Preparation for IVF
Ian Cooke
Emeritus Professor
University of Sheffield
Director of Education
International Federation of Fertility Societies
Precongress seminars
XIХ International conference of RAHR
“Reproductive technologies today and
tomorrow”
September, 10-12, 2009
Irkutsk, Siberia
Preparation for IVF
Of the patients
Of staff and facilities
Of organisation
• Review of U.K. infertility Guideline
algorithm (2004, but valid)
• Emphasis on process leading to IVF
U.K. National
Guideline developed
by a multidisciplinary
group:
Stages
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1. Process published
2. Draft formulated
3. Professional
consultation
with interested
bodies
4.Modification
5. Final publication
Background
• The Guideline was produced for the NHS because of the wide
variation in and limited access to NHS treatment. It covered a new
review of the research evidence.
• The National Institute for Clinical Excellence (NICE) Guideline was “to offer
best practice advice on the care of people in the reproductive age
group who perceive that they have problems in conceiving” (Feb.2004)
• Based on the Management of Infertility (RCOG,1998-2000) :
initial (primary) investigation and management,
management in secondary care and
management in tertiary care.
The full Guideline (CG11, 500pp. with refs) “Fertility assessment and
treatment for people with fertility problems” is available (as a 1.21Mb
file) at:
http://www.nice.org.uk/guidance/index.jsp?action=download&o=29269
Grades of Evidence
LEVEL EVIDENCE GRADE
1a Systematic review and meta-analysis of RCTs A
1b At least 1 (randomised controlled trial) RCT
At least one well-designed CT without
2a B
randomisation
At least one other type of quasi-experimental
2b
study
Well-designed non-experimental descriptive
3 studies, such as comparative, correlation or C
case-control studies
Evidence from expert committee reports or
4 opinions &/or clinical experience of respected D
authorities
The view of the Guideline Development Group GPP
Algorithm for assessment and treatment
for people with fertility problems (NICE)
• Definition of infertility - 2 years
• Initial advice to people concerned about conception
• Early investigation
- history of predisposing factors
- woman’s age ≥ 35y
- HIV status
- hepatitis B & C
• People preparing for cancer treatment (oocyte cryopreservation)
• Principles of care
- Couple centred management
- Access to evidence-based information (verbal and written)
- Counselling from someone not directly involved in management
of the couple’s infertility
- Contact with fertility support groups
- Specialist teams
Initial advice -1
Cumulative probability of pregnancy in
the general population
Fertility declines with a woman’s age
• Lifestyle advice
Preconceptual advice
-folic acid, rubella, cervical screening
Initial Advice - 2
• Intercourse at least every 2-3 days C
• Alcohol not >2-3U/day (F) D
not >3-4 U/day (M) GPP
excess alcohol is detrimental to semen quality B
• Smoking may reduce fertility in females, refer to cessation
programme A
• Smoking in males: no link, but stopping will improve
general health GPP
• Passive smoking may reduce fertility B
• No consistent evidence about caffeinated beverages (tea,
coffee, cola) B
• BMI ≥30 (F), if anovulatory, lose weight, preferably in a
group A
• BMI ≥30 (M) is likely to be associated with reduced fertility C
• BMI 2 transferred in any one cycle
- Offer cryostorage if >2 embryos
- Frozen embryos to be transferred before further
stimulated cycle
- Ultrasound guided embryo transfer on
day 2 or 3, or day 5 or 6
• Luteal support
- progesterone
Management options with IVF
or other forms of ART - 1
• ICSI
- Severe semen defects, azoospermia
- Poor IVF treatment response
- Screen by karyotype
• Donor insemination
- Azoospermia
- Genetic disease in male partner
- Severe rhesus isoimmunisation
- Severe semen defects
For female:
- Confirm ovulation, HSG if no pregnancy after 3 cycles
Management options with IVF or
other forms of ART - 2
• Oocyte donation
- Premature ovarian failure
- Gonadal dysgenesis including Turner syndrome
- Bilateral oophorectomy
- Ovarian failure following chemo- or radio-therapy
- Some cases of IVF treatment failure
- Gene disorder transmission to offspring
- Screen donors
- Risks of ovarian stimulation and egg collection
• Egg sharing - counselling
Key priorities in infertility management (3/6)
before IVF
Assessing tubal occlusion
and uterine abnormalities
• Screen for Chlamydia before uterine instrumentation B
(A key priority)
• If positive, treat and refer the sexual partner for screening C
• Consider prophylactic antibiotics before uterine
instrumentation if not screened GPP
• If no co-morbidities (pelvic inflammatory disease, previous ectopic,
endometriosis) offer HSG (hysterosalpingogram [or hysterosalpingo-
contrast-sonography] A) to screen for tubal occlusion B (A key
priority)
• If co-morbidities, offer laparoscopy B
• Hysteroscopy should be clinically indicated and not used routinely.
Treatment of uterine anomalies is not clearly linked to fertility B
• Do not use routine post-coital testing of cervical mucus as it has no
predictive value for pregnancy rate A
Intrauterine insemination
• Mild male factor, unexplained infertility and
mild to moderate endometriosis should
have 6 cycles of IUI A (A key priority)
• It should be unstimulated IUI in male factor
and unexplained infertility A
• Use stimulated IUI for mild to moderate
endometriosis A
• Use single insemination (A) and Fallopian
tube perfusion A
Standards of Care (BFS/RCOG)
STANDARD CORE ASPIRATIONAL
Primary Care
Organisation of services Local protocols Dedicated staff
Progesterone, Rubella,
Same laboratory
Initial investigation Chlamydia
for Semen Analysis
& Semen Analysis
Secondary Care
Where appropriate
Location of Services Network
staff & facilities
Availability of service 5 day & Weekend cover 24/7 access to information
Direct referral
Access to
Standard from General
infertility clinics
Practitioner
Verbal & written in
Patient information Clear
languages
Written information leaflets With contact details Online also
Consultation room Private Dedicated
Competence of clinical &
Trained Multidisciplinary meeting
nursing staff
See Consultant at
alternate visits
BFS/RCOG Standards of Care
Summary
And so on… through secondary and tertiary care; also providing auditable standards
for the Clinic, the Andrology lab and the Assisted Reproduction clinic
Secondary Care Tertiary Care
• Initial investigations • Location of Services
• Pelvic assessment • Organisational and
management responsibility
• Patient choice of management
• Quality management
• Support services • Resource management
• Ovulation induction • Assisted conception services
• Unexplained infertility • Gamete donation
• Endometriosis • Evaluation and improvement
• Continuing professional
development
CONCLUSION
• A great deal of preparation is required
before IVF can be implemented:
- agreed protocols
- informed staff
- patients prepared factually and
emotionally
- Efficient, responsible organisation