Practical Guide to Infertility Management and IVF Sonal Panchal, Chaitanya Nagori
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen, acute 217
Abortion 134
rate 60, 98
Acanthosis nigricans 122
Acetylcholinesterase inhibitor 151
Acid-fast bacilli 219
Activated partial thromboplastin time 350
Acupuncture 151, 393
Acute respiratory distress syndrome 247, 255
Adenomyomas 186, 187f
Adenomyosis 185, 186, 189, 189f, 324, 361
classification of 185, 186t, 187f
external 187f
focal 186, 190
incidence of 190
internal 187f
investigations 186
locations of 187f
medical treatment 191
pathogenesis 185
phenotypes of 190
presentation 185
signs 185
superficial 186
surgical treatment 190
symptoms 185
Adenosine monophosphate 120
Adequate progesterone production 100
Adhesions 324
Adrenal androgen 123fc
production 50
Adrenal dysfunction 17, 380
Adrenal hyperplasia, congenital 122, 380, 383, 387
Advanced sperm selection methods 283
Albumin 277
intravenous 252
Alcoholism, chronic 378
Allis forceps 297
Alloimmunity 340, 357
Alyce's forceps 270
Amenorrhea 178, 183, 217
hypothalamic 117
American College of Obstetricians and Gynecologists 340
American Fertility Society 340
American Society for Reproductive Medicine 6, 158, 183, 251, 303, 381
Anastrozole 59, 393
Androgen 163, 388
metabolism 122fc
receptor gene mutations 383
stimulation 56
Androstenedione 12
Anesthesia 290
general 291
Angiotensin-converting enzyme 389
Anorexia 234
Anovulation 133, 177
Antagonist
advantages of 83
disadvantages of 83
dosage of 82
timing of 82
treatment 149
use of 83
Antagonist cycle 84, 164
endocrine changes in 82
Antagonist protocol 70, 132, 137
advantages of 132b
Antagonist-agonist protocol 71
Antibiotic therapy 256
Antibody
antimicrobial 182
antinuclear 351
antipaternal lymphocytic 358
Anticardiolipin 350
antibody 349
Anticoagulants 256, 257
therapy 256
Anticytokine effect 350
Antihistamine 256
Anti-inflammatory drugs 389
Anti-Müllerian hormone 12, 13, 14t, 2224, 27, 28, 31, 38, 72, 145, 151, 163, 164, 248, 270, 304
actions of 24b
assays 25
clinical uses of 25
immunoassays 25
normal values of 25t
physiology of 24
Antioxidants 384, 390
dosage of 393
Antiphosphatidic acid 350
Antiphosphatidylcholine 350
Antiphosphatidylethanolamine 350
Antiphosphatidylglycerol 350
Antiphosphatidylinositol 350
Antiphosphatidylserine 350
Antiphospholipid syndrome
detection of 350
diagnosis of 350
Antiphospholipid antibodies 349
Antiphospholipid syndrome 349, 350
Antiserotonin agents 389
Antisperm antibodies 379
Antithrombin deficiency 353
Antithyroid antibody 351
Antitubercular treatment 219, 220
Antral follicle 21, 39, 310f
count 9, 20, 2729, 31, 39, 43, 66, 122, 164, 248, 270, 303
grows 63
multiple 308f
normal 163
number of 39, 41, 308
secondary 90
Anxiety 2
Apoptosis 384
Apoptotic cell depletion 285
Arginine 390, 391, 393
Aromatase 61
inhibitors 56, 58, 60, 158, 389
Arterial thrombosis 349
Artificial insemination 5
Ascites 218, 254, 256
Ascitic fluid, autotransfusion of 258
Ascorbic acid 231, 390
Asepsis 297
Asherman's syndrome 330, 336
Asoprisnil 214
Aspiration 202
Aspirin 151, 231, 351, 355
low-dose 53, 332, 333
Assessing ovarian reserve 20
physiology 20
Assisted hatching 325
Assisted reproductive technology 3, 10, 20, 36, 79, 90, 105, 137, 137b, 145, 156, 161, 191, 198, 202, 212, 221, 228, 250, 285, 308, 322, 330, 376, 380, 386, 400
gonadotropins in 70
natural cycle 250
protocols for 70
treatment in 81
Autocrine-paracrine mechanism 389
Azithromycin 331
Azoospermia 393, 398, 400
diagnosis of 398
evaluation of 399
management of 398
prevalence of 398
testicular causes of 398
Azoospermia factor 383
B
Bardet-Biedl syndrome 383
Basal body temperature chart 226
Beta-thalassemia 383
Bicarbonate 277
Binding buffer media 285
Biochemical monitoring 254, 255
Biopsy, excisional 282
Bird's nest appearance 196
Blastocyst 375f
culture 322, 324
grading 375t
Blastomere number 374
Blood
comp 254
count 254, 255
flow, low-resistance 101f
gases 254, 255
pressure 254
prolactin level 178
Body mass index 28, 29, 43, 66, 248, 360
Bologna criteria consensus 145
Bone morphogenetic protein 249
Bowel endometriosis 197f
Bowel wall
enhancement of 219
thickening of 219
Breast
cancer 50
carcinoma of 59
Bromocriptine 11, 51, 178, 179
C
Cabergoline 178
Calcium, intravenous 253
Cancer antigen 196
Captopril 389, 393
Carbimazole 183, 184
Cardiac failure 184
Carnitines 390
Carotenoids 393
Cartridge-based nucleic acid amplification test, GeneExpert of 219
Catheter types 300
Cavity, abdominopelvic 219
Cell adhesion molecule 1 350
Central nervous system 179
Central venous pressure 256
Centrifuge machine 278
Cerebellar ataxia 383
Cervical
anomaly 341
aplasia 341
dysmenorrhea 49
encerclage 344
factor 263
counseling for 3
hostility 262
incompetence 345, 347, 348
congenital 348
length 348
Cervix 3, 216
antiestrogenic effects on 48
normal 341
Cetrorelix 85
Chemotherapeutic agent 59
Chemotherapy 377
Chest X-ray 254, 256
Cholesterol 195
Chromopertubation 315
Chromosomal abnormalities 356, 381, 402
Chromosomal translocation 383
Chronic low-dose protocol 65, 66, 129, 130, 265, 265f
Cilia, movements of 4
Citrate-phosphate dextrose anticoagulant 336
Cleavage-stage embryo grading 375t
Clinical pregnancy rate 72, 83
Clinical touch method, ultrasound-guided instead of 299
Clomiphene 53, 129, 393
therapy 50
Clomiphene citrate 9, 26, 46, 5053, 56, 60, 63, 91, 124126, 149, 157, 165, 233, 263, 269f, 332, 386, 387
antiestrogenic effects of 48
challenge test 26, 31
contraindications 47
dose of 47t
indications 46
luteal phase defect 46
mechanism of action 46
monitoring 48
resistant cases, metformin in 127
risks of 49
side effects 48
treatment
alternatives 50
regimes 47
Clonogenic cells 336
Coagulation profile 254, 255
Color Doppler, use of 36
Computed tomographic scan 218
Conception 4
chances of 6
opportunity for 2
rates 52
Controlled ovarian
hyperstimulation 30, 147, 157, 165, 198, 265
stimulation 14, 63, 72, 170, 172, 202
Conventional testicular sperm extraction 402, 404
Corpora lutea, multiple 106, 247
Corpus luteal flow 100
normal 99f
Corpus luteal function 11
Corpus luteum 79, 224, 226
functional efficacy of 99
rescue of 225
resistance index, correlation of 226
Cortex, adrenal 172
Corticotropin-releasing factor-beta 390
Cortisol 380
Craniosynostosis 49
Cryomyolysis 213
Cusco's speculum 270
Cyclic adenosine monophosphate 174
Cyproheptadine 393
hydrochloric acid 389
Cyst
avascular myometrial 217
endometriotic 202
formation 79
rupture 257
Cystectomy 202
Cystic fibrosis transmembrane
conductance regulator 249, 381, 399, 400
mutations 383
Cytokines 334
changes in 194
Cytomegalovirus 349
Cytoplasmic maturation 138
D
Danazol 199, 256
Dandy-Walker malformation 49
D-chiro-inositol 128
Deficit hyperactivity disorder 78
Dehydroandrosterone 12
Dehydroepiandrosterone 12, 123, 151, 174, 175
sulfate 11, 12, 50, 380
Density functional theory 384
Density gradient methods 275, 278
Deoxyribonucleic acid 67, 150, 163, 194, 274, 390
fragmentation
index 363, 384
treatment of 384
Dexamethasone 128
dose of 128
treatment 172
Dextrose normal saline 257
Diabetes mellitus 361, 362, 377, 378
Diarrhea 247, 254
Diethylstilboestrol, clinical significance of 343
Diluted russel viper venom test 350
Directly observed treatment, short course 221
Disrupted endometrial-myometrial junction 217
Diuretics 256, 257
Donor insemination, counseling for 5
Dopamine 177, 256, 257
agonist 252
inhibitory, reduction in 179
Double intrauterine insemination 268, 269f
Doxycycline 331
Drugs 333, 377, 385
Dual stimulation 148
Dysmenorrhea 194, 207, 217
Dysovulatory infertility 262
Dyspareunia 194, 217
Dyspnea 247, 254
Dysuria 194
E
Earle's balanced salt solution 276
Ectopic endometrial glands 198
Ejaculate volume
low 399
normal 400
Ejaculation, disorders of 387
Ejaculator, transurethral resection of 399
Ejaculatory duct 400
obstruction 400
Ejaculatory dysfunction 398
Ejaculatory failure 263
Elagolix 85
Electrolyte 254
replacement 256, 257
Electrophoretic system 288
Embryo 203
development 165, 202
freezing cycle 29t
genetics 322
Embryo transfer 297, 298f, 325, 326, 336
day of 301
functional uterocervical length for 297f
technique 297b, 299
Embryogenesis 49
Empiric therapy 387
Enclomiphene 46, 48
Endocrinal tests 22
Endocrine
dynamic tests 26
workup 17
Endometria 95
Endometrial biopsy 219, 226
Endometrial cavity 217, 218f, 332f
Endometrial cells 326
Endometrial damage 217, 222
Endometrial development 118
Endometrial fibroid 347f
Endometrial myometrial junction 329f
Endometrial polyp 347f
Endometrial receptivity 224, 308
assessment of 312
Endometrial scratching 325, 332, 334
Endometrial vascularity 98, 314f
Endometrioma 38, 61, 195, 195f, 196f, 201, 202
Endometrio-myometrial junction 96
Endometriosis 57, 61, 194, 196, 198, 202, 203, 234, 239, 340, 360
clinical features 194
deep infiltrating 200f
deep penetrating 194
diagnosis 195
fertility index 201f
mild 200
mild-to-moderate 262
moderate 201
severe 6, 201
signs 194
surgical classification for 199f
ultrasound 195
Endometriotic patch 196
Endometritis 331
chronic 324, 331, 347, 348
Endometrium 96f, 97, 100, 309, 312, 313f, 314f, 329
B-mode features of 95
echogenic
flecks in 217
inner layer of 217
measurement of 330
molecular study of 324
morphology of 95, 97
persistently thin 217
three-dimensional power Doppler-acquired volume of 314f, 315f
Endoscopy 219
normal 5
Enzyme-linked immunosorbent assay test 380
Epidermal growth factor 224, 335
Epididymis 378, 381
procedures on 403
Epithelial progenitor cells 336
Esophageal atresia 49
Estradiol 31, 78, 108, 161, 183, 380
administration 149
level 249
replacement 110
supplementation 233
upregulates cystic fibrosis transmembrane regulator 249
valerate 149
Estrogen 207, 332, 334
deficiency 332
exogenous 49
levels of 58
pretreatment with 119
priming 149
production 116, 118
testosterone to 59
Estrone-3-glucuronide 224
Ethambutol 220, 221
European Society for Gynecological Endoscopy classification of
female genital tract anomalies 341, 341t
Müllerian duct abnormalities 342f
European Society for Gynecological Endoscopy 209, 340, 341, 342f
European Society for Human Reproduction and Embryology 232, 303, 340, 341
classification of
female genital tract anomalies 341, 341t
Müllerian duct abnormalities 342f
guidelines 340
F
Failed artificial insemination 263
Fallopian tubes 216
Female fertility 104
Fertility
desiring females 20
drugs 127
effect on 190
preservation 138
treatment 14
advancement of 21
Fertilization 93, 173
and embryo development, effect on 203
and pregnancy rate 127
assessment of 373
Fetal growth restriction 351
Fetal karyotyping, place of 356
Fibrinogen deficiency 354
Fibroid 207, 323, 347
classification of 209, 210f
color Doppler image of 209f
intramural 209, 211, 214
surgical management of 210f
Five-alpha reductase deficiency 383
Flow index 265f, 309f
Fluid 217
aspiration 257
collection of 248
intravenous 256
Fluorescence in situ hybridization 322
Fluorodeoxyglucose 219
Folic acid 390, 391, 393
Follicle 110
development 13
less number of 38
matures 131
number per ovary 28, 43, 248
physiology of rupture of 268
pretrigger evaluation of 309
secretes 170
stimulation of 81
surface-rendered volume of 312f
three-dimensional power Doppler volume of 311f, 313f
total number of 306f
vocal calculated volume of 94f
volume calculation 311f
Follicle aspiration
equipment 293f
single-lumen needle 293f
Follicle-stimulating hormone 8, 9, 2124, 31, 37, 39, 46, 56, 63, 65f, 68, 78, 90, 104, 116, 118, 120, 125, 134, 145, 146, 151, 157, 161, 165, 173, 174, 181, 246, 264, 386, 388
receptor 249
Follicular development, maintenance of 129
Follicular diameter 266
Follicular dominance 43
Follicular fluid 24, 127
Follicular flushing 294
Follicular immaturity 10
Follicular maturation 161
Follicular maturity 9
assessment of 308, 309
Follicular monitoring 308
Follicular number per ovary 303
Folliculogenesis 57
Follitropin alpha 67
Fothergill's surgery 263
Fragmentation 374
Frozen embryo transfer 44, 146, 232, 237, 238, 334
Frozen sample 263, 281
G
G sperm 276, 277
Galactorrhea 11, 51, 178
Gamete intrafallopian tube transfer 270
Gastrointestinal tract 179, 228
GeneExpert 219
Genetic 322, 340
abnormalities 383
conditions 145
testing 402
Genital organs 216
Genital tract infections 387
Genital tuberculosis 216, 221
epidemiology of 216
female 216, 217, 220fc
latent 220
Genomic hybridization 322, 356
Genuine empty follicle syndrome 166
Germ cell failure 16
Germinal vesicle 370
Glucocorticoids 50, 124, 128, 150, 252, 352
Glutathione 390, 391, 393
Gonadotropin 24, 38, 43, 51, 52, 59, 60, 63, 78, 80, 124, 125, 128, 129, 131, 147, 148, 150, 156, 158, 246, 264, 266, 386
bioactivity of 129
clomiphene combined with 157
consumption of 167
deficiency 72
demand of 63
dose of 44, 79, 118, 130, 146, 156
exogenous 150
injection of 119
low-dose 28t, 57, 158
physiology 63
protocol, low-dose 250
releasing hormone 8, 31, 39, 46, 79, 84, 104, 117, 124, 146, 156, 161, 177, 250, 266, 386
agonist 10, 52, 7880, 83, 108, 110, 111, 132, 146148, 170, 199, 213, 228, 233, 234, 236, 239, 251, 252, 256, 266, 267, 332, 402
analog stimulation test 26
antagonist 8183, 131, 148, 213, 233, 250, 256, 266
therapy 117, 117b
secretion 116
specific bioactivity of 129t
stimulation 59, 63, 79, 133, 233
theory 173, 173fc
two-cell-two 72
therapy 106, 118
different regimes of 64
indications of 64
principles of 64
Granulocyte colony-stimulating factor 332, 335, 359
Granulosa cells 13, 23, 59, 171, 173, 181
Growth hormone 119, 150
actions of 150b
releasing factor 151
H
Heart rate 254
Hegar's dilator 348
Hegar's test 348
Helicobacter pylori 349
Hematocrit 254
Hemiuterus 341, 346
Hemizona and zona binding test 383
Hemochromatosis 383
Hemoglobin, high-glycated 362
Heparin 351
Hepatitis C 349
Herpes simplex 349
High pulsatility index 362
High-efficiency particulate air 369
High-intensity focused ultrasound 213
Hormone 15
adrenocorticotropic 12, 50
antidiuretic 248, 255
replacement therapy 117
theory 161
Humaidan's group administered 110
Human chorionic gonadotropin 36, 51, 59, 65f, 71, 81, 92, 94, 111, 118, 166, 170, 224, 225, 228, 237, 246, 250, 254, 264f, 265f, 332, 386, 388, 393
disadvantages of 232
reducing dose of 251
supplementation 232, 363
surge 106
timing of 266
Human embryonic stem cells 336
Human immunodeficiency virus 281, 349
Human menopausal gonadotropin 24, 63, 67, 68, 85, 118, 129, 146, 158, 164, 166, 170, 264, 332
highly purified 69
Human serum albumin 275
Hyaluronan, microdots of 288f
Hyaluronic acid 287
sperm binding 283, 287
Hyaluronidase binding assay 364
Hydrosalpinx 324
Hydrothorax 254
Hydroxychloroquine 351, 352
Hydroxyethyl starch 250
Hydroxysteroid dehydrogenase 173
Hyper androgenemia 122
Hyper homocysteinemia 354
Hyper plastic myometrium 185
Hyperprolactinemia 11, 12, 17, 116, 177, 179, 201, 361, 363, 387
causes of 177
diagnosis 178
drug induced 177
effect of 179
investigations 178
pathological 177
physiological 177
presentation 178
treatment 178
Hyperstimulation, risk of 10
Hypertension 377, 378
Hyperthyroidism 183
diagnosis 183
mechanism of action 183
medical therapy 183
treatment 183
Hypogonadism 377, 383
idiopathic hypogonadotropic 383
Hypogonadotropic hypogonadism 24, 46, 105, 116, 118, 118b, 150, 162, 386, 402
medical therapy for 401
Hypohyperthyroidism 361
Hypo-osmotic swelling 283, 284f
Hypoprolactinemia 234
Hypothalamic dysfunction 110
Hypothalamo-pituitary
disorders 182
dysfunction 64, 234
failure 116
ovarian axis 8
testicular axis 8f
Hypothalamus, anterior 117
Hypothyroid 181
Hypothyroidism
diagnosis of 182
isolated 116
mechanism of action 181
treatment 182
Hysterocontrast sonosalpingography 315, 318
Hysterosalpingogram 315, 341
Hysterosalpingography 219
Hysteroscopy 219, 221, 343
I
Immature oocyte 370, 371f
in vitro maturation of 250
Immobile ciliary syndrome 383
Immunoglobulin 351
intravenous 326, 352
Immunomodulators 326
Imperforate hymen 341
In vitro fertilization 2, 8, 13, 21, 29, 44, 59, 66, 84, 136, 146, 156, 217, 231, 250, 262, 274, 290, 323, 333, 356, 372f, 379, 385
conventional 372
cost 6
counseling for 6
cycles 44fc
disadvantages of 202
indications 6
natural cycle 151, 156
ovulation induction in 60
results 6
role of 221
In vitro maturation 59, 136, 137, 137b, 146
Indomethacin 257, 389, 393
Infections 234, 330, 331, 340, 359, 377
Inferior vena cava 248
Infertile couple
counseling of 1
hormonal assessment of 8
Infertile female, investigations for 9
Infertile males, management of 399fc, 401fc
Infertility 1, 181, 194, 201, 202, 207, 211, 216, 217
cases of 184
cervical factor of 3
immunological 263
long-term 4
management of 8, 212
backbone of 1
practice 4
relation to 199
severe male factor 6
surgical treatment for 200
unexplained 5, 47, 51, 59
Inner cell mass 374, 375
Insemination
motile count 269
timing of 268
Insulin
like growth factor 119, 150, 151, 224, 225
binding proteins 226
lowering drugs 124, 126
resistance 15
severe 15
sensitizer 24, 126, 128, 250
Intensive care unit 255
International Federation of Gynecologists and Obstetricians 209, 210f
Intracytoplasmic morphologically selected sperm 364
injection 283, 287f, 323
Intracytoplasmic sperm injection 2, 10, 127, 263, 284f, 357, 369, 372, 373f, 377, 385, 400
Intrafollicular androgen 59
Intraovarian resistance index 37
Intrauterine adhesions 330, 347, 347f, 348
Intrauterine contraceptive device 330
Intrauterine growth restriction 352
Intrauterine insemination 2, 10, 29, 44, 44fc, 47, 60, 131, 212, 232, 248, 262, 269, 269f, 274, 277, 383, 386
cannula 335
counseling for 5
indications of 262
ovulation induction with 202
single 269f
steps of 263
Intravenous hydroxyethyl starch solution 252
Invasive monitoring 256
Isolated testosterone deficiency 387
Isoniazid 220, 221
Ixaprep 280
K
Kallmann syndrome 377, 383
congenital 386
Kaolin clotting time 350
Ketotifen 389, 393
Kissing ovaries 195, 195f
Kisspeptin 112, 119
infusion 132
role of 112
Klinefelter syndrome 377, 383, 402
L
L-acetylcarnitine 391
Laminar airflow 369
Laparoscopic ovarian
diathermy 127
drilling 133, 134, 250
multineedle intervention 134, 135
Laparoscopy 198, 219, 221, 222, 343
diagnosis during 200
Laparotomy 221
L-arginine 150, 332, 333
Laser-assisted hatching 325
L-carnitine 391
Leiomyomas 207
Letrozole 56, 59, 60, 124, 125, 149, 158, 214, 233, 266
advantages of 57, 59
challenge test 59
characteristics 57
indications 56
inhibits aromatase enzyme 56
replace 59
side effects 59
stimulated cycle 234
Leukemia inhibitor factor 235, 334
Leukocyte elastase 69
Leukorrhea 348
Leuprolide acetate 147
Levonorgestrel intrauterine contraceptive device 214
Levothyroxine 182, 183
Liquid chromatography 69
Liver function tests 247, 254, 255
Low attenuation necrotic lymph nodes 219
Low molecular weight heparin therapy 326, 351, 355
Lowenstein-Jensen medium 219
Lower progesterone level 171
Ludwig's protocol 82
Lump, abdominal 217
Lupus anticoagulant 350
Lupus antigen 349
Luteal phase defect 11, 100, 110, 224, 227, 227f, 233, 263, 361, 362
diagnosis of 226
pathophysiology of 225
Luteal phase estrogen pretreatment 85
Luteal phase physiology 224
Luteal phase starts 224
Luteal phase support 227, 232236, 263, 271
Luteinized unruptured follicle 11, 108, 268
Luteinizing hormone 8, 29, 46, 56, 63, 84, 100, 104, 118, 122, 123, 134, 146, 150, 157, 161, 163166, 173, 174, 183, 224, 250, 251, 266, 306, 386, 401
action of 161f
ceiling effect 72
disadvantage of 163
dose of 118
functionally and clinically 166
in ovulation induction
addition of 85
role of 161
in ovulation, physiology of 161
levels 162f
polymorphism 165, 166
ratio 23
receptor 174
releasing hormone 57
rise of 162
role of 161
supplementation 72, 147
surge, functions of 104
therapeutic window of 162
Lycopene 390, 393
Lymphokine-activated killer cell 225
M
Magnetic activated cell sorting 283
Magnetic resonance imaging 209, 219, 343
Male infertility 15, 385
medical management of 385
Male subfertility 262
Manchester's operation 348
Mantoux test 217
Maternal blocking antibody 358
Maternal immune suppression 358
Mature follicle 10, 90f
B-mode features of 91
number of 172
Mature oocytes 137
Maximum implantation potential 300
Mechanical distortion 194
Mechanical partial zona dissection 325
Medroxyprogesterone acetate 85
Menopause, diagnosis of 9
Menorrhagia 181, 183, 207, 217
Menstrual cycle 36, 101
Menstrual disorders, range of 183
Menstrual irregularities 181
Menstrual pattern 22
Menstruation 80
Mesenchymal stromal stem cells 336
Metabolic derangements 123
Metabolic function 15
Metaphase oocyte 370, 371f
Metformin 24, 52, 126, 127, 250
after conception 127
and infertility 126b
during pregnancy 127
in PCOS, role of 128b
safety of 127
therapy 129
to gonadotropins, addition of 126
Methimazole 183, 184
Methylenetetrahydrofolate reductase 353
Metroplasty, hysteroscopic 344
Microdissection testicular sperm extraction 401, 402, 404
Microdose flare 148
protocol 80
Microfluidics 364
Micro-intraovarian endometriomas 198
Micronized progesterone 53
vaginal 231
Micropolyposis 217, 332f
Micropuncture technique 282
Microsurgical epididymal sperm aspiration 281, 282, 282f, 403
Microsurgical reconstruction 403
Midluteal serum progesterone 11
Midproliferative phase 217
Mifepristone 213
Mild stimulation, disadvantages of 158
Miscarriage 49
rate 203, 225
Mixed gonadal dysgenesis 383
Mixed lymphocyte culture reactivity 358
Mock transfer 301
Modern rapid tests 219
Monitoring pregnancy 357
Monofollicular development 61, 119, 130
Mononuclear stem cells, subendometrial autologous stem cell transplantation of 336
Mosaic embryos 158
Motile sperm organelle morphology examination, selection of 283, 286
Motile spermatozoa, selection of 285
Motility 379
congenital 330, 331
Müllerian duct 340
abnormalities 331, 340, 341
classification of 343
congenital 330, 331
Müllerian hormone 79
Multifollicular development 130, 131
Multiple follicles 81
Multiple pregnancy 49, 52, 64, 265
high-order 133
incidence of 127
rates 44
Multiplex fluorescence in situ hybridization 356
Mycoplasmas 360
Myomas 207, 214, 347
diagnosis 207
incidence 207
intramural 347
medical management of 213
pathogenesis 207
Myomectomy 348
abdominal 212
hysteroscopic 211
laparoscopic 212, 213
laparoscopy-assisted 348
Myometrial contractions 270
Myometrial reduction 190
Myometrium 185, 186
anterior 188f
echogenic flecks in 217
normal 187
Myotonic dystrophy 383
N
Narrow contracted endometrial cavity 217
Natural cycle, modified 157
Natural killer 334
Natural luteinizing hormone surge 104
Natural progesterone 228
micronized 229b
Nausea 247, 254
Needle aspiration biopsy 404
Negative predictive value 196
Nitroglycerine 332, 333
Nonapoptotic spermatozoa, selection of 283
Nonobstructive azoospermia 398, 399, 401
Nonsteroidal anti-inflammatory drug 213, 391
Noonan syndrome 383
Norethisterone 132
Normal oocyte 370
morphology 370
Normal ovaries 37, 38f
Normal postcoital test 3
Normal prolactin
level 11, 51
with galactorrhea 179
Nucleotide polymorphism, single 30, 165
O
Obesity 234, 308, 360
Obstructive azoospermia 398, 399
management of 403
Oligoanovulation, causes of 177
Oligoasthenospermia, antioxidants used for 390t
Oligoasthenoteratozoospermia 380, 389
Oligomenorrhea 181, 217
Oligozoospermia 393
mild 388, 388b
moderate 388, 388b
Oliguria 254
Omega-3 fatty acids 393
Oocytes 51, 63, 104, 120, 173, 203
cumulus 370f
complex 371
insemination of 371
intermediate 370, 371f
maturation 105, 150
poor-quality 194
postmature 371
recovery 93
retrieve 40, 138, 167, 203, 290, 369
technique 294b
Open testicular biopsy 404
Optimal pre-HCG
endometrial parameters 266
follicular parameters 266
Oral contraceptive pills 80, 131, 146, 147, 239, 332
pretreatment with 151
treatment with 53
Oral dyhydrogestone 230
Oral progesterones 228
Outer myometrium 190
Ova
available, number of 20b
in vitro maturation of 250
Ovarian antral and preantral follicles, quantity of 20
Ovarian blood flow 27
Ovarian cancer 50
counseling for 5
Ovarian cyst, large 47
Ovarian drilling 133
advantages 134
disadvantages 134
mechanism of action of 133, 134b
method of 134, 135
Ovarian factors 216
Ovarian failure 135
Ovarian fimbria contracts 263
Ovarian function 181
Ovarian hilar resistance index 195
Ovarian hilus 195
Ovarian hyperstimulation syndrome 10, 24, 41, 49, 72, 81, 105, 111, 117, 122, 126, 156, 165, 171, 232, 246, 255, 265, 294, 303
classification of 246
clinical pathology of 247fc
medical management of 256, 256b
moderate 246, 253
pathophysiology of 247
prediction of 248
prevention of 250
primary prevention of 250, 250b
risk of 59, 60, 117, 132
secondary prevention of 250, 250b
surgical management of 257, 257b
types of 246
Ovarian malignancy 135
Ovarian reserve 20, 21, 30
and response, assessment of 308
assessment of 20
markers of 21
tests 21, 30, 31
Ovarian response, predictors of 71, 71t
Ovarian size 254, 256
Ovarian stimulation, mild 151, 156
Ovarian stroma 36, 37f, 133
Ovarian stromal blood flow 40
Ovarian stromal flow 40
index 28, 306
measurement of 28
Ovarian suppression 10, 252
Ovarian torsion 257, 258
Ovarian volume 26, 39, 40, 43, 249
acquired 39
correlates 40
Ovary 216
baseline scan of 36
bilateral cystic enlargement of 247
three-dimensional
power Doppler-acquired volume of 308f, 309f
ultrasound-acquired volume of 305f
Ovulation 57
mechanism of induction of 56
physiology of 64
resumption of 124
stimulation 263
time of 263
Ovulation induction 116, 170, 332
by ultrasound, monitoring of 90
drugs 22t
gonadotropin for 43t
life-threatening complication of 246
Ovulation trigger 104, 267
factors of 105
Ovulation-inducing actions 46
Ovulatory dysfunction 116, 128
Ovum
donation 151
pick-up 232
single 157
Oxidative stress 384
P
Pain, abdominal 247, 254
Palm-Coein classification 208
Paracentesis, abdominal 258
Paracervical block 291
Parental genetics 322
Partial septum 344, 344f
Partial thromboplastin time 352
Peak systolic velocity 29, 43, 66, 265f, 311
Pelvic lymph nodes 218
Pelvic mass 218
Pelvic pain 185
chronic 194
Penicillin 275, 276
Penis 378
Pentoxifylline 283, 332, 333, 390, 391, 393
Percutaneous embolization technique 378
Percutaneous epididymal sperm aspiration 281, 282, 282f, 284f, 403
Percutaneous testicular
biopsy 404
epididymal sperm aspiration 404
Pericardial effusion 254, 256
Perifollicular flow 269f
Perifollicular peak systolic velocity 266
Perifollicular resistance index 266
Perifollicular vascularity 92f
Phenol red 275
Phosphate buffer saline 336
Phosphatidyl serine 283
Physiological semen criteria 2
Piezo micromanipulation 325
Pioglitazone 128
Pirfenidone 214
Pituitary causes 116
Placental apoptosis, induction of 350
Plasma
exchange 351, 352
expanders 256
Platelet-rich plasma 333
autologous 335
infusion 335
Pleural effusion 254, 256
Pleurocentesis 258
Pneumonia 349
Polycarbophil 231
Polycystic kidney, autosomal dominant 383
Polycystic ovarian morphology 303, 305
Polycystic ovarian syndrome 28, 46, 57, 64, 82, 110, 116, 122, 123, 126, 137, 137b, 162, 163, 182, 234, 239, 248, 265, 303, 361, 363
endometrium of 58
luteinizing hormone in 165
ovulation induction in 122
treatment of 123
Polycystic ovary 13, 36, 39, 122
abundance of 41
diagnosis of 9, 135
Polymerase chain reaction 219, 220, 281
Polyps 324, 347, 348
Polyvinylpyrrolidone 283
Poor endometrial development, causes 177
Poor oocyte quality 165
Poor ovarian responder 145, 171
Poor pregnancy rates 52
Poor responders 166
ovary 38, 39f
ovulation induction in 145
treatment options in 146b
Poor response, causes of 145
Positron emission tomography 219, 351
Postcoital test 3
Postejaculate urinalysis 399, 400
Postmenopausal syndrome 49
Postprocedure ovarian failure 134
Prader-Willi syndrome 383
Precocious puberty 81
Prednisolone 50, 231, 351
Predominant hemorrhage 190
Pregenetic screening 323
Pregestational metformin 127
Pregnancy 227, 250
complications 351
ectopic 257, 258
loss 363
early 190
pathophysiology of 354
prognosis 345
rates 80, 83, 138, 148
high 238
status of 254, 256
termination 257, 258
Pregnancy-induced hypertension 351
Pregnanediol 3-alpha glucuronide 224
Pre-human chorionic gonadotropin
endometrial parameters 267f
follicular parameters 265f
Preimplantation genetic
diagnosis 322, 356
role of 356
screening 156, 357
Premature luteinizing hormone 78, 170
Premature progesterone 170, 172
Preovarian block 291
Preovulation luteinizing hormone 224
Preovulatory cervical mucus 3
Preovulatory endometrium, ultrasound features of 95
Preovulatory follicle
and endometrium 91t
ultrasound features of 91
Preterm deliveries 181
Pretransfer ultrasound 297
Primary genital tuberculosis 216
Primary testicular failure 401
Primordial follicles 24, 63
Progesterone 11, 36, 82, 106, 100, 108, 110, 132, 161, 171, 172, 173fc, 174, 175fc, 199, 224, 228, 238
combinations 231
concentration 107
correlation of 100
function of 225fc
gel 230
high 173
induced blocking factor 225, 362
injectable 228
intramuscular 110, 228
levels 106, 130
long-term use of 332
on oocyte and endometrium, effect of 173
preparations 228
production of 225fc
progressive diffusion of 229f
reaches 106
resistance 239
rise 171
rescue strategies for 174
role of 224b
secretion 107
supplementation 235, 362
role of 362
vaginal effervescent tablets 230
Progestins 214
Prolactin 177
level 178
on reproduction, effect of 177
types of 178
Prophylactic low molecular weight heparin 355
Propylthiouracil 183, 184
Prostaglandin synthetase inhibitor 256
Protein
C deficiency 353
S deficiency 353
Prothrombin G mutations 353
Protocol exploits 70
Puberty, number of 377
Pulmonary artery pressure assessment 256
Pulse repetition frequency 37, 92, 312
Pump-regulated embryo-transfer 301
Puresperm 280
Pyelography, intravenous 343
Pyrazinamide 220, 221
Pyridostigmine 151
R
Radiotherapy 330, 331, 377
Randomized controlled trial 264
Rapid eye movement 177
Reactive oxygen species 233
production of 194
Recombinant follicle-stimulating hormone 29, 44, 66, 68, 71, 129, 249
clinical benefits of 70
types of 69
Recombinant human chorionic gonadotropin 118
Recombinant luteinizing hormone 111, 237
Rectosigmoid deep penetrating endometriosis 196
Recurrent implantation failure 212, 322
causes of 322
Recurrent pregnancy loss 177, 231, 340, 356, 359, 362, 364, 402
Red Indian head sign 197f
Relugolix 85
Renal failure 255
Renal function test 254, 255
Reproduction technology 37
Reproductive failure, mechanism of 350
Requires intensive care unit support 247
Resistance index 265f
Resistant ovary syndrome 138
Respiratory rate 254
Retrograde ejaculation 281, 400
Reverse transcription polymerase chain reaction 219
Revised National TB Control Programme 221
Rifampicin 220, 221
Ringer's lactate 256
solution 211
Rosiglitazone 128
Royal College of Obstetricians and Gynaecologists 340
Rubella 349
Rubin's test 2
Ruptured cyst, surgery for 258
Ruptured membranes, history of 348
S
Saline infusion
salpingography, three-dimensional power Doppler acquisition of 316
sonography 315
sonohysterography 341
Scandinavian media 276, 277
Scandinavian method 280
Scanty ovarian stromal flow 39f
Scanty secretory endometrial flow 227f
Scottish unexplained infertility trial 264
Scrotal ultrasound 380
Scrotum 378
Secretory endometrial flow, normal 227f
Secretory endometrium 101f
Secretory phase assessment 99
Segmental uterine
and ovarian artery 99
artery perfusion 312
Selective estrogen receptor modulator 214
Selective progesterone receptor modulator 214
Selenium 390, 391, 393
Self-prepared medium 276
Semen 274
analysis 2, 378, 384, 385
computer-assisted 379
counseling for 2
parameters, normal 378t
preparation 263, 268
sample 274
collection of 274
Seminal parameter 378, 379
Seminal vesicle 400
Septate cervix 341
Septate uterus 341, 344
management of 344
Serine phosphorylation 123, 123fc
Serological tests 219
Sertoli cell syndrome 383
Serum
anti-müllerian hormone 13
dehydroepiandrosterone sulfate 12
estradiol 23
level 9, 43
follicle-stimulating hormone 9, 379, 401
luteinizing hormone 9, 379
progesterone 11, 226, 227
prolactin 11, 177, 380
testosterone 12, 380
value of 12
thyroid-stimulating hormone 178
Severe oligozoospermia 388, 388b
Severe ovarian hyperstimulation syndrome 247
management of 255
Sex hormone-binding globulin 12, 123
Short-term intrauterine devices 326
Sickle cell anemia 383
Sildenafil 332, 333
Sim's speculum 297
Simple washing 275
Skin infections 349
Small follicles 80
Social stigma 1
Society of Assisted Reproductive Treatment 21
Sodium
bicarbonate 275
pyruvate 275
Sonographic-based automated volume calculation 305f
Sonosalpingography 5
Spatiotemporal image correlation 315
Special semen tests 383
Sperm
acrosome reaction test 383
aneuploidy 364
birefringence 283, 287
chromatin structure assay 384
genetics 322, 323
head birefringence 287
membrane integrity test 383
morphology 379
mucous penetration test 383
normal 379
nucleus integrity test 383
penetration test 383
preparation 274, 371
methods 275
preparation media 276, 277t
composition of 275
retrieval technique 403
wash medium 285
Spermatogenesis 384
SpermGrad 280
Spontaneous abortion 181
risk of 163
Spontaneous miscarriage 98
Static tests 22
Stem cell 336
therapy 333
Step-down protocol 264
Steroid production in ovary, pathway of 174, 174f
Steroidogenesis 150
Steroidogenic acute regulatory 224
Stillbirth, unexplained 181
Stimulate follicular estradiol 46
Stimulation protocol 39, 66
deciding 39
Strassman's operation 330, 345
Streptomycin 276
Streptopenicillin 276
Stress 234
role of 361
Stromal cells 133
Stromal density, assessment of 36
Stromal edema 247
Stromal flow 308
index 249
Stromal peak systolic velocity 248
Stromal vessels resistance index 248
Subclinical hyperthyroidism 183
Subclinical hypothyroidism 182
treatment of 182, 183
Subcutaneous injections 70
Subfertile male, evaluation of 377
Submucous fibroid 209, 211, 214
treatment of 211
Submucous myomas 347
Suboptimal responders 109
Subserous fibroids 209
Subtle hormonal deficiencies 263
Superovulation 263
Supraphysiological estrogen, decreased 59
Suprasperm 280
method for 280
Surface charge sperm selection 283, 288
Surgery 221, 377, 378
hysteroscopic 348
intrauterine 330
laparoscopic 191
laparotomic 190
Surrogate luteinizing hormone surge, indications of 105
Swim-up methods 275, 276
Synthetic progesterones 231
Synthetic serum replacement 275
Systemic diseases 116, 377
Systemic lupus erythematosus 352
T
Tamoxifen 332, 334, 388, 393
Testicular biopsy, indications of 403
Testicular epididymal sperm
aspiration 281, 282, 284f
extraction 282, 284f
Testicular sperm 384
aspiration 403
extraction 282
Testicular volume, normal 399
Testis 378
atrophy of 381
procedures on 404
Testosterone 12, 183, 388
low 16
sources of 12t
Theca cells 161
Thin endometrium 218f, 329, 332f
B-mode image of 331f
causes of 330
Three-dimensional
hysterocontrast sonosalpingography, advantages of 317
hysterosalpingo-contrast sonography volumes 317f
Three-dimensional ultrasound 341, 303
acquired virtual organ computer-aided analysis 307f
acquired vocal calculated ovarian volume 307f
Thrombocytopenia 349
Thromboelastography 353
Thromboembolism 257
Thrombophilia 340, 353355
acquired 354
Thrombosis 350
Thyroid 361
disorder 181
effect of 181
dysfunction 17, 380
function tests 15
Thyroiditis, autoimmune 17
Thyroid-stimulating hormone 178, 181, 380
mechanism of action of 182fc
Thyroxine 182, 380
Tissue
factor pathway inhibitor 355
hormone 389
Tocopherol 332, 333, 390
Total intravenous anesthesia 291
Total ovarian
stromal area 308
vascularization index 28
volume 308
Total oxyradical scavenging capacity 392
Toxoplasmosis 349
Traditional Chinese herbal medicine 393
Transforming growth factor 13, 224, 390
Transient hyperprolactinemia 179
Transrectal ultrasound 380, 381, 399, 400
Transvaginal hydrolaparoscopic drilling 135
Transvaginal sonography 258, 362
Transvaginal ultrasonography 188
Transvaginal ultrasound 293f
Transverse vaginal septum 341
Trigger oocyte maturation 104
Trigger, type of 93
Trophoectoderm 374, 375
Tubal factor 216
counseling for 4
Tubal ligation 5
Tubal patency assessment 315
Tubal pathology 315, 322, 324
Tuberculin test 217
Tuberculosis 216, 331
diagnosis of 220
endometrial 4
etiopathogenesis 216
genital 216, 221
Tuberculous endometritis 331
Tubo-ovarian mass
formation leads 216
ruptures 217
Tuboplasty 222
Tumor, adrenal 12
Turner syndrome 145
Tyrode's solution 325
U
Ultrashort protocol 70, 80
Ultrasonography 341, 380
Ultrasound 214, 226, 254, 290, 315, 381
guided embryo transfer, advantages of 299
high-frequency 348
monitoring 254, 263, 266
Unexplained infertility 262
Unhealthy endometrium 96
Unilateral cervical aplasia 341
United States Food and Drug Administration 348
Urinary follicle-stimulating hormone 67, 68, 71
Urinary tract infection 349
Urine output 254
Usher syndrome 383
Uterine adenomyosis 185
Uterine anomaly 341
Uterine artery 267f
embolization 213, 214
flow waveform, high-resistance 98f
occlusion, Doppler-guided 213
Uterine cavity 317
Uterine factor 217
counseling for 4
Uterine natural killer 352
Uterine pathology 322, 323
Uterine rupture 191
Uterocervical length 269
Uterus 216
adenomyotic 188f
arcuate 346, 346f
bicorporeal 341, 345, 345f
dysmorphic 341, 343
hypoplastic 343, 343f
infantalis 343, 343t
layers of 329f
normal 341
restricted mobility of 217
T-shaped 343, 343f, 343t
unicornuate 346, 346f
V
Vagina 216
normal 341
Vaginal absorption 230f
Vaginal anomaly 341
Vaginal aplasia 341
Vaginal discharge, abnormal 217
Vaginal oocyte retrieval 111
Vaginal progesterone 229, 240, 271
rings 230
Vaginal septum
longitudinal
non-obstructing 341
obstructing 341
Vaginal suppositories 229
Vaginosis, bacterial 360
Varicocele 381
bilateral 402
correction 393
grading 381t
repair 384
Vas deferens 378
congenital bilateral absence of 399
Vascular cell adhesion molecule 1 350
Vascular endothelial growth factor 13, 104, 108, 224, 247, 334
Vascular permeability factor 248, 255
Vascularity flow index 306, 309f
Vascularization index 265f
Vasoepididymostomy 403
Venous thrombosis 247, 255, 349
Ventricular septal defect 49
Virtual organ computer-aided analysis 303, 304f
Visual scotomata 49
Vitamin
B12 390, 391, 393
C 390, 391, 393
D 214, 390, 392
E 333, 390, 393
Vomiting 247, 254
Vulva 216
W
Warfarin 351
Weight loss 124
White blood cell 274
World Health Organization 221
X
XYY syndrome 383
Y
Y chromosomal microdeletion 383, 402
Z
Zeta potential method 288
Ziehl-Neelsen stain 219
Zinc 389, 393
Zona pellucida 283
binding 288
Zuclomiphene 46, 49, 332
Zygotes 374
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Chapter Notes

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Counseling of an Infertile CoupleChapter 1

 
INTRODUCTION
Counseling is the backbone of infertility management. The correct explanation about reproduction and dialog with the patients help them conceive. Insler has mentioned in his book that “many patients conceive when they are sitting outside the consulting room.” This means that there should be informative literature placed in the waiting room, handouts given to patients, and elaborative explanatory displays placed in the waiting room that patients can read and would help them clear a lot of their misconceptions about reproduction, which they might be reluctant to clear in person.
In the busy outpatient department (OPD), it is very difficult for a practicing gynecologist to spend time with the patients for counseling. I shall put forward a few suggestions from my side:
  • There should be informative and illustrative posters placed in the waiting room explaining the physiology of conception.
  • Attractive and interesting literature regarding reproductive physiology, causes of infertility, and outline of management should be placed in the waiting room, which should be easily accessible to them.
  • We have prepared a small booklet regarding the same, which is given to every patient once detailed consultation has been done about their problems. This booklet helps the patient to go through the things that are already discussed and take a correct decision about the management of their problem.
Such an explanation or literature allows the patients to know what would be the management strategy for their problem and therefore they appreciate the treatment that is given. This transparency also builds the patient's confidence in the treating doctor. It also answers several questions which the couple might be hesistant to ask.
Moreover, it also would be a great means of propagating the correct knowledge about infertility through patients as they would discuss whatever they have read and understood by reading the book with their friends.
One very important suggestion that I would like to give to very busy practitioners is: please allot a specific and separate time slot for patients with fertility problems, so that you can patiently listen to them and discuss the solutions or treatment strategy with them. Remember that the initial counseling and the time spent with them play a very vital role in management of the patient.
Let us now discuss in detail about the different aspects of infertility and its management as these need to be discussed with the patients.
As infertility is a social stigma in our culture, not only the couple (I mean the husband also) but also concerned relatives should be involved in counseling, so that they 2would allow and co-operate with the couple to take the correct treatment. The refusal of treatment in majority of cases is by in-laws or parents. Therefore, it is very vital that all the people concerned and all those who are going to play a role in decision-making as to whether to continue the treatment or not should know about infertility and the correct treatment option for that particular couple.
 
WHEN TO START THE TREATMENT?
About 85% of the couples conceive within 1 year of unprotected intercourse and 95% in 2 years. Therefore, if a patient comes for treatment, earlier than a year and a half of continuous unprotected intercourse (active married life), which is very common in rural areas of India and in lower socioeconomic class of people, explaining the above-mentioned fact will increase their faith in you and your treatment and will also prevent unnecessary investigations, anxiety, and frustrations for the patient.
No invasive investigations such as laparoscopy should be done within these 2 years and nature should be given enough time to work for the couple to achieve pregnancy.
Among noninvasive investigations, semen analysis and midcycle/preovulatory scan are the two investigations that may be done. These will more or less prove the normalcy of the couple and then counseling only can help them conceive.
It is commonly observed that couples do conceive very often after the treatment is stopped. This is because the stress and anxiety of treatment are removed and the patient is relaxed. Moreover, when a specialist is treating these couples. They become very enthusiastic about doing some invasive investigation/procedure in every cycle, one after the other such as Rubin's test (RT), hysterosalpingography (HSG), dilatation and curettage (D&C), and laparoscopy, and do not allow an opportunity for conception. Therefore, when this patient is exhausted and abandons treatment, she conceives spontaneously.
Therefore, remember that counseling is more important than overenthusiastic invasive investigations.
 
COUNSELING FOR SEMEN ANALYSIS
In 40–50% of couples presenting with fertility problems, the male factor is responsible either partially or completely. In our social setup even today, males do not accept this fact and therefore they do not agree for examination or investigations. This problem is more prevalent in people who are less educated. Proper counseling is a must with the male partner before subjecting the female partner to treatment of infertility.
The couple must be explained that according to the recent World Health Organization (WHO) criteria 2010,1 15 million sperms/mL, 30% motility, and 4% sperms with normal morphology are considered normal physiological semen criteria. In spite of this even today, we read several laboratories quoting 60 million counts as normal in their reports. Because of this wrong information and ignorance of laboratory officials and clinicians, several patients unnecessarily have to take medicines for long periods to increase their sperm count. Remember that when the sperm count is 15 million/mL or more, no treatment is required. Up to 86% of abnormal sperms is normal and physiological and even patients with 4–14% normal sperms can conceive either naturally or by intrauterine insemination (IUI). It is only when <4% of sperms are normal that in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) may be required.3
When the sperm count is <15 million/mL, semen analysis must be done at least three times—2 weeks apart and 2 months apart to confirm the diagnosis. These patients should directly not be subjected to IVF or ICSI. Instead, we must try medical treatment for these males to improve the sperm count so that they can conceive naturally or with IUI. The whole moto of medical management of a subfertile male is not to increase the sperm count 5−10 times or to achieve excellent semen parameters. It is to increase the count by a few million so that ICSI can be converted to IVF, IVF to IUI, and perhaps IUI into natural conception. Medical management has been discussed in the chapter on male infertility of this book.
 
COUNSELING FOR CERVICAL FACTOR
The cervical factor of infertility is rare at present, as surgeries on cervix are not often done. Frequent D&Cs may damage endocervical glands and epithelium. Cauterization of the cervix should be discouraged.
I believe that even today, postcoital test (PCT) is very useful in infertility management. When more than seven sperms are seen per high-power field of microscope, 10–12 hours after intercourse, it is considered an excellent PCT according to the WHO standards.2
Majority of assisted reproductive technology (ART) textbooks opine that PCT has no significance. I have found it very useful for counseling the husband. He gets assured that he is normal when PCT is normal, so he does not feel guilty and becomes more cooperative for the treatment. It may not have much role for ART, but it is helpful in cases for regular infertility treatment. These are the patients for whom even timed intercourse can be an option. Many a times when the couple changes the gynecologist, semen analysis is asked for. If the patient already has a few semen analysis reports, I will depend on PCT. The satisfaction of the couple is of the highest level and the confidence increases when the couple sees the moving spermatozoa in cervical secretions under the microscope after 10–12 hours of intercourse. Before doing the test it must be confirmed that it is preovulatory period for the female, considering the cycle length and also that the intercourse was done the previous night.
 
WHAT INFORMATION DO WE GET FROM A NORMAL POSTCOITAL TEST?
  • Preovulatory cervical mucus is normal.
  • Sperm count is normal.
Moreover, when the patient (the couple) is shown these moving sperms under microscope even after 12 hours of intercourse, it gives them confidence that both the partners are normal and that helps them conceive.
The patient is explained that these sperms may remain alive for 48–72 hours in the cervix in most patients and in a few, these have also been seen till 7 days. There is a misconception in majority of the couples that intercourse must be done when ovulation occurs. Showing PCT to patients removes this misconception. The cervix acts as a reservoir for sperms, so after the intercourse even if ovulation occurs in 2–3 days, conception can occur. We can explain to the patient that if for conception, the intercourse was needed exactly when ovulation occurs, hardly any raped girl would conceive. The couple should therefore be advised intercourse at least once in 2–3 days during 10–20 days of a 28–30-day cycle. The couple should be clearly told that abstinence of more than 3 days is not advisable during this period, in natural cycle as well as in stimulated cycles for IUI.4
Majority of the couples believe that if IUI is done, it is better to have abstinence before to get a good sperm count. But this is not true. An abstinence of more than 3–4 days does not increase the count; instead the percentage of dead sperms in this semen increases. Therefore, intercourse should not be planned; it should be absolutely voluntary and can be done irrespective of the day of IUI.
Abstinence is one of the causes for failed IUI. In majority of gynecology clinics, where there is no IVF setup, the semen preparation laboratory is not adequately equipped, and so the semen preparation is suboptimal and thus chances of conception are less. Moreover, the patient observes abstinence before IUI, so the chance of natural conception also is denied. As a result, the patient does not conceive when she is on treatment but conceives spontaneously when she abandons treatment. Therefore, remember that intercourse at regular intervals in the fertile period is absolutely essential.
Majority of couples with long-term infertility have lost the charm of their marital relations. Their sexual relations are only planned and compulsory, only targeted for childbearing. They must be explained that a child is only a byproduct. The main thing is the love and affection; intercourse is just an expression of this feeling and results in conception. Counseling can help them regain the charm of their marriage. All myths regarding intercourse must be discussed and sorted out, e.g., posture, position, timing, and washing.
Nothing including diet can give gender selection or increase in pregnancy rate.
 
COUNSELING FOR UTERINE FACTOR
This is to be discussed with the patient after a three-dimensional (3D) ultrasound as 3D ultrasound is now a gold standard for congenital uterine malformations and endometrial pathologies. The patient also can see and understand these 3D pictures and the optimum management then can be easily explained. Fibroids <4–5 cm in size and not touching the endometrium do not require removal. The patient can also be convinced by explaining to them how the embryo comes from the tube to the uterus and implants in the endometrium.
Majority of the patients have a wrong concept that dilatation and curettage (D&C) helps conception. This is a myth and should be clarified. D&C should not be done in modern infertility practice. The only role today of D&C is to exclude endometrial tuberculosis (TB) by either histopathology or TB polymerase chain reaction (PCR) of the endometrial sample along with culture. D&C must not be done to diagnose luteal phase defect or to check whether the endometrium is in the proliferative phase or the secretory phase. It has a higher chance of damaging the endometrium and resulting in infertility.
 
COUNSELING FOR TUBAL FACTOR
The patient must be explained that fertilization occurs in the fallopian tube and after 4–5 days, the embryo comes to settle in the uterus. This explanation is also useful to counsel if the patient gets an ectopic pregnancy. Tubal evaluation is very important in infertility practice. RT for tubal evaluation should be discarded. Laparoscopy is the gold standard for evaluation of the tubes.
The patient should be explained that at the time of ovulation, the fimbrial end of the tube covers the ovary and a negative pressure of −1 mm Hg (mercury) develops due to movements of the cilia, which sucks the ovum 5from the follicle into the tubal lumen. So the ovum does not separate and release from the follicle to roll into the tubal lumen, but the tube is vital and instrumental. Therefore, it is important that the tubo-ovarian relation should be healthy; a patent tube is not sufficient. HSG gives us only incomplete information about the patency of the tube. This can be replaced by sonosalpingography (SSG).
Now microsurgery is almost replaced by ART for pathological tubes. The results of microsurgery are very good in tubotubal anastomosis in patients with tubal ligation (TL), especially laparoscopic TL. Therefore, in young patients where TL is done microsurgery should be offered as an alternative to ART as it is a one-time procedure and the patient gets a breathing time for up to 2 years and also has a chance to conceive more than once if the couple wishes so.
 
COUNSELING FOR OVARIAN CAUSES
The patient should be counseled that ovum is released from the ovary only once in a month and survives for 6–8 hours. Sperms that are stored in the cervix can reach the ova and conception can occur. Ovulation can be confirmed by serum progesterone levels assessed on Day 21–22. Daily sonography is not required just to confirm whether the ovulation has occurred or not if no active treatment or intervention is planned. Basal body temperature record and cervical mucus assessment do not help much in management.
 
UNEXPLAINED INFERTILITY
About 5–10% of patients are infertile in spite of everything being normal. They have normal semen analysis, normal endoscopy, normal luteal phase, and normal endocrinological reports. These are the patients with unexplained infertility and are the ideal patients for IUI. Six cycles of superovulation with IUI must be tried for these couples before subjecting them to ART. The IUI is the choice of treatment for idiopathic infertility rather than IVF.
 
COUNSELING FOR INTRAUTERINE INSEMINATION
Intrauterine insemination is a very effective method for fertility treatment. But the couple must be explained that it is not the IUI procedure alone that gives pregnancy; selection of the patient, correct stimulation protocol, precise ultrasound monitoring, and optimum luteal support are all equally important to get pregnancy. So six cycles of properly and dedicatedly done IUI must be tried in patients of <35 years of age and at least three to four cycles in patients up to 40 years of age. It gives an excellent pregnancy rate provided all the steps mentioned earlier are done correctly.
There should not be any abstinence of >48 hours before IUI; otherwise, it decreases the pregnancy rate. Gynecologists should have a good setup for IUI to get excellent results. In-house laboratory should be established in a gynecologist's setup.
 
COUNSELING FOR DONOR INSEMINATION
Counseling for donor insemination should be done to all the patients who have very low count or azoospermia before proceeding to ICSI. Many patients who cannot afford ART may opt for artificial insemination by donor (AID).
The donor must be unknown. At times, patients may ask to use semen sample from a known donor and that must be discouraged. 6The sample must be ordered from a registered semen bank. The donor and couple's identity must not be revealed to each other in any case. The child has a right to ask about his/her genetic prints after 18 years and so the records should be maintained. But when that information is given, the donor's identity must not be revealed.
 
COUNSELING FOR IN VITRO FERTILIZATION
There are many misconceptions prevailing for IVF treatment regarding three aspects:
  1. Indications
  2. Results
  3. Cost
 
Indications
It must be clearly understood that IVF is the first choice in only those patients who have bilateral tubal block, severe endometriosis, or severe male factor infertility. IVF may be done in patients with unexplained infertility only when six well-tried superovulation with IUI cycles have failed to give pregnancy. Dysovulatory infertility like polycystic ovaries (PCO) is not an indication of IVF.
 
Results
Patients believe that IVF is a sure-shot solution to infertility. They have been misled about the same. They must be explained that the results of IVF in the best centers of the world are:
  • 30% in the first cycle
  • 40–45% in the second cycle
  • 50–55% in three cycles
  • 60–65% in four cycles
  • 65–70% in five cycles
  • 70–73% in six cycles
Therefore, patients who do not have absolute indications for IVF should be given a chance of IUI instead of taking them for IVF because about six superovulation with IUI cycles cost the same as one IVF cycle, with more chances of success.
 
Cost
The IVF is a very expensive procedure. Its cost includes charges for gonadotropins and medicines, which comprises the largest amount, nearing
60,000–80,000 depending on the requirement of the patient. The second highest cost is of disposables and media. This is also about
10,000–15,000. Over and above this, the cost also includes consulting fees of the IVF consultant, embryologist, anesthetist, etc. Therefore, it must be understood that when we try to cut-off the cost, one has to compromise on drug quality and disposables. This would definitely compromise with the results also.
With fixed packages, it is likely to do compromise with the quality of treatment.
 
POINTS TO BE EMPHASIZED (AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE RECOMMENDATIONS, 2017)
Chances of conception decrease after 35 years and so evaluation must be done after 6 months of marriage in elder age group only.
Intercourse every 1–2 days minimum during the fertile period gives a comparable pregnancy rate. The fertile window starts 6 days prior to ovulation. Smoking, alcohol (>2 pegs), coffee, recreational drugs, and commercially available vaginal lubricants should be discouraged.7
 
CARRY HOME MESSAGE
REFERENCES
  1. Morshedi M (2010). New 2010 WHO standards (5th edition) for the evaluation of human semen. WHO Guidelines for Semen Analysis. [online] Available from: https://www.aab.org/images/aab/pdf/2014/CRBPPT14/NotesMM%20WHO.pdf [Last accessed March, 2021].
  1. Moghissi KS. Postcoital test: physiologic basis, technique and interpretation. Fertil Steril. 1976;27(2):117–29.