This document provides guidance on preparing patients for IVF. It discusses counseling patients, evaluating them through history, exams, screening tests, and managing associated conditions. Key points include screening both partners for infections, evaluating ovarian reserve with tests like AMH, addressing lifestyle factors and medical issues like obesity, diabetes and endometriosis, and providing preventive treatments like antibiotics and aspirin before IVF. The goal is to optimize the patient's physical and emotional health prior to starting IVF treatment.

1. Patient preparation before IVF
Prof Aboubakr Elnashar
Benha University, Egypt
Aboubakr Elnashar

2. CONTENTS
I. COUNSELING & INFORMATION
II. EVALUATION
1. History
2. Examination
3. Investigation
Screening for HBV &HCV
III. MANAGEMENT OF ASSOCIATED CONDITIONS
IV. PREVENTIVE TREATMENT.
Semen analysis 1. ORT
2. Hormonal.
3. TVS.
4. Hysteroscopy??
4
Aboubakr Elnashar

3. I. COUNSELING & PATIENT INFORMATION
 How pregnancy occur
 Indication of the procedure
 The steps of the procedures
 PR in general and that for their condition
 The possible problems:
sensitive and nonthreatening way
 Financial information.
 Handbook for information
Aboubakr Elnashar

4. Indications of IVF/ICSI
I. Male factor infertility:
1.Severe semen:
NF: ≤2% (4), C: ≤5m (15), M: ≤10% (40)
2.Azoospermia
II. Endometriosis
1. Moderate and Severe
2. Other factors: Poor ORT, abnormal semen, tubal dis
3. Failure of conception after 6-18 m of surgery
Aboubakr Elnashar

5. III. PCOS:
1. Other factors: tubal factor, male factor
(Tannys, 2010)
2. Failure to conceive despite at least 6 ovulatory cycles
IV. Tubal factor infertility:
1. Moderate to severe tubal disease:
tubal block, pelvic adhesions, hydrosalpinx
2. Other factors:
abnormal semen, age >36 yr
Aboubakr Elnashar

6. V. Unexplained infertility
1. ≤35 y: failure of 6 trials of (HMG, IUI)
2. 35-39: failure of 4
3. ≥39: failure of 2
Aboubakr Elnashar

7. Prediction of success
(NICE, 2013)
1. Female age
Success falls with rising female age
2. Number of previous tt cycles
Success: falls as the number of unsuccessful cycles increases.
3. Previous pregnancy history
Success: higher
Aboubakr Elnashar

8. 4. BMI
Ideal: 19–30
BMI outside: reduce the success.
5. Lifestyle factors
i. Maternal and paternal smoking
ii. Maternal caffeine consumption can adversely affect
success rate.
6. Advanced Paternal age
(Liu et al, 2011)
 > 40y risks: small. (II-2C)
Spontaneous abortion
Autosomal dominant conditions
Autism spectrum disorders
Schizophrenia. Aboubakr Elnashar

9. II. EVALUATION
1. History taking
 Surgical: laparotomies
 Medical: Hepatitis, DM, thyroid disease, SLE
 Current and Previous TT
2. Examination
 Speculum
 Trial ET
Aboubakr Elnashar

10. 3. Investigations
For both:
Screening for HBV and HCV
 protect the uninfected partner and the future
child
 prevent contamination of samples
Aboubakr Elnashar

11.  For husband:
Semen analysis
(WHO, 2010)
:
:
Lower reference limitParameter
1.5 mlVolume
7.2pH
15 million/mlConcentration
39 million/ejaculateTotal sperm number
40% or
32%
Total Motility: (PR+NP)
PR
58% live spermatozoaVitality
4% (strict criteria).Normal Forms
Aboubakr Elnashar

12.  For wife:
1. Ovarian reserve testing
 Woman’s age:
Predictor of
 quality of oocytes
 success of
 natural conception
 IVF
Aboubakr Elnashar

13.  OR T:
Predictors of:
quantity of oocytes
ovarian response to Gnt stimulation
(NICE, 2013)
High responseLow response
16 or more4 or lessTotal AFC
3.5 or more
25
0.8 or less
5.5
AMH
ng/ml
pmol/l
Conversion ratio:7
4 or less8.9 or moreFSH IU/L
Aboubakr Elnashar

14. Indications:
 ≥ 35 ys or
< 35 years
1. Endometriosis
2. Unexplained infertility
3. Poor response to FSH,
4. Single ovary
5. Previous ovarian surgery,
6. Previous exposure to chemotherapy or
radiation.
(Iii-b)
Aboubakr Elnashar

15. 2. Hormonal assay
 Day 3:
 FSH, LH: Only in irregular prolonged cycles
 E2
 Prolactin: Only in
ovulatory disorder
galactorrhoea or
pituitary tumour
 TSH: only if
symptoms of thyroid disease
(NICE, 2013)
Aboubakr Elnashar

16. Information
Uterus Assessment: Dimension, Endometrial: thickness, appearance
Abnormalities: Anomalies, Tumors
Ovaries Assessment: Position, Mobility, Volume, AFC
Abnormalities: PCOS, Cysts, Tumors
Tube Hydrosalpinx, Patency
Pelvis Free fluid, Mass
3. Basal Vaginal U/S
The Pivotal US (performed D8-12)
± Saline infusion sonography (SIS)
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17. 4. Hysteroscopy
Before the 1st trial of IVF?
(inSIGHT): a multicentre, RCT
(Smit et al, 2016, Lancet)
750 women who had a normal TVS of the uterine cavity undergo
either hysteroscopy (with treatment of any detected abnormalities, such
as polyps) before starting IVF, or immediate IVF
LBR did not differ significantly between the groups (roughly 55%)
Routine hysteroscopy does not improve LBR in infertile women with a
normal TVS of the uterine cavity scheduled for a first IVF treatment.
Women with a normal TVS should not be offered
routine hysteroscopy.
Aboubakr Elnashar

18. Before IVF in women with RIF (2-4):
(TROPHY): multicentre, RCT (8 hospitals in the UK, Belgium, Italy,
and the Czech Republic) assigned 350 women to hysteroscopy and
352 to control.
LBR: 29% in each group, no significant difference between
either group (relative risk 1.0; 95% CI 0・79–1.25; p=0.96).
Hysteroscopy before IVF in women with a normal
TVS and a history of unsuccessful IVF does not
improve LBR.
(El-Toukhy , 2016, Lancet)
Aboubakr Elnashar

19. 3. MANAGEMENT OF ASSOCIATED
CONDITION
 HABITS
 PSYCHOLOGY
 PCOS
 OBESITY
 DM
 THYROID DISEASE
 HEPATITIS
 SLE
 Thrombophylia
 Heart disease
 Hyperprolactinaemia
ENDOMETRIOMA
HYDROSALPINGES
FIBROID & POLYP
CERVICAL
STENOSIS
UTERINE
PROBLEMS
Aboubakr Elnashar

20. HABITS
Smoking:
 ↓ conception rate
 ↑abortion and Gnt dose
 stop before IVF.
Caffeine:
 use ≤ 2mg (one cup of decaf coffee):
No deleterious effect
Aboubakr Elnashar

21. PSYCHO-SOCIAL ASPECTS
Stress, anxiety, and depression
linked to lower IVF outcomes
Psychological intervention improves success
(Sanders et al.1999; Klonoff-Cohen 2001; Smeenk et al.2001; Domar et
al. 2000)
Aboubakr Elnashar

22. OBESITY
Decrease:
CPR , LBR
Increase:
miscarriage rate
duration and dose of Gnt
(Rittenberg et al, 2011)
33 studies including 47,967 tt cycles
Unethical to refuse to accept a patient solely because
she is obese
(ACOG, 2014)
Violation of Articles Human Rights
12 (Right to marry and found a family)
14 (Prohibition of discrimination).
Aboubakr Elnashar

23. Before starting IVF cycle:
1. Above 35y:
tt rather than unsuccessful attempts to lose wt.
{Age stronger negative effect on oocyte number, number of mature &
fertilized oocytes, CPR and LBR}
(Sneed et al., 2008).
2. Counseling
unbiased manner, avoiding blame and maintaining her dignity
Impact of: raised BMI on IVF outcome
 wt loss on IVF tt outcome.
 raised BMI on pregnancy
Wt loss should be encouraged
3. Informed consent:
I wish to proceed under these circumstances
Aboubakr Elnashar

24. Management
Preconceptional
Screen for:
DM and optimization of glucose control
Thyroid disease.
Healthy diet and lifestyle
Prenatal vitamins
Aboubakr Elnashar

25. Weight loss:
1. Hypo-caloric diet:
2. Lifestyle changes, Exercise program
3. Pharmacologic agents Orlistat (Xenical):
4. Bariatric surgery
 Metformin:
not a wt loss drug
 Gonadotopins dose:
Increased after exclusion of PCOS
Aboubakr Elnashar

26. DM
 Female:
Preconception counseling
Risks of miscarriage & teratogenicity
Wt loss & optimal BMI
Tight glycemic control
Optimize HBA1c before the start of ART:
If on statin therapy:
check serum lipids and stop tt during ART& pregnancy
COS:
Will affect glycemic contol
{change in hormonal milieu and stress}:
check and maintain
OR:
Antibiotics and thromboprophylaxis (if indicated)
Aboubakr Elnashar

27. Men
Optimal BMI:
control DM
improve ED and T levels
Check androgen status
TT of ED:
phosphodiestrase inhibitors
If on statin therapy:
{can reduce T levels}
check serum lipids:
if normal: stop temporarily
Aboubakr Elnashar

28. ENDOMETRIOMA
Check:
 previous surgical or medical tt
ORT
Avoid surgery if:
previous history of surgeries
reduced ovarian reserve
COS protocol according to AMH:
During OR:
Avoid puncturing or drainage of endometrioma
Give IV antibiotics
Aboubakr Elnashar

29. HYDROSALPINX
Prior to starting IVF:
Salpingectomy
Tubal occlusion
During ovarian stimulation
TV aspiration at OR
Freeze all embryos
surgery for HS
freeze-thaw cycle
Laparoscopic salpingectomy should be considered for all women with
hydrosalpinges prior to IVF
(Cochrane Systematic Reviews 2008 )
Occlusion of the proximal tube seems to be equally effective
US guided aspiration of hydrosalpinges during OR improves PR (20 v43%)
(Hammadieh et al , 2008)
Aboubakr Elnashar

30. Fibroid
Myomectomy:
1. Distorting the cavity
Submucous:
(Gambadauro,2012).
Intramural:
2. Not distorting .
1. >5 cm
2. Multiple >3 (3cm)
(Bajekal & Li, 2000)
UAE:
infertility is a relative contraindication
Reproductive outcome is less favorable with UAE
than myomectomy
Aboubakr Elnashar

31. CERVICAL STENOSIS
History
previous surgery
difficult or painful cervical instrumentation
Mock ET
Before the start of IVF
identify cases: plan action
1. Cervical dilatation:
 At the start of IVF cycles:
ET easier and increase PR
{allow time for the endometrium to recover from any trauma,
inflammation or bacterial contamination resulting from dilatation at time
of OR}
At the time of OR:
ET easier but does not increase PR
Aboubakr Elnashar

32. 2. Tramsmyometrial ET: Towako method
Under TVS guidance
overcome the most difficult or impossible cases
{bypass the cervix}:
PR similar to easy transcervical transfers
 The echogenic line represents the needle equipped with an
ET catheter protruding into the uterine cavity.
Aboubakr Elnashar

33. 3. Tubal ET:
Cases with normal fallopian tubes
requires laparoscopy and GA
4. Hysteroscopic canalization of the cervix:
cases associated with
amenorhea or
significant dysmenorhea
Operative hysteroscopic shaving of the cx to create
a new canal
(Pabucca et al, 2005)
Aboubakr Elnashar

34. IV. PREVENTIVE TREATMENT
Day 1 For both partners
 Doxycyclin: 100mg 1x2x7d.
 Diflucan or Flucoral one caps.
 Flagentyl 4 tablet
Folic acid 0.5mg
Aspirin 75mg /day are continued
Prevention of OHSS in PCOS:
 Metformin: given in the period prior to ART
(Cochrane Systematic reviews Costello et al2010)
Aboubakr Elnashar