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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

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Managing Difficult Infertile Patients

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