The document provides guidance on selecting the right patient for IVF treatment. It discusses various factors of infertility that may indicate IVF, including male factor infertility, female factor infertility, and genetic disorders. Male factors include abnormal semen analysis, genetic abnormalities, and failed treatment. Female factors include tubal issues, uterine anomalies, ovarian dysfunction, and failed treatment. It also provides diagnostic evaluation and criteria for determining when IVF may be the best treatment option.

1. HOW TO SELECT THE
RIGHT PATIENT FOR
IVF
BY DR . MOSTAFA AL WAKIL
Ph.D.

2. In vitro fertilization (IVF) is a complex series of procedures used
to help with fertility or prevent genetic problems and assist
with the conception of a child but it has disadvantages also.
IVF cycle may be unsuccessful and it may be associated with
side effects and risks.
IVF treatment can also take an emotional/psychological toll.
IVF treatment can be expensive.

3. -Male factor of infertility
-Female factor of infertility
-Un explained infertility
- Genetic disorder . PGD
-Recurrent pregnancy loss of genetic origin
-Sex selection
-Fertility preservation for cancer or other health
conditions.
-one of the partners is a HIV or HCV carrier
-Age related predictive factor of infertility
INDICATIONS OF IVF

5. Malfunction of the hypothalamus
The hypothalamus is the portion of the brain responsible for
sending signals to the pituitary gland, which, in turn, sends
hormonal stimuli to the testes and to the ovaries in the form of
FSH and LH to initiate spermatogenesis and egg maturation.
Malfunction of the pituitary gland
The pituitary's responsibility lies in producing and secreting
FSH and LH. The testes and ovaries will be unable to work
properly if either too much or too little of these substances is
produced. This can occur due to physical injury, a tumor or if
there is a chemical imbalance in the pituitary.
INDICATIONS OF IVF

6. 1- male factor of infertility

7. -Male factor is a sole cause of infertility in approximately 25% of
infertile couples
-Spermogram is a little bit trickier and hard to judge and must
be correlated with the wife's condition and period of marriage
so be aware of abnormal history or abnormal semen analysis
-More than one analysis is needed in different times and in
different labs
-Conventional semen analysis or CASA are equal. hormonal and
genetic screening are important for patients of doubt e. g. (
delayed puberty , small sized testes)
-Sperm DNA fragmentation test for life style ,occupational
exposure of toxins and un explained infertility
1- male factor of infertility

8.  Period of infertility must be with regular and unprotected intercourse (with
reduction of periods of abstinence or lactation e.g. travelling)
 Husband age and history of previous marriage with or without children is of
a great importance
 Smoking habit and drugs (specially addictive drugs) and occupational
history (exposure to chemicals and toxins ) or family history of male
infertility is essential . childhood urogenital surgery or trauma or viral
infection must be taken.
 History of hernia repair.
 History of Sexual dysfunction.
 History of marriage of more than one wife with no children in spite of
normal semen analysis ( think of sperm failure to reach or to penetrate the
ovum)
 Idiopathic male infertility
1- male factor of infertility

9. -Semen analysis (two or more samples)
-complete blood cell count (if infection suspected)
- FSH (Follicle-stimulating hormone) level
-testosterone levels (if hypogonadism suspected)
-LH level
-TSH
-Serum prolactin
-Testicular ultrasound
Basic Investigations needed for diagnosis of
male factor of infertility

10. -Karyotyping (chromosomal pattern) only in
cases of azospermia or severe oligoathenospermia with
positive history of delayed puberty or signs of
deficient sex character–( 5.8% of infertile men has
chromosomal abnormalities )
-Testicular biopsy only in cases of azospermia after
failure of medical or surgical treatment with normal
testicular size and normal FSH levels with
cryopreservation (more than one vial) for positive
patients and histopathological examination specially
for negative patients
Confirmatory steps

11. -Impaired sperm function
-Severe male factor e.g (oligospermia,
athenospermia,teratospermia)
not responding to medical treatment for sufficient period
of time
-Azospermia resistant to medical or surgical treatment
-Obstruction of both ejaculatory duct
-Failed vaso vasostomy
Criteria for patient selection for IVF

12. -Hyperviscus semen, pyospermia and low semen
volume is not an absolute indication for IVF and
must be treated medically or by IUI before
referring to an IVF specialist and after exclusion
of wife's genital pathology.
-Failed varicocellectomy to correct semen
parameters.
-Failed hormonal therapy to correct semen
quality.
Criteria for patient selection for
IVF

13. -Three failed trials of IUI or more
-Klienfelter syndrome with positive TESA followed by
cryopreservation after retrieval of spermatozoa or
spermatids
-Sperm auto immunity
-Congenital bilateral absence of vas
-High levels of antibodies in semen after failed trial of
medical treatment or IUI
Criteria for patient selection for
IVF

14. Some husbands with untreatable azospermia or severe
oligoathenospermia hide their illness from their wives and
fabricate semen analysis reports or bring a hidden fertile
semen sample from other person e.g. friends or relatives
So let husbands of doubt bring their samples by coitus
interrupts and by their wives to the lab if they don’t know
Another way to detect such husbands is by post coital test to
detect sperms before IVF/ ICSI
DNA testing may be an option

15. Female infertility is a multifactorial and sometimes
need a decision whether to start an IVF treatment or
to wait for anther solution.
Age and BMI and period of infertility is the
starting keys for the decision making, put the
apparent and irreversible causes as another key to
take your decision
Vaginal or cervical anomalies ( failed operative
correction of cervical stenosis, surgical amputation
of cervix ) ICSI with trans myometrial ET
2-Female factor of infertility

17. History taking must include
Coital practices
Medical history (e.g., genetic disorders, endocrine disorders,
history of pelvic inflammatory disease, diabetes)
Medications (e.g., hormone therapy)
Menstrual history, History of induction of ovulation (number
of cycles and response of ovaries)
Potential sexually transmitted disease exposure, symptoms of
genital inflammation (e.g., vaginal discharge, dysuria,
abdominal pain, fever)
Previous fertility
Substance use, including caffeine ,SMOKING
History and examination

18. Surgical history (previous genitourinary surgery)
Toxin exposure
Physical examination
Breast formation
Galactorrhea
Genitalia (e.g., patency, development, masses,
tenderness, discharge)
Signs of hyperandrogenism (e.g., hirsutism, acne,
clitoromegaly)
History and examination

19. AMH
FSH , LH
S. PROLACTIN
TSH
CBC
Pelvic ultrasound
Basic investigations needed
to diagnose female factors of
infertility

20. -VAGINAL AND CERVICAL FACTORS
-UTERINE FACTORS
-TUBAL FACTORS
-OVARIAN FACTORS
- FEMALE AGE.
-Sometimes Immediate IVF is the most effective
treatment for couples when the female partner is at
the end of her reproductive years
Female factors of infertility
indicated for IVF

21. Uterine factors
Uterine factor infertility (UFI) may affect up to
1 in 500 reproductive age women. The uterus
is an essential component of achieving
pregnancy and carrying a pregnancy to term
successfully. There are many etiologies of UFI
which may be categorized into either
congenital or acquired causes.

22. Being born without a uterus.
This is a rare congenital (something you are born with)
condition called Mayer-Rokitansky-Küster-Hauser syndrome
(MRKH). This condition causes parts of the female
reproductive system to be underdeveloped — meaning the
vagina can be shorter than normal or the uterus may not be the
correct shape and size. In severe cases, there’s no uterus
present at birth. In MRKH, the ovaries are present and
functioning.
Unicornuate uterus Bicornuate uterus uterine septate may need an IVF as
an optionl treatment in the presence of other anomalies ,
uterine anomalies

23. AQUIRED
ASHERMAN SYNDROME
is a rare condition where the scar tissue in the uterus creates
adhesions — physical blocks — inside the uterus, preventing a
pregnancy. Causes of Asherman’s syndrome include infections,
radiation, and uterine surgery, such as dilation and curettage
(D&C) procedures
UTERINE CAVITY SURGERY FOLLOWED BY A PERIOD OF
INFERTILITY after a good assessment by hysteroscopy
HYSTERECTOMY.
Having the uterus surgically removed

24. Uterine myomas
The mechanisms proposed by which they can affect fertility
include interference with sperm transport secondary to
displacement of the cervix and enlargement of uterine cavity,
obstruction of the interstitial segment of fallopian tubes,
distorted adnexal anatomy interfering with ovum capture,
distortion of uterine cavity, increasing myometrial
contractions, or glandular atrophy at endometrium overlying
myoma. Although there is little evidence to support the
majority of these mechanisms, they all hold some biological
plausibility.
Criteria for patient selection
for IVF

25. fibroids come in different numbers, sizes, locations, and
consistencies.
small and medium sized Subserosal fibroids, remote
from the uterine cavity, do not affect fertility and are
typically not removed prior to in vitro fertilization (IVF)
Subserosal fibroids are unlikely to have an impact on
ART outcomes, except when they cause difficulties with
ovarian access for egg collection. For this reason, the
majority of subserosal fibroids are left alone during IVF
cycles.
patients who have intramural fibroids that do not
distort the cavity prior to IVF treatment. We try to avoid
surgery in the presence of fibroids <5 cm when the
uterine cavity is regular.
Uterine myomas

26.  the IVF model helps to isolate the effect of fibroids on
implantation and miscarriage outcomes in infertile
populations.
 larger fibroids and those with fibroids that distort
the cavity undergo myomectomy. Therefore, the
real impact of these fibroids on IVF outcomes is
likely to be larger.
Uterine myomas

27. ENDOMETRIAL POLYPS
Endometrial polyps are aberrant endometrial growths
consisting of glands, stroma, and blood vessels with a
vascular center and sessile or pedunculated shape that
extends into the uterine cavity. They range in size from a
few millimeters to several centimeters and can be found in
isolation or multiples.
Multiple case reports show conception and live birth
in women with infertility and adenomyosis after
pretreatment with GnRH-a for 3 to 5 months. In other
retrospective studies, pretreatment with GnRH-a prior
to fresh- or frozen-embryo transfer appears to increase
pregnancy rates .
ADENOMYOSIS
invagination of the endometrial basalis layer into the
myometrium.

28. DIAGNOSIS OF UTERINE FACTORS
can be detected by
1- ultrasonography or saline infusion
sonohysterograghy (hydrosonogram )
2- hysterosalpingograghy
3- CT or MRI
4- hysteroscopy
5- laparoscopy
Not all causes of uterine factors of infertility need
an IVF as a standard treatment

29. Surrogacy is a form of third-party reproduction in which a
woman consents to carry a pregnancy for intended parent(s)
who cannot conceive for medical reasons. There are two
forms of surrogacy.
Traditional surrogacy
uses the surrogate mother’s egg for conception(forbidden
and debatable by some religions).
gestational surrogacy
is performed by transferring embryos made through IVF
with eggs and sperms from the intended parents.(forbidden
and debatable by some religions)
Surrogacy may be an alternative for
uterine factor of infertility

30. it accounts
for 25-30% of female factor for infertility.
Tubal infertility includes the changes due to
inflammation
which involve the fallopian tube and its relation
towards ovary in a way that will affect ovulation, the
transportof egg, sperm or embryo or alter the
function of the tube as the site of fertilization...
Tubal factor of infertility

31. Congenital absence of fallopian tubes or part of it
Aplasia
Atresia
Hypoplasia tubal hypoplasia (Abnormally long or
abnormally thin tubes)
Accessory horn or Ostia and tubal diverticulum
Fallopian tube a genesis
Tubal factor of infertility

32. . 1-Extensive Pelvic-peritoneal adhesions
(mostly sequelae of previous infections) constitute the
single most common class of tubal pathology
responsible for tubal infertility.
2- Other conditions include
endometriosis, hydrosalpinx and proximal tube
obstruction due to complications of endoluminal
salpingitis.
3-Bilateral tubal ligation.
Tubal factor of infertility

33. .. Pelvic
inflammation (PID) is the most common cause of tubal
disease, representing more than 50% of the cases. It
may affect the fallopian tube at multiple sites. After one
episode of PID the rate of infertility has been estimated
to be 11%, which increases to 23% and 54% after two
and three episodes respectively
Tubal factor of infertility

34. Tubo peritoneal adhesions results from both
proximal and distal tubular diseases
Female genital tuberculosis (G T.B)

35. history of surgery for ectopic pregnancy and
appendectomy has been associated with tubal
infertility. However, infections that damage the
tubes to cause ectopic gestation usually affect
both tubes. In addition, surgery for ectopic
pregnancy may lead to post-operative adhesions
especially when done by open surgery or
laparotomy
Tubal factor of infertility

36. Diagnosis of Tubal Infertility:
-Hysterosalpingography (HSG)
-Endoscopic evaluation
laparoscopy is the chief diagnosis of tubal damage
and abnormalities ( hydrosalpnix , phymosis,
abnormal length, adhesions , obstruction ,TB,):
-Sonographic evaluation:
Tubal factor of infertility

37. egg release from the ovary accounts for 20% of female
infertility problems.
-ovarian adhesions
-PCOS
-Endometriosis
-LUF
-Low ovarian reserve
-Thick zona ( zona pellucida defects)
-Fertility preservation
Ovarian factor infertility

38. Luteinized un ruptured follicle (LUF) syndrome is defined as
a failure of ovulation in which, despite the absence of
follicular rupture and release of the oocyte, the un ruptured
follicle undergoes luteinization under the action of LH.
LUF is seen in 10% of menstrual cycles of normal fertile
women
A higher incidence has been reported in infertile women . The
occurrence of LUF has been linked to many conditions such as
unexplained infertility, endometriosis, pelvic adhesions and
the use of non-steroidal anti-inflammatory drugs (NSAIDs).
LUF has been demonstrated in both spontaneous and
stimulated cycles
Luteinized unruptured follicle (LUF)
syndrome

39. -Thick zona ( zona pellucida defects)
the zona pellucida (ZP) is a highly organized dynamic structure
that
is essential for oogenesis, fertilization, and embryo development
Throughout oocyte maturation and embryonic development, the
ZP undergoes specific structural and functional changes. Any
intrinsic or extrinsic factors that disturb these events may cause
lack of fertilization and decrease embryo viability, leading to
infertility .It has been reported that the ZPT is influenced by
various factors, including maternal age, elevated basal FSH
concentrations
Ovarian factors need an ivf

40. Scarred Ovaries
Physical damage to the ovaries may result in failed
ovulation. For example, extensive, invasive, or multiple
surgeries, for
repeated ovarian cysts may cause the capsule of the
ovary to become damaged or scarred, such that follicles
cannot mature
properly and ovulation does not occur. Infection may
also have this impact
Ovarian factor infertility

41. 1- more than one year of infertility after medical or
successful surgical or laparoscopic treatment of
endometriosis
2- more than one year of infertility after medical and
laparoscopic treatment of PCOS
3- more than one year of infertility after successful
laparoscopic adhesiolysis of pelvic adhesions
4-more than one year of infertility after myomectomy of
uterine fibroids
5-more than one year of infertility after failure of treatment
of male factor of infertility
Immediate IVF

42. Unilateral hydrosalpnix doesn't need an
immediate IVF after tubal disconnection ( the
other tube may be functioning)
6-Extensive pelvic adhesions or frozen pelvis
7-Tubal abnormalities (e.g. abnormally long tubes )
8-Double factor of infertility (e.g. PCO and
oligospermia) after one year of failure of medical
or surgical treatment of one or both of them
Immediate IVF

43. 1- males with undescended testis and high FSH
level
2- klienfelter Syndrome
2-sertoli cell syndrome
3- empty follicle syndrome
4- low ovarian reserve below 0.2 ng / ml with
negative AFC by us
5- ladies above 45 years old
6-females with extreme obesity
7- asherman syndrome
8- primary ovarian failure
IVF
except by donation

44. Fertility declines with age. Female fertility is at its peak between
the ages of 18 and 24 years, while, it begins to
decline after age 27 and drops at a somewhat greater rate after
age 35. In terms of ovarian reserve, a typical
woman has 12% of her reserve at age 30 and has only 3% at age
40 .
81% of variation in ovarian reserve is due
to age alone, making age the most important factor in female
infertility.
delaying marriage for men and women, delaying childbearing,
more frequent divorce is an important factors.
Age related factor of
infertility

45. Age related factor of
infertility

48. FSH and estrogen are good indicators of fertility, as
well as of a woman’s response to ovulation
induction or stimulation.
The anti-Müllerian hormone usually correlates
well with fertility potential by reflecting the
number of eggs left in the ovaries.
These two hormone level tests, combined with a
tran svaginal ultrasound for AFC to give you an
idea how to take the decision .
at 45, there is a one percent chance of getting
pregnant at all and then at least a fifty
percent chance of miscarrying

49. Most fertility clinics set an age limit, often
between 42 and 45 years old.
Should There Be an IVF Age Cutoff ?