This document outlines an action plan for the prevention, detection, and management of infertility. It discusses the need for such a plan given infertility is a growing public health issue. The plan aims to improve access to diagnosis and treatment through primary, secondary, and tertiary prevention approaches. It also seeks to establish low-cost in vitro fertilization to help more people address infertility issues. Key factors that influence infertility treatment costs and outcomes are identified. Prevention strategies target conditions like sexually transmitted infections that can lead to tubal damage. The role of lifestyle factors in both causing and treating infertility is addressed. Diagnostic tools and assisted reproduction techniques are outlined along with when each is most appropriate. Challenges in making these services accessible in developing countries are

1. Action Plan for Prevention, Detection &
Management of Infertility

2. Why Action Plan…
• Infertility is an emerging public health priority
• Possibilities for prevention..in three
levels..Primary, Secondary & Tertiary
• Need for better access to diagnosis and
treatment
• Preventing adverse outcomes of infertility
treatment..need of the hr
• Process for developing the Action Plan for
Advanced Infertility Management..costeffective
approach..Low Cost IVF

3. Infertility Management…
Two main partners are involved with
many invisible forces
Its Race with TIME….Time bound

4. Active management for one year..Action Plan
Standard management ( EBM )
Expectant management in years ( old )

5. Poor Outcome…More expensive
• Age more than 35 yrs
• BMI > 30 kg/m2
• Genital Kochs
• Single ovary
• Previous repeated ovarian surgeries
• Endometriosis
• Long term thyroid disorder

6. Possibilities of Prevention….
• Known or potential causes of infertility include
genetic abnormalities, environmental, occupational,
and infectious agents, pcos, delayed childbearing,
and behavioral risk factors.
• Prevention….May be substantial…
• For example, tubal infertility affects 18% of the couples who
try to overcome infertility using assisted reproductive
technology (ART) and is typically the consequence of chronic
pelvic inflammatory disease (PID), Genital TB which can lead
to tubal scarring.
• Clinical trials have shown that the risk of PID can be greatly
decreased by early detection and treatment of sexually
transmitted diseases (STDs) and, in particular, chlamydia
infection

7. Diagnosis of Genital Koch’s

8. • There are 2.2 million new cases of
tuberculosis in India, each year.
• About 5,00,000 people die of
tuberculosis each year in India.
Report by Serum Institute of India
Incidence

9. • Involvement of organs---Norries
• Fallopian tubes------85 to 90%
• Endometrium--------35 to 50%
• Ovaries---------------- 5 to 6%
• cervix—-----------------3 %
• Vagina & vulva -------2 %

10. Incidence
Country Author Year Incidence
• India Nair hosp. 1989 14.7%
• India Mukerjee 1967 14.5%
• Saudi Arabia 1985 1 to 7%
• Spain Botella l 1967 10.6%
• Japan Shinjawa 1960 5.5%
• England Hainas 1958 4.0%
• U.S.A. Foss 1958 0.6%
• Australia Townsend 1955 0.7%
Incidence of genital tuberculosis in U.S.A. is increasing
due to increase in immigrant population

11. • The newer methods for detection of growth of
M.tuberculosis along with gene probe and
gene amplification technologies have
provided excellent tools for
• Rapid identification of isolates,
• Direct detection of mycobacterial pathogens
from clinical specimens
• Detection of drug Resistance.
these methods to achieve the highest
sensitivity and specificity in future..

12. • There is increasing evidence that lifestyle
factors such as tobacco smoking and obesity,
which can cause chronic disease and disability
later in life, can also adversely affect fertility
during the reproductive years

13. Age And Infertility
The Biological Clock: Fact!!!

15. Effect of Maternal age
• Depletion of the primordial follicle pool
(Gougeon, 1979 ; Richardson et al., 1987 ; Faddy et al., 1992 )
• Disorganization of the oocyte meiotic spindle
(Battaglia et al., 1996 , 1997 )
• Older eggs with poorer quality
• Ovarian age parallels chronological age.
• A marked decrease in fertility

16. Concept to remember
• Up to 30 years of age, the loss of follicles (and
oocytes) in the human ovary is mainly due to atresia
of resting follicles.
• After reaching a critical threshold in the number of
follicles (estimated at 25,000), the recruitment of
growing follicles is increased twofold and thereafter
the loss of follicles is mainly due to atresia of growing
follicles
Gougeon 1996, Erickson 2000.

17. Age and Fertility
Optimal
Fertility Declining
Fertility
Menopause
End of
Fertility
Irregular
Cycles

18. 10% of the whole population … women become
menopausal by the age of 45 years, have
experienced an accelerated decline of fertility
around the age of 32.
These women can be classified under a separate
clinical entity, “early ovarian ageing”

19. • Fixed time-interval between accelerated
decline of fertility and the menopause….13yrs
Human Reproduction, Vol. 18, No. 3, 644-648, March 2003
Subfertility reflects accelerated ovarian ageing
Medical Center Utrecht, Utrecht, The Netherlands

20. Clinical suspects…..
• Age >35yrs
• Unexplained Infertility
• Poor stimulation
• Recurrent cyst formation
• A short follicular phase,
• Early LH surge,
• Premature elevation of progesterone
(P4)
• Requiring very high gonadotrophin doses
• Idiopathic Recurrent abortions with anupleidies
(Farhi et al., 1997; Crosignani et al., 2000; De Boer et al., 2002; Nikolaou et al., 2002;Lawson et al., 2003)

21. • Women with a family history of an early menopause
• Chemotherapy
• Radiotherapy
• Pelvic surgery (Lass et al., 1998;Tulandi et al., 2002),
• Pelvic infections or tubal disease (Keayet al., 1998;
Sharara1998),
• Severe endometriosis (Barnhart et al., 2002),
• Long standing Hypothyriod
• Single ovary

22. Need of the hour….
Judicious use of the finite supply of the
eggs and preservation of the
nature’s gift is in our hands……..

23. Ultrasound tests
• Antral follicle count (AFC)
• Ovarian volume
• Ovarian stromal blood flow

24. Think of Advanced management …..
• High doses of gonadotrophins are required
• Multifollicular development
• Addition of borderline male problem
• PCOS
• Moderate to Severe Endometriosis
• Six IUI cycles (Justified) unexplained infertility
• Women’s age ,Type of infertility, Duration of
infertility

25. What are we trying to predict?
• How likely pt. has chance to conceive
spontaneously presently?
• How long can she can delay trying to
conceive?
• What treatment options should we use?

26. Assisted Reproductive Technologies
IUI
IVF
ICSI
GIFT
Blastocyst Transfer
Cryopreservation
Assisted Hatching
PGD

27. In vitro fertilization (IVF).. Indications
• Blocked tubes
• Severe Endometriosis
• Unexplained Infertility
• IUI failures
• Egg & embryo donation

28. Pre ART Preparation..
Diagnostic Hysteroscopy
• polyps
• Submucous fibroids
• Intrauterine septum
• Intrauterine adhesions
• Cervical stenosis
• Cx Canal direction mapping

29. Conditions should be looked into..
• Hydrosalphinx
• Genital TB
• Endometriosis
• Adenomyosis
• Fibriods
• PCOS

30. Polycystic Ovarian Syndrome

31. Optimization
• Adjusting BMI
• Controlling high or tonic LH levels
• Decreasing severity of Hyperandrogenism
• Sensitization of ovary to insulin

32. PCOS
• Improvement of BMI
• Ovarian drilling
• Metformin
• Treatment of allied conditions such as
hyperprolactinaemia & hypothyroidism

33. In-Vitro-Fertilization
• Ovarian Stimulation
– Pure FSH/Recombinant FSH/HMG
– Downregulation using GnRH analog
– Soft protocols – CC or letrozole with gonadotropins and
antagonists
• Cycle monitoring
– USG u Estradiol
• Trigger
– HCG – urinary or recombinant
– GnRH analog
• Oocyte retrieval
– 34-36 hrs after HCG
• Fertilization in Lab
• Embryo transfer between 2-5 days

34. Protocols
USG
E2
USG
E2
HCG
5000
10,000
ET
D2
ET
D3
ET
D5
Blastocyst
OPU
35-37
hr
Day21 1 2 3 4 5 6 7 8 9 1011
GnRha
- SC
- Nasal
- Depot
Progesterone
IM
Oral
Vaginal
FSH HMG
GnRH Antagonist

35. ICSI – Indications
• Severe OAT <5 mill
• Failed fertilization in IVF
• Azoospermias
• Preimplantation genetic diagnosis
• Immunological factors
• Oncology : frozen thaw sperms may be
grossly impaired
• Ejaculatory dysfunction
• Paraplegic males : TESE with ICSI

37. Obstructive Azoospermia
PESA
 No sperms
TESA

TESE
Offer Cryopreservation
CBAVD – Screening for cystic fibrosis carrier status

38. Non Obstructive Azoospermia
TESA (2 hits)
 No sperms
Open biopsy 7-8 punctures & pull out tubules

Open biopsy

Opposite testes
*Timing 6-24 prior to OPU ideal 6 hrs prior
Offer Cryopreservation

39. Failure of ICSI Cannot Afford Rx
IUI – Donor
Simple & effective therapy
Khalil et al, Acta Obstet, Gynaecol Scand, 2001

40. Sperm Banking : Husband
• Prevasectomy storage
• Pretherapy storage
• Retrograde ejaculations
• Oligozoopermia
• Backup for assisted reproduction
• Sperm antibodies

41. Blastocyst Culture

42. Blastocyst Culture
• PR of 50 %
• BC culture reduces multiple pregnancy rates
• BC can make PGD application much easier
• Can be combined with day 2/3 ET for doing
Seqential Transfer

43. Assisted Laser Hatching

44. Assisted Laser Hatching
• Indications:
1.Age >35 years
2. Zona thickness >15 microns
3.Repeated IVF failures
4.Post thaw Embryo transfer
5. Prior to PGD
Routine use in all patients does not improve
Pregnancy Rates.

45. Pre Implantation Genetic Screening

46. PGD : Indications
• Traditional PGD :Screening embryos for
Genetic defects
• PGS Anueploidy screening in recurrent
failures
• PGD Therapy : Creating genetically matched
siblings for treating affected children

47. Embryo Cryopreservation
• Freezing extra embryos
• OHSS
• Poor endometrial lining
• Difficult embryo transfer
• Combination

48. Cryopreservation :
Slow Freezing or Vitrification???

49. Slow Freezing :Traditional & Time Tested

50. Vitrification : New RAY of Hope

51. Cryopreservation :Innovations
• Egg Banking :Introduced in India 2006
• Pre therapy Ovarian tissue preservation for
young patients suffering from cancer and to
treat menopause??

52. In Vitro Maturation (IVM)
• Good Alternative for Poor Responders
/PCOS
• FSH priming on Day 3/4/5
• HCG 10,000 on Day 8
• Retreival,filteration and identification.
• Maturation for 24 to 48 hours
• ICSI and Embryo Transfer
• Clinical Pregnancy rates of 20 to 40 %

53. The Fact….
• While ART can help a large number of infertile
couples, it is estimated that only 5% of ART
candidates utilize this medical service, the
reason being cost or lack of accessibility and
awareness in certain geographic areas.

54. FINE TUNNING…IN OI & INFERTILITY MANAGMENT
Low Cost ART Services..National INTEREST
group Initiative

55. Need of the hour…
Developing countries, children are so highly valued that a
woman’s status is often solely defined through
motherhood…and infertility becomes a terrible
stigma…uproots whole family…
Policies on reproduction have become an increasingly important
tool for governments seeking to meet the
so-called demographic ‘challenge’ created by the combination
of Low fertility & Lengthening life expectancies
The political will to act on matters of reproduction

56. Facts…
• Infertility is a global problem, but the highest prevalence is in
low resource countries, where infection-related tubal damage
is the commonest cause.
assisted conception can treat the infertility.
• Globalization …..PCOS, Endometriosis, Male factor…
• ART services either unavailable or inaccessible to most of
resource poor countries.
• There is urgent need for a comprehensive sexual and
reproductive healthcare initiative involving maternal and child
health, safe abortions, family planning and infertility
prevention and management
• The provision of low cost ART services for couples in poorly
resourced countries needs to be revisited

57. WHO recommendations…
• 2001…meeting held..Review progress in assisted
reproduction with focus on developing world..
• Infertility..a global health problem
• Needs more innovative approaches for Low-cost ART
services in true sense in low resource settings..

58. Followers…
Independent Initiatives…
• Non Profit Organization..Low Cost IVF
Foundation..2007
• International Society for Mild Approaches in
Assisted Reproduction (ISMAAR)..2007
• ESHRE..2008

59. Present scenario…
• An attitude shift toward ART in developing countries
has resulted in attempts exploring
low-cost ART suitable to limited resource settings
• This is a positive and needed development
Fertil Steril 2009;92:413–6. 2009 by American Society for
Reproductive Medicine.

60. Challenges….
• How simplified can the ART protocols become?
• Will quality be compromised with such approaches?
• What reduction in success rates would be
acceptable in a trade-off?
• How should resource allocations be determined, vis-
a-vis prevention versus treatment of infertility,
including provision of ART?
• How will infertility as a medical condition be viewed
relative to other health needs?
• As universal access to ART is unlikely?
• What criteria should be used for patient eligibility?

61. Meeting the challenges…
To increase the chances of achieving the provision of accessible
ART services in developing countries,
the following issues will need to be addressed…..
• National Infertility Needs
• The position of infertility services within a
comprehensive reproductive health program
• Appropriate reporting and surveillance of ART
activities
• The overarching issue of equitable access

62. • Political stability
• Health Priorities
• Health Care System Capacity
• Culture
• Religion
• Pace of Development

63. Our duties..
• National Infertility prevalence data..to assess
the magnitude for resource allocation…
• Assessment of local capacity & expertise to
carry ART services..in terms of sustainability…
• Data collection & reporting …to build national
confidence..

64. Possibilities…
• Join an International Reporting system
through national initiatives…
• Clinics…to State registers..to National
registers..to Regional registers..to World
registers…International Committee
Monitoring ART (ICMART)

65. Equity..
• Appro. 12 % of U.S. women of childbearing age gets
Insurance coverage, about 1 in 8 couples, have
received assistance for infertility
Updated March 2010
• 20% of all needy, from developed countries could
seek ART
• 1% of the projected needy could avail ART in
developing countries
• IVF costs..appro. 50% higher than the gross national
income per capita in developing countries..

66. Equity…
• In India Rs.5000 to 10000/ should be the one IVF
cycle cost…
• How can be this bridged?
• Public Funding?
• Public-Private partnership to increase the availability
of ART services?
• Awareness about right way to approach Infertility
Management?
• Attitude ?
• Wait till International group forcefully motivate us?

67. Guiding Principles…
• Minimizing Risks
• Maximizing benefits….through
Maintaining Quality & Sustainability

68. • Urgent need …likeminded scientists,
specialists to come together and
start thinking & acting….motivating…
pollicy makers…insurance providers…

70. Thank You Indeed…..