3. •Faculty
• Dr. Sharda Jain
Prog. Director , Course Chairperson
• Dr Jyoti Agarwal
Director /Course Co- Chair person
• Dr. Aruna saxena
Director Course Co- Chairperson
• Dr. Jyoti Bhaskar
Director
• Dr. Abhishek Singh Parihar
Director
• Dr. Sushma Ved
Director
4. 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
6. • 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 %
7. 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
8. GENERAL
• 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 CONDITIONS
Intrauterine insemination
Unstimulated IUI
Insemination is to be timed around
ovulation
9. 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
10. If the man is HIV positive …….
But not compliant
offer sperm washing
13. Patients with unexplained infertility on CC as
stand alone treatment does not increase the
chances of pregnancy
IVF is to be offered to these women
who do not conceive in 2 yrs of
regular unprotected sexual
intercourse.
Unexplained infertility
new 2013
14. Criteria for referral for IVF
When considering IVF as a treatment
option…
COUNSEL
Discuss the risks and benefits of IVF
treatment based on Human Fertilisation and
Embyrology Authority code of practice
(new 2013)
15. Inform the couple …
One full cycle of IVF consists of
1 episode of Ovarian Stimulation
with or without ICSI
Transfer of fresh or frozen embryo(s)
(new 2013)
16. 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
• If the women reaches the age of 40 during
treatment complete the current full cycle
but
• Do not offer any further cycles (new 2013)
17. In 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
18. 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)
19. Prediction of IVF success
Female age
Number of previous treatment cycles
Previous pregnancy history
Body mass index (19 – 30)
(new 2013)
(new 2013)
(2004, amended 2013)
(2004, amended 2013)
20. Prediction of IVF success
Lifestyle factors
Alcohol
Maternal / Paternal smoking
Maternal caffeine consumption
All are inversely proportional to IVF
success
(2004, amended 2013)
21. In IVF programme
• Pretreatment with OCP or
progestogen does not affect the
chances of having a live birth
• Can be considered in order to
schedule IVF treatment
(new 2013)
23. Controlled ovarian stimulation
Individualised starting dose
• Age
• BMI
• Presence of polycystic ovaries
• Ovarian reserve
Max dose of FSH - 450 IU / day
Urinary or recombinant FSH
25. Considerations in Ovarian Stimulation
Clomiphene stimulated and gonadotrophin
stimulated IVF cycles have higher pregnancy
rate per cycle than natural cycle IVF
Use of growth hormone and DHEA as adjuvant
treatment is not advocated
(new 2013)
Do not offer Natural cycle IVF
treatment
26. Important !!!!
Clinics providing ovarian
stimulation with
gonadotrophins should have
protocols in place for
-Preventing
-Diagnosing OHSS
-Managing (2004)
27. Embryo transfer strategies in IVF
•Ultrasound guided
• ET in an endometrium of less than 5
mm is not advocated
• Bed rest of more than 20 minutes
does not improve the outcome
(2004)
(new 2013)
28. How many embryos to be
transferred ?
Women less than 37 yrs of age
• First IVF cycle - single embryo
• Second cycle - single top most quality
or
- Two if no top quality
• Third cycle - Never more than 2
embyros
(new 2013)
29. Between ages 37 – 39 years
First and second IVF cycles
-single embryo if it is a top quality
or
-2 embyros if there are no top quality
Third cycle IVF
Transfer not more than 2 embyros
(new 2013)
30. For women aged 40 – 42
years consider double
embyro transfer
No more than 2 embyros
should be transferred during
any cycle of IVF (new2013)
31. Special considerations
For women undergoing IVF with
donor eggs , embyro transfer strategy
is based on the age of the donor
• If top quality blastocyst is available
transfer only one embyro
• Cyropreserve the remaining good
quality embyros
(new 2013)
33. Luteal phase support after IVF
Progesterone
Routine use of HCG not advised
Evidence does not support
continuing luteal phase support
beyond 8 weeks of gestation
(2013)
34. IVF vs ICSI
Couples should be informed that ICSI
improves fertilisation rates wrt
IVF
but
Once fertilisation is achieved there is
no difference in the pregnancy
rates (2004)
35. Recognised indications for ICSI
•Severe defects in semen quality
• Obstructive azospermia
• Non obstructive azospermia
• Previous IVF cycle has resulted in failed
or very poor fertilisation
(2004)
36. 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)
