infertility 2014 : evidence that matters

Infertility evidence that matters

Not here to say

• Infertility is inability of a couple to conceive after one year of sexual intercourse without contraception

RCOG,1999

Conception rates for fertile couples

0102030405060708090

100

0 6 12 18 24

Months of intercourse (cycles)

Perc

ent o

f Cou

ples

Con

ceiv

ing

© 2008, March of Dimes Foundation

Not here to say (Continued)

(Speroff & Fritz, 2005)

Not here to say (Continued)

Best care not usual care

here to say

Integrate

Clinical Expertise

Research Evidence

Patient Preferences

The Best Example

Men should not be offered surgery for varicocele as a form of fertility treatment because it does not improve pregnancy rates. (Evers & Collins, 2003)

Post-coital test

The routine use of post-coital testing of cervical mucus in the investigation of fertility problems is not recommended because it has no predictive value on pregnancy rate (Oei et al, 1998).

AimTo provide the most recent available Patient oriented evidence in infertility Management based on :-

Cochrane Library, 2013 issue IV

NICE guideline 2013.

Investigations

How to proceed?

Concept to keep in mind A simplified approach will lead to a

significant reduction in both the time and cost of investigating an infertile couple.

(Strandell 2000)

Basic fertility work up referral gyn

HistoryPhysical examination

Ovulation evaluation Semen analysisTubalpatency:CATHSGDLS

Diagnostic studies to confirm Ovulation

BBTInexpensive Accurate

Endometrial biopsy

ExpensiveStatic information

Serum progesterone

Urinary ovulation-detection kits

Serum Progesterone

Progesterone starts rising with the LH surge

drawn between day 21-24

Mid-luteal phase>10 ng/ml suggests ovulation

Tubal Factor

hysterosalpingography (HSG) is a reliable test for ruling out tubal occlusion, and it is less invasive and cheaper than laparoscopy

When to do DL

Unless there is history of pelvic inflammatory disease, previous ectopic pregnancy or endometriosis, then, D.L is justified.

Hormonal Assay

Women with irregular menstrual cycles should be offered a blood test to measure serum (FSH, LH)

TSH

the routine measurement of thyroid function should not be offered.

Prolactin assay

This test should only be offered to women who have an ovulatory disorder, galactorrhoea or a pituitary tumour But not on routine basis

Tests of ovarian reserve

AMH Any day of cycleReliableexpensive

Hysteroscopy

Women should not be offered hysteroscopy on its own as part of the initial investigation

Semen analysis

Serial semen samples (at least two) should be assessed in the same laboratory    

Semen analysis

CASA vs. conventional analysisIn a randomized controlled trial, the determination of motility characteristics as obtained by CASA systems is of limited value to optimizing the evaluation of male fertility status

(Krause ,1995 )

What to do?

Gonadotrophins Nutritional supplements ?

ICSI

Moderate or Severe male factor•Obstructive azoospermia

•non-obstructive azoospermia.

hypogonadotrophic hypogonadism

hMG is a must because these are effective in improving fertility

PCOS

treatment with clomifene citrate (or tamoxifen) as the first line of treatment for up to 12 months (not only 6) VanderVeen, 2014)

Monitoring

ultrasound monitoring during at least the first cycle of treatment to ensure that they receive an adequate dose

Metformin

In CC resistant casesFor at least 45 days

IUI

Its use is questionable (Reindollar et al, 2010)

IUI

If done, offer up to 3 cycles

Tubal surgery

For women with mild tubal disease, tubal surgery may be more effective than no treatment in centres where appropriate expertise is available.

IVF

Couples in which IVF is justified should be offered up to three stimulated cycles of in vitro fertilisation treatment.

recFSH vs hMG

hMG, u FSH and recombinant FSH are equally effective in achieving a live birth when used following pituitary down-regulation as part of in vitro fertilisation treatment.

GnRHa in IVF/ICSI

Long protocol is the standard .

IUA

should be offered hysteroscopic adhesiolysis because this may restore menstruation and improve the chance of pregnancy.

Endometriosis

Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women and should not be offered

Laparoscopic Ablation

Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis

Endometrioma

Women with ovarian endometriomas should be offered laparoscopic drainage because this improves the chance of pregnancy.

Endometriosis III / IV

Women with moderate or severe endometriosis can be offered surgical treatment because it improves the chance of pregnancy

Endometriosis III / IV

Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended.

Hydrosalpinx

Women with ultrasound visible hydrosalpinges should be offered salpingectomy before in vitro fertilisation treatment because this improves the chance of a live birth

BMI female body mass index should ideally be in the range 19–30 before commencing assisted reproduction, and that a female body mass index outside this range is likely to reduce the success of assisted reproduction procedures.

ET

Women undergoing in vitro fertilisation treatment should be offered ultrasound-guided embryo transfer because this improves pregnancy rates.

Day 2 vs day 5

Embryo transfers on day 2 or 3 and day 5 or 6 appear to be equally effective in terms of increased pregnancy and live birth rates per cycle started

ET

Replacement of embryos into a uterine cavity with an endometrium of less than 6 mm thickness is unlikely to result in a pregnancy and is therefore not recommended

ET

Bed rest of more than 20 minutes’ duration following embryo transfer does not improve the outcome of in vitro fertilisation treatment

Luteal Phase Support

luteal support using progesterone improves pregnancy rates

ICSI vs IVF

ICSI improves fertilisation rates compared to IVF, but once fertilisation is achieved the pregnancy rate is no better than with in vitro fertilisation

Karyotype

Where the indication for intracytoplasmic sperm injection is a severe deficit of semen quality or non-obstructive azoospermia, the man’s karyotype should be established

Children

Current research is broadly reassuring about the health and welfare of children born as a result of assisted reproduction

BreakThrough