Doctors aim to provide their infertile couples with the best care. This can only be done if we follow evidence from clinical trials and accepting patient preferences

1. Infertility
evidence that matters

2. Not here to say
• Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception
RCOG,1999

3. Conception rates for fertile
couples
100
90
80
70
60
50
40
30
20
10
0
0 6 12 18 24
Months of intercourse (cycles)
Percent of Couples Conceiving

4. Not here to say (Continued)
(Speroff & Fritz, 2005)
© 2008, March of
Dimes Foundation

5. Not here to say (Continued)

6. here to say
Best care not usual care

7. Integrate
Clinical
Expertise
Research
Evidence
Patient
Preferences

8. The Best Example
Men should not be offered surgery for
varicocele as a form of fertility treatment
because it does not improve pregnancy
rates. (Evers & Collins, 2003)

9. Post-coital test
The routine use of post-coital testing of
cervical mucus in the investigation of
fertility problems is not recommended
because it has no predictive value on
pregnancy rate (Oei et al, 1998).

10. Aim
To provide the most recent available
Patient oriented evidence in infertility
Management based on :-
Cochrane Library, 2013 issue IV
NICE guideline 2013.

12. Investigations
How to proceed?

13. Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigating an infertile
couple.
(Strandell 2000)

14. Basic fertility work up
referral gyn
History
Physical examination
Ovulation evaluation Semen analysis
Tubal
patency:
CAT
HSG
DLS

15. Diagnostic studies to confirm
Ovulation
BBT
Inexpensive
Accurate
Endometrial
biopsy
Serum progesterone
Urinary ovulation-detection
Expensive
Static information
kits

16. Serum Progesterone
Progesterone starts rising with the LH
surge
drawn between day 21-24
Mid-luteal phase
>10 ng/ml suggests ovulation

17. Tubal Factor
hysterosalpingography (HSG) is a
reliable test for ruling out tubal
occlusion, and it is less invasive and
cheaper than laparoscopy

18. When to do DL
Unless there is history of pelvic
inflammatory disease, previous ectopic
pregnancy or endometriosis, then, D.L
is justified.

19. Hormonal Assay
Women with irregular menstrual cycles
should be offered a blood test to
measure serum (FSH, LH)

20. TSH
the routine measurement of thyroid
function should not be offered.

21. Prolactin assay
This test should only be offered to
women who have an ovulatory disorder,
galactorrhoea or a pituitary tumour
But not on routine basis

22. Tests of ovarian reserve
AMH
Any day of cycle
Reliable
expensive

23. Hysteroscopy
Women should not be offered
hysteroscopy on its own as part of the
initial investigation

24. Semen analysis
Serial semen samples (at least two)
should be assessed in the same
laboratory

25. Semen analysis

26. CASA vs. conventional analysis
In a randomized controlled trial, the
determination of motility characteristics
as obtained by CASA systems is of
limited value to optimizing the
evaluation of male fertility status
(Krause ,1995 )

27. What to do?
Gonadotrophins
Nutritional supplements ?

29. ICSI
Moderate or Severe male factor
•Obstructive azoospermia
•non-obstructive azoospermia.

30. hypogonadotrophic
hypogonadism
hMG is a must because these are
effective in improving fertility

31. PCOS
treatment with clomifene citrate (or
tamoxifen) as the first line of treatment
for up to 12 months (not only 6) VanderVeen,
2014)

32. Monitoring
ultrasound monitoring during at least
the first cycle of treatment to ensure that
they receive an adequate dose

33. Metformin
In CC resistant cases
For at least 45 days

34. IUI
Its use is questionable (Reindollar et al,
2010)

35. IUI
If done, offer up to 3 cycles

36. Tubal surgery
For women with mild tubal disease,
tubal surgery may be more effective
than no treatment in centres where
appropriate expertise is available.

37. IVF
Couples in which IVF is justified should
be offered up to three stimulated
cycles of in vitro fertilisation treatment.

38. recFSH vs hMG
hMG, u FSH and recombinant FSH are
equally effective in achieving a live birth
when used following pituitary down-regulation
as part of in vitro fertilisation
treatment.

39. GnRHa in IVF/ICSI
Long protocol is the standard .

40. IUA
should be offered hysteroscopic
adhesiolysis because this may restore
menstruation and improve the chance of
pregnancy.

41. Endometriosis
Medical treatment of minimal and mild
endometriosis does not enhance fertility
in subfertile women and should not be
offered

42. Laparoscopic Ablation
Women with minimal or mild
endometriosis who undergo
laparoscopy should be offered surgical
ablation or resection of endometriosis
plus laparoscopic adhesiolysis

43. Endometrioma
Women with ovarian endometriomas
should be offered laparoscopic drainage
because this improves the chance of
pregnancy.

44. Endometriosis III / IV
Women with moderate or severe
endometriosis can be offered surgical
treatment because it improves the
chance of pregnancy

45. Endometriosis III / IV
Post-operative medical treatment does
not improve pregnancy rates in women
with moderate to severe endometriosis
and is not recommended.

46. Hydrosalpinx
Women with ultrasound visible
hydrosalpinges should be offered
salpingectomy before in vitro fertilisation
treatment because this improves the
chance of a live birth

47. BMI
female body mass index should ideally
be in the range 19–30 before
commencing assisted reproduction, and
that a female body mass index outside
this range is likely to reduce the
success of assisted reproduction
procedures.

48. ET
Women undergoing in vitro fertilisation
treatment should be offered ultrasound-guided
embryo transfer because this
improves pregnancy rates.

49. Day 2 vs day 5
Embryo transfers on day 2 or 3 and day
5 or 6 appear to be equally effective in
terms of increased pregnancy and live
birth rates per cycle started

50. ET
Replacement of embryos into a uterine
cavity with an endometrium of less than
6 mm thickness is unlikely to result in a
pregnancy and is therefore not
recommended

51. ET
Bed rest of more than 20 minutes’
duration following embryo transfer does
not improve the outcome of in vitro
fertilisation treatment

52. Luteal Phase Support
luteal support using progesterone
improves pregnancy rates

53. ICSI vs IVF
ICSI improves fertilisation rates
compared to IVF, but once fertilisation is
achieved the pregnancy rate is no better
than with in vitro fertilisation

54. Karyotype
Where the indication for
intracytoplasmic sperm injection is a
severe deficit of semen quality or non-obstructive
azoospermia, the man’s
karyotype should be established

55. Children
Current research is broadly reassuring
about the health and welfare of children
born as a result of assisted reproduction

56. BreakThrough