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Handbook on Managing Infertility (Meeting the Challenges in Low-Resource Settings)
Dr Jaideep Malhotra, Rohana Haththotuwa, Jaydeep D Tank
CHAPTER 1:
History of Human Assisted Reproductive Technology
MAJOR MILESTONES OF THE PROCESS
The History of In Vitro Fertilization (IVF)—The Milestones
CHAPTER 2:
Infertility in the Developing World
CHAPTER 3:
Need for Assisted Reproductive Technology in Low-resource Settings
INTRODUCTION
PREVALENCE OF INFERTILITY IN LOW-RESOURCE SETTINGS
FERTILITY PREFERENCE AND FACTORS INFLUENCING PREFERENCES
Consequences of Childlessness
NEED FOR ART IN LOW-RESOURCE SETTINGS
BARRIERS FOR ART PROGRAMS
Low Priority
Overpopulation
High Cost
SUGGESTED PROCEDURES TO IMPROVE THE MANAGEMENT OF INFERTILITY IN LOW-RESOURCE SETTINGS
Infertility Treatment should be a Part of an Integrated Reproductive Care Program
Investments for Prevention of Infertility
Public Education
Empowering Women
Simplifying Diagnostic Procedures
Simplified Treatment and Non-IVF Assisted Reproduction
Simplified Assisted Reproduction
RESEARCH ON ART
Monitoring ART Services
Economic Prosperity, Bridging the Economic Disparities
FUNDING FOR ART IN DEVELOPING COUNTRIES
CONCLUSION
CHAPTER 4:
Meeting the Challenges in Low-resource Settings
INTRODUCTION
BURDEN
CONTEXT OF INFERTILITY IN NEPAL
THE CHALLENGES IN PROVIDING AFFORDABLE ART: THE PRESENT SCENARIO IN LOW-RESOURCE COUNTRIES
TOWARDS SOLUTION: A PLEA FOR AFFORDABLE ART FOR ALL
Simplifying Technology
Education and Training
Surveillance and Reporting for Affordable ART of Quality
Affordable IVF through Private Public Partnership
Role of Government
CONCLUSION
ACKNOWLEDGMENTS
CHAPTER 5:
Establishing an ART Unit in a Low-resource Setting
ETIOLOGY
INVESTIGATIONS
Preliminary Workup
HYSTEROSALPINGOGRAPHY
Sonohysterography
Laparoscopy
Treatment
Controlled Ovarian Stimulation (COS)
Natural Cycle
Clomiphene Citrate
Aromatase Inhibitors
Intrauterine Insemination
Low Cost IUI Facility
Surgery for Tubal Blockage
Assisted Reproductive Technique
HOW TO REDUCE THE COST OF ART?
Facility (Fig. 5.1)
Personnel
Laboratory Equipment
Follicular Tracking
Training
Cost of Disposables/Culture Medium
Treatment in Batches
Satellite Clinics
Intravaginal Culture (INVOCEL)
IN VITRO MATURATION OF OOCYTES
Ovarian Hyperstimulation Syndrome (OHSS)
Single Embryo Transfer
CONCLUSION
CHAPTER 6:
The Laboratory Minimum Acceptable Standards
INTRODUCTION
MINIMAL PERSONNEL REQUIREMENTS OF AN ART CLINIC
Laboratory Staff Requirement
Laboratory Director
Clinical Embryologist
MINIMAL PHYSICAL REQUIREMENTS OF AN ART CLINIC
Laboratory Design
Laboratory Equipment
Cryofreezer, Containers
CO2 Incubator
Laminar Air Flow
Microscope
Cryostorage
MINIMAL QUALITY CONTROL PARAMETERS
Hydrogen lon Concentration (pH)
Osmolality
Temperature
Light
MISCELLANEOUS
Identification
Record Keeping
Data Analysis
CHAPTER 7:
Counseling of the Infertile Couples
FUNDAMENTAL ISSUES IN COUNSELING
Implications Counseling
Support Counseling
Therapeutic Counseling
THE COUNSELOR
THE BENEFICIARIES
SPECIAL ISSUE
CHAPTER 8:
Transvaginal Sonography in Infertility
CERVIX
UTERUS
Endometrium
Uterine Biophysical Profile3
Uterine Cavity Evaluation
TUBES
OVARY
FOLLICULAR MONITORING
Oocyte Retrieval
ROLE OF COLOR DOPPLER IN INFERTILITY
STUDY OF MENSTRUAL CYCLE BY COLOR DOPPLER
Changes in the Ovary
Uterine Perfusion
Changes in the Endometrium
ULTRASOUND TECHNIQUE FOR UTERINE BIOPHYSICAL PROFILE
Uterine Biophysical Profile3
ROLE OF THREE-DIMENSIONAL ULTRASONOGRAPHY
ROLE OF TVS IN INTERVENTIONAL PROCEDURES
CONCLUSION
CHAPTER 9:
Fertility Enhancing Surgeries
UTERINE SEPTUM INCISION
Procedure
INTRAUTERINE ADHESIONS
Classification
Procedure
ENDOMETRIAL POLYPS
Procedure
SUBMUCOUS MYOMAS
Procedure
REMOVAL OF FOREIGN BODIES
HYSTEROSCOPIC TUBAL CANNULATION (Figs 9.1 and 9.2)
DONNEZ AND CASANAS-ROUX CLASSIFICATION OF CORNUAL BLOCKS11
Procedure
LAPAROSCOPIC PROCEDURES FOR FERTILITY ENHANCEMENT (Figs 9.3 to 9.7)
TUBAL SURGERIES
Salpingo-ovariolysis
Procedure
Salpingostomy
Procedure
Fimbrioplasty
Procedure
SURGERY FOR ENDOMETRIOSIS
Superficial Endometriosis
Endometriosis in the Pouch of Douglas
Endometrioma
LAPAROSCOPIC MYOMECTOMY
Procedure
PCOD CAUTERIZATION
Procedure
LAPAROSCOPIC CORRECTION OF UTERINE ANOMALIES
CHAPTER 10:
Endometriosis and Infertility
INTRODUCTION
DEFINITION
PATHOPHYSIOLOGY OF ENDOMETRIOSIS
MECHANISM OF ENDOMETRIOSIS ASSOCIATED INFERTILITY
DIAGNOSIS
Clinical
Role of Imaging
Serum Markers in Endometriosis
Endometrial Nerve Fibers
Laparoscopy
MANAGEMENT
Expectant Management
Medical Management
Surgical Management
Outcomes of Surgical Treatment
Surgery for Endometriomas
Assisted Reproduction for Treatment of Endometriosis Related Infertility
Controlled Ovarian Hyperstimulation and IUI
In vitro Fertilization
Effect of Pre IVF Treatment on IVF Outcome
Challenges Related to the Management of Endometriosis in Low-resource Settings
CONCLUSION
CHAPTER 11:
Polycystic Ovary Syndrome and Infertility
INTRODUCTION
INITIAL ASSESSMENT AND INVESTIGATIONS
History
Physical Examination
Investigations
TREATMENT OF ANOVULATORY SUBFERTILITY IN PCOS
Weight Reduction
Clomiphene Citrate (CC)
Metformin
Laparoscopic Ovarian Drilling (LOD)
Gonadotropin
In Vitro Fertilization (IVF)
SUMMARY
OTHER HEALTH PROBLEMS IN PCOS
CHAPTER 12:
Fibroids and Infertility
MYOMAS AND OBSTETRICAL OUTCOMES
Laparoscopic versus Abdominal Myomectomy
ADHESIONS
Laparoscopic versus Abdominal Myomectomy
PREGNANCY AFTER LAPAROSCOPIC MYOMECTOMY
Uterine Rupture After Laparoscopic Myomectomy
ENTRY INTO THE CAVITY
HYSTEROSCOPIC REMOVAL
Management of Fibroids in Infertility
CHAPTER 13:
Managing Male Infertility Clinically in Low-resource Setting
TRANSRECTAL ULTRASOUND (TRUS) TO CONFIRM CABVD
Vasography
CRYOPRESERVATION OF SPERMS IN SITUATIONAL ANEJACULATION
DEDICATED VIBRATION DEVICE VS LOCALLY AVAILABLE VIBRATORS
ELECTROEJACULATION FOR DIAGNOSIS AND CRYOPRESERVATION
Color Duplex Doppler (CDD) for Varicocele Against Simple Doppler Probe (Fig. 13.3)
Prolonged Medical Trials
CHAPTER 14:
Milder Stimulation Only Justified
PHYSIOLOGICAL RECRUITMENT, SELECTION AND DOMINANCE OF OVARIAN FOLLICLES
PRINCIPLE OF STANDARD MAXIMAL STIMULATION AND MILDER STIMULATION
Factors are Helpful to Determine the Regime of Ovarian Stimulation for Individuals
CLOMIPHENE CITRATE
AROMATASE INHIBITOR
Gonadotropin in the Alternative Days or Clomiphene Plus Gonadotropin
CLOMIPHENE PLUS GONADOTROPIN AND ANTAGONIST PROTOCOL
DELAYED LOW-DOSE GONADOTROPIN PLUS GnRH ANTAGONIST PROTOCOL
hCG ADMINISTRATION IN THE LATE FOLLICULAR PHASE
NATURAL CYCLE IVF
ORAL CONTRACEPTIVE PRETREATMENT FOR SYNCHRONIZATION
Milder Stimulation Benefits for Endometrial Receptivity
Milder Stimulation may Benefit for Oocyte Quality
Milder Stimulation Benefits for Luteal Function
Milder Stimulation Reduces Cost, Complexity, Discomfort and Drop-out Rates
Milder Stimulation Reduces OHSS and Improves Safety
Milder Stimulation Achieves Reasonable Pregnancy Potential
Milder Stimulation with Single Embryo Transfer (SET) Prevents Complication from Multiple Pregnancy
Embryo Cryopreservation Using Vitrification is Helpful for the Milder Stimulation Strategy
Milder Stimulation can be Used for High Responder, Normal Responder and Poor Ovarian Reserve
CONCLUSION
CHAPTER 15:
The Role of Intrauterine Insemination in Low-resource Setups
INTRODUCTION
INDICATIONS OF IUI6
FACTORS AFFECTING IUI SUCCESS RATES
Patient Characteristics and Pregnancy Rate with IUI
Ovarian Stimulation
Follicle Monitoring Techniques and Timing of IUI
Type of IUI Catheter
Number of Inseminations
Number of IUI Cycles
Laboratory Factors
Luteal Phase Support
Adjunctive Therapy with GnRH Agonists and Antagonists
IUI VERSUS ART: COST-EFFECTIVENESS
CONCLUSION
CHAPTER 16:
In Vitro Maturation
INTRODUCTION
WHY IVM?
OOCYTES FROM ANTRAL FOLLICLES
HOW TO DO IVM?
CYTOPLASMIC MATURITY IN OOCYTES
INSEMINATION AFTER IVM
OOCYTE AGING
EMBRYONIC DEVELOPMENT
IVM MEDIA
IVM FOR FERTILITY PRESERVATION
PERSPECTIVES
CONCLUSIONS
CHAPTER 17:
Advances in Assisted Reproductive Technologies in Low-resource Settings
INTRODUCTION
PRETREATMENT
Uterine Myomas
Endometriosis
Hydrosalpinges
PCOD
OVULATION INDUCTION
IVF LABORATORY
Laboratory Setup
Intracytoplasmic Sperm Injection and Intracytoplasmic Morphologically Selected Sperm Injection
PICSI
In Vitro Maturation
Laser Hatching
Blastocyst Culture
INVO Vaginal Culture
Embryo Cryopreservation
Semen and Oocyte Banking
Human Embryo Selection — based on Morphology/Metabolism/Genetics
Luteal Phase Support
CHAPTER 18:
The Art and Science of Embryo Transfer
FACTORS AFFECTING THE ET SUCCESS
Timing or Stage of Embryo Transfer
Introduction of Foreign Body (transfer catheter) into Endometrial Cavity
Endometrial Trauma from Embryo Transfer Catheters
Embryo Misplacement, Displacement and Uterine Contractions
Ultrasound Guidance and Depositing Embryo
EMBRYO TRANSFER
DIFFICULT TRANSFERS
CHAPTER 19:
Third Party Reproduction: Techniques, Ethics and Economics
OOCYTE DONATION
Selection and Screening of Oocyte Donor
Donor Stimulation
Recipient Preparation
Intrafamilial Donation: Ethical Issues
Shared Oocyte Donation: Economical in a Low-Resource Setting
Oocyte Donation in Postmenopausal Women: Ethical Issues
Oocyte Donation: Emotional Aspects
EMBRYO DONATION
GESTATIONAL SURROGACY
Selection and Screening of Surrogate
Gestational Surrogacy: ICMR Code of Practice, Ethical Considerations18
Unanswered Ethical Issues
Intrafamilial Surrogacy: Economical Option
CHAPTER 20:
In Vitro Fertilization on the Move
CHAPTER 21:
Minimizing Risks and Complication of ART in Restricted Resource Setup
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
Classification
Mild Hyperstimulation
Moderate Hyperstimulation
Severe Hyperstimulation
Prevention
Treatment
MULTIPLE PREGNANCIES
COMPLICATIONS OF OOCYTE PICK-UP
CONCLUSION
CHAPTER 22:
Cryopreservation: A Frozen Life
SLOW FREEZING VS VITRIFICATION
VITRIFICATION OF OOCYTES
ASSISTED HATCHING IN CRYOPRESERVATION
ENDOMETRIUM PREPARATION
FUTURE
CHAPTER 23:
The Law and Assisted Reproductive Technology
INTRODUCTION
WHAT IS ASSISTED REPRODUCTIVE TECHNOLOGY?
THE LAW AND ART
LAWS AND GUIDELINES REGARDING ASSISTED REPRODUCTION
AUSTRALIA
BELGIUM
CANADA
FRANCE
Germany
ITALY
INDIA
ICMR Guidelines for Setting up ART Clinics
Primary (Level 1A) Infertility Care Units
Primary (Level 1B) Infertility Care Units Engaging in IUI
Secondary (Level 2) Infertility Care Units
Tertiary (Level 3) Infertility Care Units
Surrogacy in India
Finances Involved in Surrogacy
Surrogate Mother Criteria
Commercialization
Rights of the Child Born Via Surrogacy
Risks in Being a Surrogate
JAPAN
SINGAPORE
UNITED KINGDOM
UNITED STATES OF AMERICA
CHAPTER 24:
Role of Alternative Therapies
WHAT ARE ALTERNATIVE THERAPIES?
HERBAL MEDICINES
Improvement of Reproductive Function
Herbal Medicine for Polycystic Ovary Syndrome
Hachimijiogan for Hyperprolactinemia and Male Infertility
Wen-Jing-Tang for Inducing Ovulation
Other Herbal Medicines for Various Symptoms of Female Patients
ACUPUNCTURE
AUTOGENIC TRAINING
SUPPLEMENTS
Antioxidant Supplements for Male Infertility
Anti-aging Supplements for Female Infertility
Melatonin
LIFESTYLE
Cessation of Smoking
Avoidance of Alcoholic Beverages and Recreational Drugs
CHAPTER 25:
Managing Failures—Troubleshooting and Patient Counseling
INTRODUCTION
APPROACHES TO LACK OF SUCCESS IN INFERTILITY TREATMENT
Adequate Diagnosis
Counseling
ASSISTED REPRODUCTIVE TECHNOLOGY
In Vitro Fertilization
CHAPTER 26:
When to Call it a Day
BIOLOGICAL FACTORs INHIBITING PREGNANCY AND THEIR PROGRESSION
ECONOMIC AND FINANCIAL IMPLICATIONS
ALTERNATIVES TO ART IN OBTAINING A FAMILY, THE RELiGIOUS AND ETHICAL LIMITATIONS
IMPLICATIONS OF THE EXTENDED FAMILY IN INDO-PAKISTAN
INDEX
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