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NICE Guidelines 2013, in relation to IUI & IVF Dr. Jyoti Agarwal,Dr. Sharda Jain


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NICE Guidelines 2013, in relation to IUI & IVF Dr. Jyoti Agarwal,Dr. Sharda Jain

  1. 1. NICE Guidelines 2013, in relation to IUI & IVF DR. Jyoti Agarwal DR. Sharda Jain
  2. 2. At Certificate Course IUI & Ovarian Stimulation
  3. 3. •Faculty • Dr. Sharda Jain Prog. Director , Course Chairperson • Dr Jyoti Agarwal Director /Course Co- Chair person • Dr. Aruna saxena Director Course Co- Chairperson • Dr. Jyoti Bhaskar Director • Dr. Abhishek Singh Parihar Director • Dr. Sushma Ved Director
  4. 4. Women who are ovulating regularly & have patent tubes should have minimum of 6 cycles of insemination without ovarian stimulation to reduce the risk of multiple pregnancies (2004,amended 2013) Artificial insemination Stimulated cycle Unstimulated cycle
  5. 5. (new 2013)
  6. 6. • Over 50 % of women under 40 years will conceive within 6 cycles of IUI • Of those who do not conceive within 6 cycles of IUI about half will do so in next 6 cycles Chances of conception Cumulative pregnancy rate is over 75 %
  7. 7. Success with IUI • IUI using fresh sperms is associated with higher conception rates than frozen thawed sperms . • Intrauterine insemination is associated with higher conception rates than intracervical insemination even with frozen sperms . • Donor sperm should always be IUI as it improves the pregnancy rates
  8. 8. GENERAL • Couples who are unable to or find it difficult to have normal intercourse because of physical psychosexual problem • eg. man is HIV positive • Same sex relationship SPECIFIC CONDITIONS Intrauterine insemination Unstimulated IUI Insemination is to be timed around ovulation
  9. 9. If the man is HIV positive …… The risk of transmission to the female partner is negligible if •The man is compliant with highly active antiretroviral therapy (HAART) •Plasma viral load is less than 50 copies / ml for more than 6 months Unprotected intercourse at the time of ovulation Sperm washing does not further reduce the risk of infection
  10. 10. If the man is HIV positive ……. But not compliant offer sperm washing
  11. 11. Insufficient evidence to recommend that HIV negative women needs pre – exposure prophylaxsis ……. Hence NOT recommended
  12. 12. •Unexplained infertility •Mild endometriosis •Mild male factor infertility In patients with Do not offer IUI Advice them to try to conceive for a total of 2 years before offering IVF (new 2013)
  13. 13. Patients with unexplained infertility on CC as stand alone treatment does not increase the chances of pregnancy IVF is to be offered to these women who do not conceive in 2 yrs of regular unprotected sexual intercourse. Unexplained infertility new 2013
  14. 14. Criteria for referral for IVF When considering IVF as a treatment option… COUNSEL Discuss the risks and benefits of IVF treatment based on Human Fertilisation and Embyrology Authority code of practice (new 2013)
  15. 15. Inform the couple … One full cycle of IVF consists of 1 episode of Ovarian Stimulation with or without ICSI  Transfer of fresh or frozen embryo(s) (new 2013)
  16. 16. women less than 40 years who have not concieved after * 2 yrs of unprotected intercourse or * 12 cycles of insemination (where 6 or more are by IUI ) Offer full 3 cycles of IVF with / without ICSI • If the women reaches the age of 40 during treatment complete the current full cycle but • Do not offer any further cycles (new 2013)
  17. 17. In women aged 40 – 42 years Who have not concieved after * 2 yrs of unprotected intercourse *12 cycles of insemination (where 6 or more are by IUI ) Offer one full cycle of IVF with / out ICSI (new 2013) provided ……… -They have never previously had IVF treatment -There is no evidence of low ovarian reserve -Couple is fully counselled about pregnancy at this age
  18. 18. Refer directly to an IVF specialist Where investigations show there is no chance of pregnancy with expectant management , irrespective of the age IVF is the only effective treatment in these patients (new 2013)
  19. 19. Prediction of IVF success Female age Number of previous treatment cycles Previous pregnancy history Body mass index (19 – 30) (new 2013) (new 2013) (2004, amended 2013) (2004, amended 2013)
  20. 20. Prediction of IVF success Lifestyle factors Alcohol Maternal / Paternal smoking Maternal caffeine consumption All are inversely proportional to IVF success (2004, amended 2013)
  21. 21. In IVF programme • Pretreatment with OCP or progestogen does not affect the chances of having a live birth • Can be considered in order to schedule IVF treatment (new 2013)
  22. 22. Type of Protocols (controlled ovarian stimulation in IVF) Agonist - low risk of OHSS Antagonist - high risk of OHSS
  23. 23. Controlled ovarian stimulation Individualised starting dose • Age • BMI • Presence of polycystic ovaries • Ovarian reserve Max dose of FSH - 450 IU / day Urinary or recombinant FSH
  24. 24. Monitoring essentials Ultrasound monitoring With or without estradiol levels should be an integral part for efficacy & safety throughout ovarian stimulation (new 2013)
  25. 25. Considerations in Ovarian Stimulation Clomiphene stimulated and gonadotrophin stimulated IVF cycles have higher pregnancy rate per cycle than natural cycle IVF Use of growth hormone and DHEA as adjuvant treatment is not advocated (new 2013) Do not offer Natural cycle IVF treatment
  26. 26. Important !!!! Clinics providing ovarian stimulation with gonadotrophins should have protocols in place for -Preventing -Diagnosing OHSS -Managing (2004)
  27. 27. Embryo transfer strategies in IVF •Ultrasound guided • ET in an endometrium of less than 5 mm is not advocated • Bed rest of more than 20 minutes does not improve the outcome (2004) (new 2013)
  28. 28. How many embryos to be transferred ? Women less than 37 yrs of age • First IVF cycle - single embryo • Second cycle - single top most quality or - Two if no top quality • Third cycle - Never more than 2 embyros (new 2013)
  29. 29. Between ages 37 – 39 years First and second IVF cycles -single embryo if it is a top quality or -2 embyros if there are no top quality Third cycle IVF Transfer not more than 2 embyros (new 2013)
  30. 30. For women aged 40 – 42 years consider double embyro transfer No more than 2 embyros should be transferred during any cycle of IVF (new2013)
  31. 31. Special considerations For women undergoing IVF with donor eggs , embyro transfer strategy is based on the age of the donor • If top quality blastocyst is available transfer only one embyro • Cyropreserve the remaining good quality embyros (new 2013)
  32. 32. Frozen embyro transfer Likelihood of a live birth in Women with regular ovulatory cycles Natural cycle = HRT cycles (2013)
  33. 33. Luteal phase support after IVF Progesterone Routine use of HCG not advised Evidence does not support continuing luteal phase support beyond 8 weeks of gestation (2013)
  34. 34. IVF vs ICSI Couples should be informed that ICSI improves fertilisation rates wrt IVF but Once fertilisation is achieved there is no difference in the pregnancy rates (2004)
  35. 35. Recognised indications for ICSI •Severe defects in semen quality • Obstructive azospermia • Non obstructive azospermia • Previous IVF cycle has resulted in failed or very poor fertilisation (2004)
  36. 36. Genetic issues & Counselling •Revelant genetic counseling and karyotyping should be considered before offering ICSI •Testing for Y chromosome microdeletion is not a routine investigation before ICSI (2004)
  37. 37. Thank You Say No to Cervical Cancer