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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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