when to refer a patient for assisted reproduction ( art ) / ivf by dr shashwat jani

Dr. Shashwat Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,

Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.

E-mail : drshashwatjani@gmail.com

Dr Shashwat Jani. 9909944160. 2

Greetings From Ahmedabad …

WHY… ???

It is estimated that more than 15% of couples living in developed countries are infertile.

No major change in prevalence,

but

there has been an increase in demand for treatmentduring the past decade

because

of the perception that effective assisted reproductive technology (ART) treatments are now easily available at affordable cost…!!!

3Dr Shashwat Jani. 9909944160.

Although , ART was initially developed for patients with tubal infertility only ,

But Currently used for almost all kinds of infertility problem, because its success rates are expected to be higher than those of conventional treatments.

However, ART treatment also has disadvantages.

It involves greater expense, and potentially serious complications such as OHSS and multiple pregnancies can occur.

There are also fears that drugs that induce ovulation may increase the risk of ovarian cancer.

4Dr Shashwat Jani. 9909944160.

Infertility treatment should therefore be individualized

to avoid subjecting couples to unnecessary risks due to overtreatment,

such as the unnecessary use of ART treatments,

orto inappropriate delay because of under

treatment.5Dr Shashwat Jani. 9909944160.

So …

6Dr Shashwat Jani. 9909944160.

Categories of Infertile

Couples

(1) Those with single defect in one of the partners;

(2) Those with multiple defects in one or both the partners;

(3) No apparent defect in either partner (unexplained infertility).

7Dr Shashwat Jani. 9909944160.

8Dr Shashwat Jani. 9909944160.

FEMALE

FACTORS …

9Dr Shashwat Jani. 9909944160.

Tubal Diseases…

Where microsurgical techniques for tubal and peritoneal disease have failed or are unlikely to benefit the patient.

Presence of dense peritubal adhesions, condition of the tubal wall, condition of the

ciliary epithelium and degree of fimbrialdamage

10Dr Shashwat Jani. 9909944160.

Tubeculosis

Bilateral Hydrosalpinx

Already undergone tuboplasty and those with inaccessible ovaries

H/o ectopic pregnancy

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Uterine Factors…

Mullerian agenesis or congenital uterine anomalies,

Women with severe intrauterine adhesion refractory to surgical lysis of the adhesion,

hysterectomized patients can, through IVF, transfer their embryos to a surrogate mother.

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Ovarian Factors…

Hypogonadotropic anovulation,

Oligoovulation

Luteal phase deficiency ( Rare )

LUF in severe PCOS

13Dr Shashwat Jani. 9909944160.

Cervical factors…

Only if,

repeated attempts (6 to 8 cycles) of intrauterine insemination ( I.U.I. ) have failed and other therapies have not resulted in pregnancy.

14Dr Shashwat Jani. 9909944160.

Endometriosis… Women with moderate to severe

endometriosis;

Those in whom medical or surgical therapy has failed; and

Sometimes in cases of mild to moderate endometriosis in the presence of other factors contributing to infertility.

15Dr Shashwat Jani. 9909944160.

Use of donor oocytes &

donor embryos Undergone premature or timely menopause

Women in the perimenopausal age group who do not show proper recruitment of follicles and who have other existing causes of infertility

Genetic disorder

Undergone radiation therapy

Ovaries not accessible by USG due to severe adhesions

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Male

Factors…

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SEMEN ABNORMALITY

Low concentrations of sperm

(less than 10 million/ml),

Low motility (less than 30%),

Abnormal sperm morphology

(presence of > 60% abnormal forms).

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Immunological factors…

When methods like . . . Immunosuppression,

Condoms &

IUI have failed in presence of Anti Sperm Antibodies either in Male or Female Partner…

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Unexplained Infertility…

Couples who have prolonged unexplained infertility could benefit from IVF, as

Many factors such as subtle ovulation defects, defects in ovum pick-up,

Gamete transport,

Tubal environment,

Sperm abnormality,

Oocyte abnormality

may come to light when IVF is used…!!!20Dr Shashwat Jani. 9909944160.

Assisted reproductive techniques

Dr Shashwat Jani. 9909944160. 21

methods

Intra Uterine Insemination ( IUI )-----------------------------------------------------------------------------

In-vitro fertilization and embryo transfer (IVF-ET) Gamete intrafallopian transfer (GIFT) Zygote intrafallopian transfer (ZIFT)

- Pronuclear stage tubal transfer (PROST)- Tubal pre-embryo transfer- Tubal embryo transfer ( TET )- Transcervical tubal transfer.

22Dr Shashwat Jani. 9909944160.

Micromanipulation

- Intracytoplasmic sperm injection (ICSI)

- Subzonal sperm injection ( SUZI )

- Partial zona dissection (PZD)

Oocyte and embryo donation

Cryopreservation

Assisted hatching (AH)

Percutaneous epididymal sperm aspiration (PESA)

Testicular sperm extraction ( TESE )

Pre-implantation genetic diagnosis (PGD)

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METHOD OF CHOICE…

The choice of the procedure used,

e.g. IVF-ET, GIFT, ZIFT, or ICSI,

is made depending upon the . . .

Needs,

Resources ,

Circumstances of the couple,

Availability of the facilities &

Experience and expertise of the gynaecologist / embryologist.

24Dr Shashwat Jani. 9909944160.

I.U.I. Common indications for IUI are: Hostile uterine cervix.

Oligozoospermia

Unexplained infertility

Indications for Donor IUI :(a) Non-obstructive azoospermia;

(b) The husband has a hereditary genetic defect;

(c) The couple has Rh incompatibility;

(d) The man has severe oligozoospermia and the couple does not wish to undergo any of the sophisticated ART such as ICSI 25Dr Shashwat Jani. 9909944160.

I.V.F. - ET

Irreversible Tubal pathology or surgical damage Subnormal Male factor Idiopathic infertility. Endometriosis. Infertility of

immunological origin.

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I.C.S.I.

Indications of ICSI with ejaculated spermatozoa :

Severe male-factor infertility.

Fertilization failure after standard IVF treatment.

Number of spermatozoa in the ejaculate too low for IVF.

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Indications of ICSI with surgically extracted sperm :

( MESA / PESA/ TESA / TESE )

Congenital bilateral absence of the vas deferens (CBAVD).

Obstructive azoospermia

Non-obstructive azoospermia

Anejaculation.

Retrograde ejaculation.28Dr Shashwat Jani. 9909944160.

Oocyte Donation

Gonadal dysgenesis.

Premature ovarian failure.

Iatrogenic ovarian failure due to ovarian surgery or radiation, or chemical castration.

Women who have resistant ovary syndrome,

Poor responders to ovulation induction.

Women who are carriers of recessive autosomal disorders.

Women who have attained menopause.29Dr Shashwat Jani. 9909944160.

Embryo Donation

Primary germ cell failure

Inheritable genetic disorder

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Pre Implantation Genetic Diagnosis (

P.G.D. )

1 ) Infertility and recurrent miscarriages :

For patients at risk for genetic disorders:Autosomal Dominant

• Huntington’s chorea

Autosomal Recessive

• Cystic fibrosis

• Tay-Sachs disease

• β-thalassemia

• Sickle cell disease31Dr Shashwat Jani. 9909944160.

X-linked

• Duchenne muscular dystrophy

• Hemophilia A

• Fragile X syndrome

Chromsomal disorders

• Structural Translocations, Inversions, Deletions

• Aneuploidy: Downs, Edwards, Klinefelter syndrome

• Monosomy: Turners syndrome

• Tetraploidy

32Dr Shashwat Jani. 9909944160.

Unsuccessful IVF cycles :

Couples with repeated unsuccessful IVF cycles should be evaluated for the presence of a chromosome abnormality.

The female or male partner may be carrier of a balanced translocation or may be an aneuploid mosaic.

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REMEMBER…

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Patient Selection

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Husband

Physical examination : Systemic & local

Detailed Semen Analysis – if abnormal repeat after suitable interval.

Screening for HIV , HBV, HCV.

Endocrinological report if needed and therapy.

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Wife

Physical examination : systemic & local

Detection & Timing of Ovulation by appropriate test

Assessment of Tubal Patency.

Screening for HIV , HBV, HCV .

Endocrinological report if needed and therapy

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So…

Any gynaecologist not specifically trained in the subspeciality of infertility care can also complete these investigations.

Based on the results of these investigations, couples should be referred….

38Dr Shashwat Jani. 9909944160.

NICE GUIDELINES .

When considering IVF as a treatment option for people with fertility problems, discuss the risks and benefits of IVF.

In women aged under 40 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by IUI ), offer 3 full cycles of IVF, with or without ICSI.

If the woman reaches the age of 40 during treatment, complete the current full cycle but do not offer further full cycles. 39Dr Shashwat Jani. 9909944160.

NICE GUIDELINES . . .

Where investigations show there is no chance of pregnancy with expectant management and where IVF is the only effective treatment,

refer the woman directly to a specialist team for IVF treatment…!!!

40Dr Shashwat Jani. 9909944160.

KEY POINTS…

Explosion of knowledge about human reproduction and a greater understanding has increased our scope of applying ART for providing solutions to a greater number of infertile couples.

IVF is the end-point for many causes of infertility but should not be abused or embarked upon too early.

IVF is a test of fertilization…!!!

41Dr Shashwat Jani. 9909944160.

ART gives hope to women with ovulatory dysfunction, tubal disease and a host of gynecological conditions.

Micromanipulation techniques such as ICSIhave revolutionized the treatment of malefactor infertility and couples with a history of poor fertilization in previous cycles.

Surely, with time and more awareness, we would discover yet newer indications for same…!!!

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43Dr Shashwat Jani. 9909944160.