Patient preparation before IVF involves counseling, evaluation of fertility factors, and management of associated conditions. Key parts of the evaluation include semen analysis, tests of ovarian reserve like AMH, and ultrasound exams. Conditions like obesity, diabetes, thyroid disease, and endometriosis must be addressed prior to starting IVF treatment to optimize outcomes. Hysteroscopy is not routinely recommended before the first IVF cycle but may be beneficial for women with recurrent implantation failure.

1. Patient preparation before IVF
Prof Aboubakr Elnashar
Benha University, Egypt
https://www.facebook.com/groups/227744884091351/
Aboubakr Elnashar

2. CONTENTS
I. COUNSELING & INFORMATION
II. EVALUATION
1. General
2. Semen analysis
3. ORT
4. Hormonal.
5. TVS.
6. Hysteroscopy??
III. MANAGEMENT OF ASSOCIATED CONDITIONS
IV. PREVENTIVE TREATMENT.
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: ≤2.5%, C: ≤5m, M: ≤10%
2.Azoospermia
II. Tubal factor infertility:
1. Moderate to severe tubal disease: tubal block,
pelvic adhesions, hydrosalpinx
2. Other factors e.g. abnormal semen, age >36 yr
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. Endometriosis
1. Moderate and Severe
2. Other factors: Poor ORT, abnormal semen, tubal dis
3. Failure of conception after 6-18 m of surgery
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

6. 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

7. 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

8. II. EVALUATION
1. General
History taking:
Surgical: laparotomies
Medical: Hepatitis, DM, thyroid disease, SLE
Current and Previous TT:
Gynecological exam
 Speculum
 Trial ET
Screening of both partener for HBV and HCV
protect the uninfected partner and the future child
prevent contamination of samples
Aboubakr Elnashar

9. Trial (dummy, mock) ET (Sharif et al.1995)
AIM
1. Length and direction of the uterine cavity&
cervical canal
2. Cervico-uterine angulations.
3. Choose the most suitable catheter
4. Discover any difficulty:
•pinpoint external os,
•cervical polypi or fibroids
•anatomical distortion of the cx.Aboubakr Elnashar

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

11. 3. Ovarian reserve testing
 Woman’s age:
An initial predictor of overall chance of success
through natural conception or with IVF
 Predictors of ovarian response to Gnt stimulation
in IVF: (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

12. Indications:
≥ 35 ys or
< 35 years
Endometriosis
Unexplained infertility
Poor response to FSH,
Single ovary
Previous ovarian surgery,
Previous exposure to chemotherapy or
radiation. (Iii-b)

13. 4. Endocrine Evaluation
 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

14. 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
5. Basal Vaginal U/S
The Pivotal US (performed D8-12)
Aboubakr Elnashar
± Saline infusion sonography (SIS)

15. only 1 antral, other ovary had only 2 antrals
Ovarian volume: low
D3 FSH: normal
Attempts to stimulate ovaries for IVF were not successful
Aboubakr Elnashar

16. At the beginning of a menstrual cycle, irregular periods, No
medications being given.
Antral follicles:16 are seen in this image. Ovary had a total of 35
antrals (only 1 plane is shown). This is PCO with a high antral
Ovarian volume= 37 X19.5mm
"high responder" to injectable FSH drugs.
Aboubakr Elnashar

17. Adenomyosis
Aboubakr Elnashar

18.  Bromley et al (2000)
2 or more of the followings:
1. Mottled heterogeneous myometrial texture: All
cases.
2. Globular uterus: 95% of cases.
3. Small myometrial lucent areas: 82%.
4. “Shaggy” indistinct endometrial strips: 82%.
The most predictive:
ill-defined heterogeneous echotexture within the
myometrium
(Brosen et al, 2004)
Aboubakr Elnashar

19. 6. Hysteroscopy
Before the 1st trial of IVF?
Infertile with a normal TVS or HSG: Hysteroscopy:
Minor intrauterine abnormalities: 11-45%
(Pundir 2014, SR and MA)
 One RCT + 5 NRCT (3179 participants)
 Significantly higher CPR
 The number needed to treat after hysteroscopy to
achieve one additional CP: 10
 improve tt outcome.
 High-quality RCT to confirm.
Aboubakr Elnashar

20.  Ongoing study the in SIGHT study multicenter
RCT of hysteroscopy prior to first IVF cycle
(Smit 2012) assess the effects and costs of
screening for and tt of unsuspected intrauterine
abnormalities by routine office hysteroscopy, with
or without SIS, prior to a first IVF/ICSI cycle.
Aboubakr Elnashar

21. Before IVF in women with RIF (2-4):
Detection and tt of these abnormalities by
office hysteroscopy: 9-13%: increase in PR (2RCT).
 Does Not Improve IVF Outcomes
(El-Toukhy , 2014 – ESHRE) .
No hysteroscopy (n = 352) or
hysteroscopy (n = 348) given in the cycle before IVF (day
10-25) using a 2.9-mm Trophyscope.
an endometrial cavity abnormality: 11%, with 4.3%
requiring surgical tt
Endometrium subtle abnormality: 13%.
no significant differences between the tt groups for PR
(38% vs 38%), CPR (35% vs 33%), and LBR (30% vs.
29%) IR were also similar between groups (28% vs 30%).
“Outpatient hysteroscopy cannot be routinely
recommended after RIF”
Aboubakr Elnashar

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

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

24. 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

25. 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

26. 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 and 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

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

28. 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

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

30. 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

31. THYROID DISEASE
 Before ART:
 First treat hypothyroidism or hyperthyroidism
 Normal menses restored
(Poppe et al, 2007).
 Carbimazole or methimazole: PTU
 Monitor/4w: FT4 at upper 1/3 of normal range
 L-thyroxine tt in Normal TSH before ART
1. Positive TPOAb, and history of miscarriage or
hypothyroidism.
2. TSH is greater than 2.5 mIU/L
(Am Ass of endocrinology, 2013, Grade B)
Aboubakr Elnashar

32. ART in hyperthyroid-treated women:
PTU may need to be reduced
{ increased thyroxine requirements}
TFT should be checked during COS
once PT is +ve
/2-4 w
FT4: upper 1/3 of normal range
Aboubakr Elnashar

33. ART in hypothyroid-treated women:.
LT4 dosage should be increased
1. To obtain TSH < 2.5 mIU/L before COS
{latter procedure increases TH demands}.
2. AITD treated with LT4 and developed OHSS
{E2 increase sharply and markedly:
severe hypothyroidism (TSH, 42 mIU/L)
{Association between OHSS and AITD}.
:increase daily LT4 dosage 4 wk before starting the COH
(Poppe et al, 2008)
3. Pregnancy:
Spontaneous: 30%
After COS: 32% (Davis et al., 2007)
Aboubakr Elnashar

34. ENDOMETRIOMA
Check: previous surgical or medical tt , ORT
Avoid surgery:
previous history of surgeries
reduced ovarian reserve
If ≥4 cm and surgical tt is not planned:
GnRHa for at least 3 consecutive months before IVF
During OR:
Avoid puncturing or drainage of endometrioma
Give IV antibiotics
Aboubakr Elnashar

35. HYDROSALPINX
Prior to starting IVF:
Salpingectomy
Tubal occlusion
During ovarian stimulation
TV aspiration at OR
Freeze all embryos, surgery for HS and the 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

36. UTERINE FIBROIDS
Myomectomy
1. SM
2. IM distorting endometrial cavity or ≥5 cm
UAE:
infertility is a relative contraindication
Reproductive outcome is less favorable with UAE
than myomectomy
Aboubakr Elnashar

37. CERVICAL STENOSIS
History
previous surgery
difficult or painful cervical instrumentation
Mock ET
Before the start of IVF to identify cases and 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

38. 2. Osmotic cx dilatation:
Hygroscopic rods (Dilapan)
Inserted in cx for 4 hours (day 4) in the stimulation
phase
(Serhal et al, 2003)
Laminaria tents for 24 h either at OR or early in
stimulation phase
(Mains et al, 2010)
Aboubakr Elnashar

39. 3. 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
embryo transfer catheter protruding into the uterine cavity.
Aboubakr Elnashar

40. Aboubakr Elnashar

41. 4. Tubal ET:
an alternative in cases with normal fallopian tubes
but requires laparoscopy and GA
5. Hysteroscopic canalization of the cervix:
only for cases associated with amenorhea or
significant dysmenorhea
Operative hysteroscopic shaving of the cx to create
a new canal
(Pabucca et al, 2005)
Aboubakr Elnashar

42. 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)
 LOD
Aboubakr Elnashar

43. Face book: Aboubakr Elnashar
Lectures
https://www.facebook.com/groups/227
744884091351/
Aboubakr Elnashar