Dr Rupal N Shah

M.D.(OBGYN)
Diploma in Reproductive Medicine
(Germany)

The young, enthusiastic and energetic chief

consultant at Rupal Hospital For Women, Surat,
India (for last 15 years)
Medical director and IVF consultant at Blossom
IVF Centre, Surat, India (for last 2 years)
Diploma in Reproductive Medicine from Kiel,
Germany
Intense training in Advanced infertility
treatment at numerous workshops and
conferences in USA and Europe.
Specialized in all kind of gynec endoscopic
surgeries.
Promotes health awareness by conducting
Seminars and writing articles and specialty
related books
In addition of being techno-savvy person, she
loves making friends, and keenly interested in
music and Guajarati literature. She is actively
associated with the leading cultural club of
Surat-Tarbatar.

Common algorithm of the management of

Infertility

Dr Rupal N Shah
M.D;D.G.O
Diploma In Reproductive Medicine (Germany)
Blossom IVF Centre
&
Rupal Hospital For Women
Surat,India

Objectives:
1. To present the practical concepts in the management of
infertility

2. To discuss the best possible clinical management options

with local perspective.

When to start investigations and treatment?

Whenever couple feels like having to be investigated and
treated..
20-30 Years

1 Year

30-35 Years

6 Months

35-40 Years

Immediately

Minimum tests to be offered are

-Semen test
-TVS

BACKGROUND INFORMATION
The single most important determinant of a couples
fertility is the age of the female partner
20-25 yrs

2.8% infertile

30-34 yrs

10% infertile

35-39 yrs

33% infertile

40-45yrs

86% infertile

CURRENT GUIDELINES
The current clinical approach to the investigations and the
management of infertility is backed by the evidence-based
guidelines issued by:
Royal College of Obstetricians and Gynecologists (RCOG)
American Society of Reproductive Medicine (ASRM)
European Society of Human Reproduction and Embryology (ESHRE)

INVESTIGATIONS
1st Visit
Trans vaginal USG
TSH and prolactin (apart from CBC, RBS, HIV, HbsAg, Hb
electrophoresis)
Semen analysis
AMH(ML>5 years,patients age >35 years)

Trans vaginal USG

D2 USG : AFC

1st visit:
>10 to 12 follicles per ovary (PCOS),
Persistent hemorrhagic cysts with low-level echoes
(endometriosis)
Anatomical conditions: fibroids, polyps, and Mllerian
anomalies (uterine septum)

Investigations for Ovarian Reserve

Age related decline in female fertility well recognised...
Starts at 30,
rapid decline after 37,
virtually zero at 43.
Ovarian reserve tests
1. Total D2 antral follicle count.(<5 ,Poor outcome)
2. AMH of 2 to 6 (<2 Poor ovarian reserve,>6 PCO)
3. D2 FSH > 10 IU/l poor response to ART
No evidence for ovarian volume,- ovarian blood flow
- inhibin B, -estradiol (E2)

Investigations to be required subsequently

Screening test for Tubal patency
HSG
Diagnostic laparoscopy + Hysteroscopy

Laproscopy findings
Uterus

Fibroids, Uterine Anomaly

Tubes

Patency ,Hydrosalpinx

Ovaries

PCOS ,Chocolate Cyst

POD

Endometriosis ,Adhesions

Tubal Block
Hydrosalpinx
Clipping
IVF+ICSI

http://www.rupalhospital.com/

Mid-tubal or fimbrial block

IVF-ICSI

Cornual tubal block

Hysteroscopic cornual catheterisation
Most rewarding procedure

Endometriosis and Chocolate cyst

Medical Management-Ineffective
Surgical

Drainage

Recurrence

Drainage and excision of

cyst wall

AMH

IVF-ICSI

 Hysteroscopic
myomectomy

Adhesiolysis
High dose
estrogen

Trial ET

IVF-ET

Septum

polypectomy

Intrauterine adhesions

Polyp/Submucous
fibroids

Management depending upon hysteroscopic procedures..

Minor
septum-DO
NOT CUT

Abnormal Semen??
Count

Motility
(G1+G2)

Morphology

Treatment

Mild

15-20 mill/ml

40-50%

30-40%

IUI

Moderate

10-15mill/ml

20-40%

10-30%

IUI

severe

<10mill/ml

<10%

<10%

IVF-ICSI

Minimum post-process Semen parameters for successful IUI 5 mill/ml motile sperms

MALE INFERTILITY
Medical Management Anti-oestrogens, androgens,
bromocriptine and kinin-enhancing drugs , Antioxidants, mast
cell blockers and alpha blockers, systemic corticosteroids for
treatment of antisperm antibodies have not been shown to be
effective in the treatment of Male infertility
Surgical Management The benefits of the treatment of a
varicocele in oligozoospermic men is less certain

ICSI for male infertility

IVF and ICSI are effective treatments for men with moderate
to severe semen abnormalities
ICSI has made it possible for men with only few sperms to
become fathers
Even in very severe oligospermia and azoospermia ,Sperms
for ICSI can be obtained are directly from( testicular biopsy by
TESA )as well as aspiration from epididymis (PESA)

Common algorithms
Based on
Patients age
Duration of INFERTILITY
AMH

Age 20-30 years,ML 1-2 years, Semen and TVS NORMAL

1-2 cycles fertile period
2-3 cycles OI+Follicular study
Diagnostic laparoscopy+Hysteroscopy
4 cycles IUI(Tab CC-/+ HMG)
IVF-ICSI

Age 20-30 years,ML 3-5 years, Semen and TVS NORMAL

2-3 cycles OI+Follicular study
Diagnostic
laparoscopy+Hysteroscopy
4 cycles IUI(Tab CC-/+ HMG)

IVF-ICSI

Age 20-30 years,ML 5-10 years, Semen and TVS normal

AMH

Diagnostic
Laproscopy+
Hysteroscopy

Normal

Abnormal

>2ng/ml

<2ng/ml

CC+/- HMG+IUI
(3-4 Cycles)

IVF

?DHEA
IVF+ICSI

Age 30-35 years,ML 1-2 years,Semen and TVS normal

2 cycles OI+Follicular study

Diagnostic laparoscopy+Hysteroscopy

4 cycles IUI(Tab CC+ HMG)

IVF-ICSI

Age 30-35 years,ML >3 years ,Semen normal

Age 35-40 years,ML >1 years ,Semen normal

AMH/AFC

Diagnostic
Laproscopy+
Hysteroscopy

AMH>2

AMH<2

AFC >5

AFC<5

CC+/- HMG+IUI
(3-4 Cycles)

IVF

?DHEA
IVF+ICSI

Age 35-40 years,ML >5 years ,Semen normal

AMH > 2

AMH 1 to 2

AMH < 1

AFC normal

AFC less

AFC less

IVF with own

eggs

IVF-Own
eggs/donor
eggs
?DHEA

IVF with donor

eggs

Age 40-45 years

IVF-ICSI
Own eggs

20%

Donor eggs
80%

Direct IVF treatment-Indications

Bilateral Tubal Block
Severe oligoAsthenospermia/Azoospermia
(TESA)

Premature ovarian failure

Age over 40 years
Genetic diseases(Donor gametes)

Surrogacy-Straight away.
After hysterectomy
Congenital absence of the uterus
Repeated failure of IVF or Recurrent
abortion

Severe intra-uterine adhesions

Severe medical conditions incompatible with pregnancy

PCOS

Weight reduction
Ovulation Induction
Metformin
Ovarian drilling

PCO drilling
WHO BENEFITS FROM PCO Drilling?
CC resistant patients and those who
are not responding to routine doses
of gonadotrophins,
Slim, raised S.LH
Only 4 punctures with monoplor
needle using 4 watts for 4 seconds

PCO drilling
Very damaging procedure

Please,please,please...
Dont over do it.

Take Home Massages

Infertility treatment protocols are highly dependent
on ovarian age and duration of infertility.
Hurry UPMost treatments have higher rates of
success in younger women.
AMH can be a good guide to form a plan.
ART should be resorted to after 6 months of
traditional treatment by infertility expert . ..(After
treating the respective cause)

11/11/2014

ONE SATISFIED PATIENT IS WORTH THOUSANDS OF

GUIDELINES AND PROTOCOLS!!!

www. blossomivfindia.com

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