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Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
Managing Difficult Infertile Patients
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Managing Difficult Infertile Patients

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Dr Malpani provides a helpful guide for managing infertile patients who have PCOD or a poor ovarian response and need IVF

Dr Malpani provides a helpful guide for managing infertile patients who have PCOD or a poor ovarian response and need IVF

Published in: Health & Medicine
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  • 1. Dr Aniruddha Malpani, MD www.drmalpani.com
  • 2. Superovulation is the heart of IVF
    • The key skill for the clinician is getting the patient to grow good quality eggs
    • Easy for young patients with normal ovarian reserve. Anything and everything works well !
  • 3. Difficult responders
    • Two kinds
      • Poor ovarian reserve
      • PCOD
  • 4. Poor ovarian reserve
    • Commonest cause of cancellation of cycles
    • Tests for ovarian
    • reserve:
      • CCT
      • AMH
      • AFC
      • Past history of poor response
  • 5. Treatment
    • Two different approaches
      • Increase dose of HMG, more aggressive superovulation
      • Mini-IVF/ Natural cycle IVF
  • 6. Our approach
    • Improve ovarian reserve with empiric therapy ( alternative medicine)
      • Yoga
      • Acupuncture
      • DHEA, 25 mg, thrice daily
      • Wheatgerm
      • Information Therapy
  • 7.  
  • 8. Our protocol for poor responders
    • Letrozole, 5 mg from Day 2-6
    • Menogon, from Day 2 onwards
    • GnRH antagonist from Day 7 onwards
  • 9.  
  • 10. Mismanaging patients
  • 11. Mismanaging patients
    • Do not give false hope
    • Do not take away hope.
    • Do not refuse to treat the patient, just because the prognosis is poor
    • Do not waste the patient’s money with expensive unproven treatment (Growth Hormone)
  • 12. Discuss options – Plan B
    • Help patient to have realistic expectations
    • Have a treatment plan
    • Prepare for failure
    • Donor egg/ donor embryo
    • Adoption
  • 13. PCO patients
    • Far more dangerous
    • OHSS – the IVF doctor’s nightmare
  • 14. Prevent OHSS
    • Individualise dose of HMG
    • Coasting
    • LEOS
    • Metformin
    • Cancel cycle
    • Freeze all embryos
  • 15. VEGF
    • Reduce VEGF levels by follicular curettage
    • Reduce ovarian size aggressively
    • Double puncture needle with repeated flushing
  • 16. Medical treatment
    • Reduce vasoactive chemicals
    • Cabergoline, dopamine agonist, 1 tab ( 0.5 mg) daily. Hum Reprod 2006. Alvarez.
    • Enace. ACE inhibitor, reduce angiotensin levels, 1 ( 2.5mg) tab daily
    • Avil, antihistamine, 3 ( 25 mg) tab daily
  • 17. Managing difficult responders
    • We do not manage ovarian responses – we manage patients
    • Infertile couples need a lot of hand-holding
    • You may not be able to give them a baby, but you should be able to help give them peace of mind
  • 18. Patient education
    • Treatment outcome is always uncertain, but peace of mind is invaluable.
    • High FSH, low AMH, antral follicle count, oopause - lots of jargon, but not a lot of meaning for the patient !
    • Information Therapy is the key
  • 19.  
  • 20. Helping patients to cope better
    • Teach them the Serenity Prayer
    • God grant me the serenity to accept the things I cannot change;
    • the courage to change the things I can;
    • and the wisdom to know the difference.

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