidence that treated if present, but there is no evidence that this will improve fertility.this will improve fertility.


Anti-oestrogens, androgens, bromocriptine Anti-oestrogens, androgens, bromocriptine and kinin-enhancing drugs have not been and kinin-enhancing drugs have not been shown to be effective in the treatment of shown to be effective in the treatment of Male infertility Male infertility

Antioxidants, mast cell blockers and alpha Antioxidants, mast cell blockers and alpha blockers need further evaluation.blockers need further evaluation.

The use of systemic corticosteroids for The use of systemic corticosteroids for treatment of antisperm antibodies can only treatment of antisperm antibodies can only be recommended in the context of further be recommended in the context of further research. research.


There is no evidence that semen There is no evidence that semen quality and pregnancy rates improves quality and pregnancy rates improves in men with normal sperm count after in men with normal sperm count after surgical treatment of a clinically surgical treatment of a clinically apparent varicocele apparent varicocele

The benefits of the treatment of a The benefits of the treatment of a varicocele in oligozoospermic men is varicocele in oligozoospermic men is less certain less certain


IVF and ICSI are effective treatments for IVF and ICSI are effective treatments for men with moderate to severe semen men with moderate to severe semen abnormalitiesabnormalities

ICSI has made it possible for men with ICSI has made it possible for men with only few sperms to become fathersonly few sperms to become fathers

Sperms for ICSI can be obtained by TSA Sperms for ICSI can be obtained by TSA are directly from testicular biopsy as well are directly from testicular biopsy as well as aspiration from epididymus as aspiration from epididymus

TUBAL INFERTILITYTUBAL INFERTILITY Tubal surgery should be carried out only in centres where Tubal surgery should be carried out only in centres where

there are appropriate facilities and trained staff.there are appropriate facilities and trained staff.

Where proximal tubal obstruction is suspected this should Where proximal tubal obstruction is suspected this should be confirmed by selective salpingography and a tubal be confirmed by selective salpingography and a tubal catheterisation procedure may be attempted.catheterisation procedure may be attempted.

Tubal surgery may be appropriate for selected cases of Tubal surgery may be appropriate for selected cases of mild distal tubal disease or proximal tubal obstruction.mild distal tubal disease or proximal tubal obstruction.

If pregnancy has not occurred within 12 months of tubal If pregnancy has not occurred within 12 months of tubal surgery, IVF should be discussed .surgery, IVF should be discussed .

TUBAL INFERTILITYTUBAL INFERTILITY

When distal tubal surgery is performed, a When distal tubal surgery is performed, a microsurgical approach using magnification should microsurgical approach using magnification should be used. be used.

A laparoscopic approach can be used for A laparoscopic approach can be used for adhesiolysis but the use of this approach for adhesiolysis but the use of this approach for salpingostomy needs more evaluation .salpingostomy needs more evaluation .

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


The presence of hydrosalpinges is The presence of hydrosalpinges is associated with reduced pregnancy rates associated with reduced pregnancy rates following IVF. following IVF.

Tubal reanastomosis is an effective Tubal reanastomosis is an effective treatment for women who want to reverse treatment for women who want to reverse their sterilisation.their sterilisation.

High success rates can be achieved when High success rates can be achieved when reversing mechanical tubal occlusion using reversing mechanical tubal occlusion using a microsurgical approach .a microsurgical approach .


IVF should be considered first line IVF should be considered first line treatment for moderate to severe tubal treatment for moderate to severe tubal diseasedisease

Both surgery and IVF should be discussed Both surgery and IVF should be discussed without biaswithout bias

There is no randomised comparison There is no randomised comparison between IVF and tubal surgery between IVF and tubal surgery

OVULATION DISORDERSOVULATION DISORDERS

Before ovulation induction is considered, Before ovulation induction is considered, further investigations will be necessary and further investigations will be necessary and these should be carried out only in a these should be carried out only in a specialist clinic .specialist clinic .

In undertaking ovulation induction, centres In undertaking ovulation induction, centres should adopt protocols which minimise the should adopt protocols which minimise the risk of multiple pregnancy and ovarian risk of multiple pregnancy and ovarian hyperstimulation .hyperstimulation .


Patients undergoing ovulation Patients undergoing ovulation induction must be given induction must be given information about the risks of information about the risks of multiple pregnancy, ovarian multiple pregnancy, ovarian hyperstimulation and the hyperstimulation and the possibility of fetal reduction.possibility of fetal reduction.


Clomiphene is an effective treatment for Clomiphene is an effective treatment for anovulation in appropriately selected womenanovulation in appropriately selected women

Cumulative Pregnancy Rate continues to rise until Cumulative Pregnancy Rate continues to rise until ten cycles of treatment. RCOG recommends that ten cycles of treatment. RCOG recommends that up to 12 cycles of treatment should be considered up to 12 cycles of treatment should be considered

Ovulation induction with clomiphene should only Ovulation induction with clomiphene should only be performed in circumstances which allow access be performed in circumstances which allow access to ovarian ultrasound monitoring. to ovarian ultrasound monitoring.


With clomiphene ovulation occurs in 70-80% With clomiphene ovulation occurs in 70-80% and the cumulative rate over six months is 60%and the cumulative rate over six months is 60%

Seventy percent achieve pregnancy at doses of Seventy percent achieve pregnancy at doses of 100 mgs or less100 mgs or less

Most evidence point towards less pregnancy Most evidence point towards less pregnancy rate above 100 mgs.rate above 100 mgs.


FSH and hMG are both effective for ovulation FSH and hMG are both effective for ovulation induction in women With clomiphene-resistant induction in women With clomiphene-resistant polycystic ovarian syndrome (PCOS).polycystic ovarian syndrome (PCOS).

There is no advantage in routinely using There is no advantage in routinely using gonadotrophin-releasing hormone analogues in gonadotrophin-releasing hormone analogues in conjunction with gonadotrophins for ovulation conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant induction in women with clomiphene-resistant PCOS. Furthermore, their use may be associated PCOS. Furthermore, their use may be associated with an increased risk of ovarian hyperstimulation . with an increased risk of ovarian hyperstimulation .


Laparoscopic ovarian drilling with either diathermy Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS. women with clomiphene-resistant PCOS. However, more research is needed into the However, more research is needed into the sequelae of causing ovarian damage in this way.sequelae of causing ovarian damage in this way.

The pulsatile administration of gonadotrophin-The pulsatile administration of gonadotrophin-releasing hormone is an effective treatment for releasing hormone is an effective treatment for women with anovulation due to hypothalamic women with anovulation due to hypothalamic factors.factors.


Dopamine agonists are effective treatment Dopamine agonists are effective treatment for women with anovulation due to for women with anovulation due to hyperprolactinaemiahyperprolactinaemia

Ovulation induction with gonadotrophins Ovulation induction with gonadotrophins should only be performed in circumstances should only be performed in circumstances which permit daily monitoring of ovarian which permit daily monitoring of ovarian response .response .

The criteria for abandoning ovulation The criteria for abandoning ovulation induction cycles must be carefully defined in induction cycles must be carefully defined in each specialist centre.each specialist centre.


The association between ovarian cancer risk and The association between ovarian cancer risk and gonadotrophins or prolonged clomiphene use gonadotrophins or prolonged clomiphene use remains uncertain. remains uncertain.

There is no evidence to suggest an increased risk There is no evidence to suggest an increased risk of ovarian cancer when clomiphene is used for of ovarian cancer when clomiphene is used for less than 12 cycles. less than 12 cycles.

Patients should be counseled about the putative Patients should be counseled about the putative risks of ovarian cancer associated with ovulation risks of ovarian cancer associated with ovulation induction therapy. Practitioners should confine the induction therapy. Practitioners should confine the use of gonadotrophins to the lowest effective dose use of gonadotrophins to the lowest effective dose and duration of use . and duration of use .

ENDOMETRIOSIS ASSOCIATED ENDOMETRIOSIS ASSOCIATED INFERTILITYINFERTILITY

Endometriosis should be classified using the revised AFS Endometriosis should be classified using the revised AFS system of classification, until such time as a proven system of classification, until such time as a proven functional classification is approved .functional classification is approved .

Surgical ablation of minimal and mild endometriosis Surgical ablation of minimal and mild endometriosis improves fertility in subfertile women.improves fertility in subfertile women.

Medical treatment of minimal and mild endometriosis does Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile womennot enhance fertility in subfertile women


Ovarian stimulation with intrauterine insemination Ovarian stimulation with intrauterine insemination is more effective than either no treatment or lUl is more effective than either no treatment or lUl alone in subfertile women with minimal or mild alone in subfertile women with minimal or mild endometriosis.endometriosis.

There is no evidence that medical treatment of There is no evidence that medical treatment of moderate and severe endometriosis either alone moderate and severe endometriosis either alone or as an adjunct to surgery improves fertility.or as an adjunct to surgery improves fertility.

Surgical treatment of moderate and severe Surgical treatment of moderate and severe endometriosis may improve fertility but controlled endometriosis may improve fertility but controlled studies and comparisons with assisted studies and comparisons with assisted reproduction techniques are required. reproduction techniques are required.


In cases of moderate and severe In cases of moderate and severe endometriosis, assisted reproduction endometriosis, assisted reproduction techniques should be considered as an techniques should be considered as an alternative to, or following unsuccessful alternative to, or following unsuccessful surgery.surgery.

Where large ovarian endometriotic cysts are Where large ovarian endometriotic cysts are detected, consideration should be given to detected, consideration should be given to their surgical treatment because this may their surgical treatment because this may enhance spontaneous pregnancy rates and enhance spontaneous pregnancy rates and improve access if IVF is considered. improve access if IVF is considered.

UNEXPLAINED INFERTILITYUNEXPLAINED INFERTILITY

Unexplained infertility is a diagnosis of Unexplained infertility is a diagnosis of exclusionexclusion

Spontaneous pregnancy rate are high in Spontaneous pregnancy rate are high in first three years of tryingfirst three years of trying

Clomiphene encourages multifollicular Clomiphene encourages multifollicular ovulation and increases the chances of ovulation and increases the chances of pregnancy in couple’s with unexplained pregnancy in couple’s with unexplained infertility infertility

UNEXPLAINED INFERTILITYUNEXPLAINED INFERTILITY

Ovarian stimulation with intrauterine Ovarian stimulation with intrauterine insemination is an effective treatment for insemination is an effective treatment for couples with unexplained infertility.couples with unexplained infertility.

GIFT is an effective treatment for couples GIFT is an effective treatment for couples with unexplained infertility.with unexplained infertility.

IVF may be preferred because of the IVF may be preferred because of the additional diagnostic information it provides additional diagnostic information it provides and because it avoids laparoscopy and because it avoids laparoscopy

ASSISTED REPRODUCTIONASSISTED REPRODUCTION

These techniques have revolutionized the These techniques have revolutionized the management of infertile couplesmanagement of infertile couples

Entry guidelines should be followedEntry guidelines should be followed The women should be less than 40 years The women should be less than 40 years

old and in good healthold and in good health The couple should be aware of the The couple should be aware of the

emotional and financial strainemotional and financial strain

ASSISTED REPRODUCTIONASSISTED REPRODUCTION

The most common techniques used are:The most common techniques used are:Intrauterine InseminationIntrauterine InseminationIn-vitro fertilisationIn-vitro fertilisationIntracytoplasmic sperm Intracytoplasmic sperm

injection injection The success rate of the clinic should be told to The success rate of the clinic should be told to

the patientthe patient The take home baby rate is roughly around 20%The take home baby rate is roughly around 20% There is no increase in the incidence of the There is no increase in the incidence of the

congenital abnormalitiescongenital abnormalities

P0INT TO REMENBERP0INT TO REMENBER

ONE SATISFIED PATIENT IS ONE SATISFIED PATIENT IS WORTH THOUSANDS OF WORTH THOUSANDS OF

GUIDELINES AND GUIDELINES AND PROTOCALSPROTOCALS

THANK YOUTHANK YOU

management of infertility current guidelines. objectives to present the recent concepts in the...

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