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Management of
infertility
Nice guidelines 2013
Dr. Sharda Jain
Dr. Jyoti Agarwal
…Caring Hearts, Healing hands
NICE GUIDELINES
ON
FERTILITY
Original -2004
Modified guidelines-2013
Guidelines are must in
today’s clinical practice
senario
A clinician who cannot
follow practice
guidelines is
like a
pilot without a plane……
Ain’t gonna get
anywhere
Principles of management
ADVICE AND COUNSELLINGADVICE AND COUNSELLING
Principles of care [2004]Principles of care [2004]
Couples should be
• Seen together
• Make informed decision via access to
evidence based verbal, written and audio-
visual information.
• Counselling to be offered – before , during
and after treatment and investigations
because these per se also lead to STRESS !
Treatment
Medical
Surgical
ART
WHO classification of ovulatory
disorders
3 groups
Ovulation Disorders
Group I: Hypothalamic pituitary failure
Hypothalmic amenorrhoea
(hypogonadotrophic hypogonadism).
Group II: Hypothalamic-pituitary-ovarian dysfunction
(predominately polycystic ovary syndrome).
Group III: Hypergonadotrophic
hypogonadism ( ovarian failure ).
Advice to increase their body weight
if BMI less than 19.
moderate their exercise levels ( as seen in athletes )
offer them ovulation induction -
pulsatile administration of gonadotrophin-releasing
hormone
gonadotrophins with luteinising hormone activity.
This improves ovulation , conception and
chances of having uncomplicated
pregnancy
2013
Treatment of WHO Group 1 ovulation
disorder
WHO Group II Ovulation Disorders
Advice them to loose weight
New 2013
Lifestyle changes
WHO Group II Ovulation Disorders
loosing weight alone may
• restore ovulation
• Improve their response to ovulation induction
• Has a positive impact on pregnancy outcome
new 2013
WHO Group II Ovulation Disorders
Ovulation induction – ( not more than 6 months).
- Clomiphene citrate
- Metformin.
Combination of the two
• Clinical & Follicular monitoring via TVS should be done to avoid
multiple pregnancies and risk of OHSS. –
• Day 21 progesterone levels measured to confirm ovulation
new 2013
Clomiphene Resistant Cases
Consider one of the following second line treatment
• Laparoscopic ovarian drilling
• Combined treatment with clomiphene citrate and
metformin if not already offered as first line treatment
• Ovulation induction with gonadotrophins.
new 2013
GnRHa X
Adjuvant growth hormones. X
Monitoring essentials
Ultrasound monitoring
With or without estradiol levels
should be an integral part
for efficacy & safety throughout
ovarian stimulation
(new 2013)
Important !!!!
Clinics providing ovarian
stimulation with gonadotrophins
should have protocols in place for
-Preventing
-Diagnosing OHSS
-Managing (2004)
Ovulation Disorders
Hyperprolactinaemic amenorrhoea
Bromocriptine
cabergoline
Tubal and Uterine Factors
Mild Tubal Disease surgery should be offered for it may be more
effective than no treatment.
Proximal Tubal Obstruction - selective salpingography
Hysteroscopic tubal cannulation.
Intrauterine Adhesions - hysteroscopic adhesiolysis is likely to
restore menstruation and improve the
chance of pregnancy.
Hydrosalpinges Laparoscopic salpingectomy or cliping prior to IVF
Endometriosis:
Medical
In minimal or mild
endometriosis it
does not enhance
fertility and hence
should not be offered
Surgical
Offered in minimal or
mild and moderate to
severe endometriosis
Medical treatment is not effective
Rather delays fertility restoration
Mild endometriosis surgical ablation plus laparoscopic
adhesiolysis improves the chance of
pregnancy.
Endometrioma – if > 4 cm, laparoscopic cystectomy
Post-operative medical treatment does not
improve pregnancy rates hence not
recommended
2004
Surgical Management of
Endometriosis:
UNEXPLAINED INFERTILITY
Patients with unexplained infertility on CC as
stand alone treatment does not increase the
chances of pregnancy
Do not offer ovarian stimulation agents
(clomiphine , letrazole, ananstrazole) to
women with unexplained infertility
(2013)
X
IVF is to be offered to these women
who do not conceive in 2 yrs of
regular unprotected sexual
intercourse.
new 2013
UNEXPLAINED INFERTILITY
•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)
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
(new 2013)
• 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 %
GENERALGENERAL
• 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 CONDITIONSSPECIFIC CONDITIONS
Intrauterine insemination
Unstimulated IUI
Insemination is to be timed around
ovulation
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
If the man is HIV positive …….
But not compliant
offer sperm washing
Insufficient evidence to
recommend that HIV negative
women needs pre – exposure
prophylaxsis …….
Hence NOT
recommended
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
Criteria for referral for IVF
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
(new 2013)
Criteria for referral for IVF
• If the women reaches the age of 40 during
treatment complete the current full cycle
but
• Do not offer any further cycles
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
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)
IVF vs ICSI
Couples should be informed that ICSI
improves fertilisation rates
compared to IVF
but
Once fertilisation is achieved there is no
difference in the pregnancy rates
(2004)
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)
Luteal phase support
Progesterone
Routine use of HCG not advised
Evidence does not support continuing
luteal phase support beyond 8 weeks of
gestation
(2013)
Thank you
HOPEFUL OUTCOME !!

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Management of infertility Nice Guidelines 2013 : Dr. Sharda Jain Dr. Jyoti Agarwal

  • 1. Management of infertility Nice guidelines 2013 Dr. Sharda Jain Dr. Jyoti Agarwal …Caring Hearts, Healing hands
  • 3. Guidelines are must in today’s clinical practice senario A clinician who cannot follow practice guidelines is like a pilot without a plane…… Ain’t gonna get anywhere
  • 4. Principles of management ADVICE AND COUNSELLINGADVICE AND COUNSELLING
  • 5. Principles of care [2004]Principles of care [2004] Couples should be • Seen together • Make informed decision via access to evidence based verbal, written and audio- visual information. • Counselling to be offered – before , during and after treatment and investigations because these per se also lead to STRESS !
  • 7. WHO classification of ovulatory disorders 3 groups
  • 8. Ovulation Disorders Group I: Hypothalamic pituitary failure Hypothalmic amenorrhoea (hypogonadotrophic hypogonadism). Group II: Hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome). Group III: Hypergonadotrophic hypogonadism ( ovarian failure ).
  • 9. Advice to increase their body weight if BMI less than 19. moderate their exercise levels ( as seen in athletes ) offer them ovulation induction - pulsatile administration of gonadotrophin-releasing hormone gonadotrophins with luteinising hormone activity. This improves ovulation , conception and chances of having uncomplicated pregnancy 2013 Treatment of WHO Group 1 ovulation disorder
  • 10. WHO Group II Ovulation Disorders Advice them to loose weight New 2013
  • 12. WHO Group II Ovulation Disorders loosing weight alone may • restore ovulation • Improve their response to ovulation induction • Has a positive impact on pregnancy outcome new 2013
  • 13. WHO Group II Ovulation Disorders Ovulation induction – ( not more than 6 months). - Clomiphene citrate - Metformin. Combination of the two • Clinical & Follicular monitoring via TVS should be done to avoid multiple pregnancies and risk of OHSS. – • Day 21 progesterone levels measured to confirm ovulation new 2013
  • 14. Clomiphene Resistant Cases Consider one of the following second line treatment • Laparoscopic ovarian drilling • Combined treatment with clomiphene citrate and metformin if not already offered as first line treatment • Ovulation induction with gonadotrophins. new 2013 GnRHa X Adjuvant growth hormones. X
  • 15. Monitoring essentials Ultrasound monitoring With or without estradiol levels should be an integral part for efficacy & safety throughout ovarian stimulation (new 2013)
  • 16. Important !!!! Clinics providing ovarian stimulation with gonadotrophins should have protocols in place for -Preventing -Diagnosing OHSS -Managing (2004)
  • 18. Tubal and Uterine Factors Mild Tubal Disease surgery should be offered for it may be more effective than no treatment. Proximal Tubal Obstruction - selective salpingography Hysteroscopic tubal cannulation. Intrauterine Adhesions - hysteroscopic adhesiolysis is likely to restore menstruation and improve the chance of pregnancy. Hydrosalpinges Laparoscopic salpingectomy or cliping prior to IVF
  • 19. Endometriosis: Medical In minimal or mild endometriosis it does not enhance fertility and hence should not be offered Surgical Offered in minimal or mild and moderate to severe endometriosis Medical treatment is not effective Rather delays fertility restoration
  • 20. Mild endometriosis surgical ablation plus laparoscopic adhesiolysis improves the chance of pregnancy. Endometrioma – if > 4 cm, laparoscopic cystectomy Post-operative medical treatment does not improve pregnancy rates hence not recommended 2004 Surgical Management of Endometriosis:
  • 21. UNEXPLAINED INFERTILITY Patients with unexplained infertility on CC as stand alone treatment does not increase the chances of pregnancy Do not offer ovarian stimulation agents (clomiphine , letrazole, ananstrazole) to women with unexplained infertility (2013) X
  • 22. IVF is to be offered to these women who do not conceive in 2 yrs of regular unprotected sexual intercourse. new 2013 UNEXPLAINED INFERTILITY
  • 23. •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)
  • 24. 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
  • 26. • 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 %
  • 27. GENERALGENERAL • 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 CONDITIONSSPECIFIC CONDITIONS Intrauterine insemination Unstimulated IUI Insemination is to be timed around ovulation
  • 28. 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
  • 29. If the man is HIV positive ……. But not compliant offer sperm washing
  • 30. Insufficient evidence to recommend that HIV negative women needs pre – exposure prophylaxsis ……. Hence NOT recommended
  • 31. 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
  • 33. 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 (new 2013)
  • 34. Criteria for referral for IVF • If the women reaches the age of 40 during treatment complete the current full cycle but • Do not offer any further cycles
  • 35. 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
  • 36. 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)
  • 37. IVF vs ICSI Couples should be informed that ICSI improves fertilisation rates compared to IVF but Once fertilisation is achieved there is no difference in the pregnancy rates (2004)
  • 38. 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)
  • 39. Luteal phase support Progesterone Routine use of HCG not advised Evidence does not support continuing luteal phase support beyond 8 weeks of gestation (2013)

Editor's Notes

  1. X
  2. Who have not concieved after 2 yrs of unprotected intercourse 12 cycles of IUI
  3. (2004)