WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART ) / IVF BY DR SHASHWAT JANI.

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Dr Shashwat Jani. 9909944160. 2
Greetings From Ahmedabad …

3. WHY… ???
 It is estimated that more than 15% of couples
living in developed countries are infertile.
 No major change in prevalence,
but
there has been an increase in demand for treatment
during the past decade
because
of the perception that effective assisted reproductive
technology (ART) treatments are now easily
available at affordable cost…!!!
3Dr Shashwat Jani. 9909944160.

4.  Although , ART was initially developed for
patients with tubal infertility only ,
But Currently used for almost all kinds of
infertility problem, because its success rates are
expected to be higher than those of conventional
treatments.
 However, ART treatment also has disadvantages.
 It involves greater expense, and potentially
serious complications such as OHSS and multiple
pregnancies can occur.
 There are also fears that drugs that induce
ovulation may increase the risk of ovarian cancer.
4Dr Shashwat Jani. 9909944160.

5. Infertility treatment should therefore be
individualized
to avoid subjecting couples to
unnecessary risks due to overtreatment,
such as
the unnecessary use of ART treatments,
or
to inappropriate delay because of under
treatment. 5Dr Shashwat Jani. 9909944160.

6. So …
6Dr Shashwat Jani. 9909944160.

7. Categories of Infertile
Couples
(1) Those with single defect in one of the
partners;
(2) Those with multiple defects in one or both
the partners;
(3) No apparent defect in either partner
(unexplained infertility).
7Dr Shashwat Jani. 9909944160.

8. 8Dr Shashwat Jani. 9909944160.

9. FEMALE
FACTORS …
9Dr Shashwat Jani. 9909944160.

10. Tubal Diseases…
 Where microsurgical techniques for tubal
and peritoneal disease have failed or are
unlikely to benefit the patient.
 Presence of dense peritubal adhesions,
condition of the tubal wall, condition of the
ciliary epithelium and degree of fimbrial
damage
10Dr Shashwat Jani. 9909944160.

11.  Tubeculosis
 Bilateral Hydrosalpinx
 Already undergone tuboplasty and
those with inaccessible ovaries
 H/o ectopic pregnancy
11Dr Shashwat Jani. 9909944160.

12. Uterine Factors…
 Mullerian agenesis or congenital uterine
anomalies,
 Women with severe intrauterine
adhesion refractory to surgical lysis of
the adhesion,
 hysterectomized patients can, through
IVF, transfer their embryos to a surrogate
mother.
12Dr Shashwat Jani. 9909944160.

13. Ovarian Factors…
 Hypogonadotropic anovulation,
 Oligoovulation
 Luteal phase deficiency ( Rare )
 LUF in severe PCOS
13Dr Shashwat Jani. 9909944160.

14. Cervical factors…
Only if,
repeated attempts (6 to 8 cycles) of
intrauterine insemination ( I.U.I. )
have failed and other therapies have
not resulted in pregnancy.
14Dr Shashwat Jani. 9909944160.

15. Endometriosis…
 Women with moderate to severe
endometriosis;
 Those in whom medical or surgical therapy
has failed; and
 Sometimes in cases of mild to moderate
endometriosis in the presence of other factors
contributing to infertility.
15Dr Shashwat Jani. 9909944160.

16. Use of donor oocytes &
donor embryos
 Undergone premature or timely menopause
 Women in the perimenopausal age group who do
not show proper recruitment of follicles and who
have other existing causes of infertility
 Genetic disorder
 Undergone radiation therapy
 Ovaries not accessible by USG due to severe
adhesions
16Dr Shashwat Jani. 9909944160.

17. Male
Factors…
17Dr Shashwat Jani. 9909944160.

18. SEMEN ABNORMALITY
 Low concentrations of sperm
(less than 10 million/ml),
 Low motility (less than 30%),
 Abnormal sperm morphology
(presence of > 60% abnormal forms).
18Dr Shashwat Jani. 9909944160.

19. Immunological factors…
When methods like . . .
Immunosuppression,
Condoms &
IUI have failed in presence of
Anti Sperm Antibodies either in
Male or Female Partner…
19Dr Shashwat Jani. 9909944160.

20. Unexplained Infertility…
 Couples who have prolonged unexplained
infertility could benefit from IVF, as
 Many factors such as subtle ovulation
defects, defects in ovum pick-up,
 Gamete transport,
 Tubal environment,
 Sperm abnormality,
 Oocyte abnormality
may come to light when IVF is used…!!!
20Dr Shashwat Jani. 9909944160.

21. Assisted reproductive
techniques
Dr Shashwat Jani. 9909944160. 21

22. methods
 Intra Uterine Insemination ( IUI )
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 In-vitro fertilization and embryo transfer (IVF-ET)
 Gamete intrafallopian transfer (GIFT)
 Zygote intrafallopian transfer (ZIFT)
- Pronuclear stage tubal transfer (PROST)
- Tubal pre-embryo transfer
- Tubal embryo transfer ( TET )
- Transcervical tubal transfer.
22Dr Shashwat Jani. 9909944160.

23.  Micromanipulation
- Intracytoplasmic sperm injection (ICSI)
- Subzonal sperm injection ( SUZI )
- Partial zona dissection (PZD)
 Oocyte and embryo donation
 Cryopreservation
 Assisted hatching (AH)
 Percutaneous epididymal sperm aspiration (PESA)
 Testicular sperm extraction ( TESE )
 Pre-implantation genetic diagnosis (PGD)
23Dr Shashwat Jani. 9909944160.

24. METHOD OF CHOICE…
 The choice of the procedure used,
e.g. IVF-ET, GIFT, ZIFT, or ICSI,
is made depending upon the . . .
 Needs,
 Resources ,
 Circumstances of the couple,
 Availability of the facilities &
 Experience and expertise of the gynaecologist /
embryologist.
24Dr Shashwat Jani. 9909944160.

25. I.U.I.
 Common indications for IUI are:
 Hostile uterine cervix.
 Oligozoospermia
 Unexplained infertility
 Indications for Donor IUI :
(a) Non-obstructive azoospermia;
(b) The husband has a hereditary genetic defect;
(c) The couple has Rh incompatibility;
(d) The man has severe oligozoospermia and the
couple does not wish to undergo any of the
sophisticated ART such as ICSI 25Dr Shashwat Jani. 9909944160.

26. I.V.F. - ET
 Irreversible Tubal
pathology or surgical
damage
 Subnormal Male factor
 Idiopathic infertility.
 Endometriosis.
 Infertility of
immunological origin.
26Dr Shashwat Jani. 9909944160.

27. I.C.S.I.
Indications of ICSI with ejaculated
spermatozoa :
 Severe male-factor infertility.
 Fertilization failure after standard IVF
treatment.
 Number of spermatozoa in the ejaculate
too low for IVF. 27Dr Shashwat Jani. 9909944160.

28. Indications of ICSI with
surgically extracted sperm :
( MESA / PESA/ TESA / TESE )
 Congenital bilateral absence of the vas
deferens (CBAVD).
 Obstructive azoospermia
 Non-obstructive azoospermia
 Anejaculation.
 Retrograde ejaculation. 28Dr Shashwat Jani. 9909944160.

29. Oocyte Donation
 Gonadal dysgenesis.
 Premature ovarian failure.
 Iatrogenic ovarian failure due to ovarian
surgery or radiation, or chemical castration.
 Women who have resistant ovary
syndrome,
 Poor responders to ovulation induction.
 Women who are carriers of recessive
autosomal disorders.
 Women who have attained menopause.
29Dr Shashwat Jani. 9909944160.

30. Embryo Donation
 Primary germ
cell failure
 Inheritable
genetic disorder
30Dr Shashwat Jani. 9909944160.

31. Pre Implantation Genetic Diagnosis (
P.G.D. )
1 ) Infertility and recurrent miscarriages :
For patients at risk for genetic disorders:
Autosomal Dominant
• Huntington’s chorea
Autosomal Recessive
• Cystic fibrosis
• Tay-Sachs disease
• β-thalassemia
• Sickle cell disease
31Dr Shashwat Jani. 9909944160.

32. X-linked
• Duchenne muscular dystrophy
• Hemophilia A
• Fragile X syndrome
Chromsomal disorders
• Structural Translocations, Inversions, Deletions
• Aneuploidy: Downs, Edwards, Klinefelter syndrome
• Monosomy: Turners syndrome
• Tetraploidy
32Dr Shashwat Jani. 9909944160.

33. Unsuccessful IVF cycles :
 Couples with repeated unsuccessful IVF
cycles should be evaluated for the
presence of a chromosome abnormality.
 The female or male partner may be
carrier of a balanced translocation or
may be an aneuploid mosaic.
33Dr Shashwat Jani. 9909944160.

34. REMEMBER…
Dr Shashwat Jani. 9909944160. 34

35. Patient Selection
35Dr Shashwat Jani. 9909944160.

36. Husband
 Physical examination : Systemic & local
 Detailed Semen Analysis – if abnormal 
repeat after suitable interval.
 Screening for HIV , HBV, HCV.
 Endocrinological report if needed and
therapy.
36Dr Shashwat Jani. 9909944160.

37. Wife
 Physical examination : systemic & local
 Detection & Timing of Ovulation by
appropriate test
 Assessment of Tubal Patency.
 Screening for HIV , HBV, HCV .
 Endocrinological report if needed and therapy
37Dr Shashwat Jani. 9909944160.

38. So…
 Any gynaecologist not specifically
trained in the subspeciality of
infertility care can also complete
these investigations.
 Based on the results of these
investigations, couples should be
referred….
38Dr Shashwat Jani. 9909944160.

39. NICE GUIDELINES .
 When considering IVF as a treatment option for
people with fertility problems, discuss the risks and
benefits of IVF.
 In women aged under 40 years who have not
conceived after 2 years of regular unprotected
intercourse or 12 cycles of artificial insemination
(where 6 or more are by IUI ), offer 3 full cycles of
IVF, with or without ICSI.
 If the woman reaches the age of 40 during
treatment, complete the current full cycle but do
not offer further full cycles. 39Dr Shashwat Jani. 9909944160.

40. NICE GUIDELINES . . .
 Where investigations show
there is no chance of
pregnancy with expectant
management and where IVF is
the only effective treatment,
refer the woman directly
to a specialist team for
IVF treatment…!!!
40Dr Shashwat Jani. 9909944160.

41. KEY POINTS…
 Explosion of knowledge about human
reproduction and a greater understanding has
increased our scope of applying ART for providing
solutions to a greater number of infertile couples.
 IVF is the end-point for many causes of infertility
but should not be abused or embarked upon too
early.
 IVF is a test of fertilization…!!!
41Dr Shashwat Jani. 9909944160.

42.  ART gives hope to women with ovulatory
dysfunction, tubal disease and a host of
gynecological conditions.
 Micromanipulation techniques such as ICSI
have revolutionized the treatment of male
factor infertility and couples with a history of
poor fertilization in previous cycles.
 Surely, with time and more awareness, we
would discover yet newer indications for
same…!!!
42Dr Shashwat Jani. 9909944160.

43. 43Dr Shashwat Jani. 9909944160.