Managing Difficult Infertile Patients

Dr Aniruddha Malpani, MD www.drmalpani.com

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 !

Difficult responders
Two kinds
Poor ovarian reserve
PCOD

Poor ovarian reserve
Commonest cause of cancellation of cycles
Tests for ovarian
reserve:
CCT
AMH
AFC
Past history of poor response

Treatment
Two different approaches
Increase dose of HMG, more aggressive superovulation
Mini-IVF/ Natural cycle IVF

Our approach
Improve ovarian reserve with empiric therapy ( alternative medicine)
Yoga
Acupuncture
DHEA, 25 mg, thrice daily
Wheatgerm
Information Therapy

Our protocol for poor responders
Letrozole, 5 mg from Day 2-6
Menogon, from Day 2 onwards
GnRH antagonist from Day 7 onwards

Mismanaging patients

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)

Discuss options – Plan B
Help patient to have realistic expectations
Have a treatment plan
Prepare for failure
Donor egg/ donor embryo
Adoption

PCO patients
Far more dangerous
OHSS – the IVF doctor’s nightmare

Prevent OHSS
Individualise dose of HMG
Coasting
LEOS
Metformin
Cancel cycle
Freeze all embryos

VEGF
Reduce VEGF levels by follicular curettage
Reduce ovarian size aggressively
Double puncture needle with repeated flushing

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

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

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

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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Managing Difficult Infertile Patients

by Aniruddha Malpani

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