Level 1 has been sub classified into two categories: Level 1A and 1B. Investigations suggested and treatment offered at Level 1A should be cost-effective. Level 1A infertility care unit is not required to be accredited or licensed. But accreditation is mandatory for higher levels. The responsibilities of personnel and the requirements of each Level of infertility care unit have been elaborately discussed in the currently published ICMR guidelines. Depending on the severity of infertility problems, the couple should be referred to higher specialty clinics (Level 1B, Level 2 or Level 3).

The basic infertility work-up consists of clinical evaluation including history taking, physical examination, simple semen analysis and exclusion of tubal and tubo-peritoneal defects. Following these basic investigations, the infertile couples with regard to the cause of infertility can be categorized into three groups: (a) Single defect (b) Multiple defects (c) having no defect or Unexplained Infertility. For example, single ovulatory defect can be treated with clomiphene citrate or letrozole, with or without adjuncts, like eltroxin, bromocriptine, spironolactone or metformin at Level 1A infertility care unit.

In level B infertility care unit, facilities for intrauterine insemination (IUI), in addition to other requirements which are available in Level 1A care unit, must exist.

Level 2 infertility care unit should have provisions for supporting couples with multifactorial or 6unexplainable causes of infertility. These include expanded facilities of investigations like sperm function test for male infertility, basic endocrine investigations or facilities for TVS for further assessment of pelvic pathology, folliculometry and assessment of endometrial thickness, morphology, volume and vascularity. In addition, these units should also provide the facilities for endoscopic surgeries specially for those indications which are commonly associated with infertility.

Level 3 infertility care unit should have arrangements for upgraded and sophisticated investigative procedures like hormone estimations, cytogenetics, in-depth andrology, Reactive Oxygen Species (ROS) and many other similar procedures. Apart from other advanced medical or surgical approaches, therapeutic intervention with different types of Assisted Reproductive Technology should be available in the category of tertiary infertility care units. Facilities for preimplantation genetic diagnosis (PGD) may or may not be available. These tertiary units are also expected to have a research unit – which may carry out research on In-Vitro Maturation, Cryopreservation of gametes or gonadal tissues and embryonic stem cell culture.

In such a complex situation of infertility management, invariably there will be plenty of dilemmas which frequently arise in the mind of consultants. This has stimulated the editor Dr. Prakash Trivedi to compile this informative book “Your Infertility Dilemma – The Experts Final Verdict” covering around 130 questions on different aspects of infertility answered by twelve well-reputed national experts in the field of infertility. Discussion and answers have been based on their wide experiences which they have accumulated over the years through their devoted services to vast number of infertile couples whom they have investigated and treated.

The first question that arises in relation to infertility treatment in our circumstances is; Are we doing too much or too less? For example, in PCOS women; is it 7necessary in all cases to estimate all reproductive hormones like FSH, LH, E2, Androgens and Insulin or is it enough in majority to evaluate the patient clinically from history and physical stigma and confirm the diagnosis by Ultrasound? Apart from anovulation and infertility the current emphasis in PCOS is related to early diagnosis for prevention of far reaching consequences like Type 2 diabetes mellitus and hypertension. Also the approach to infertility treatment by ART in PCOS women is being reviewed through different protocols. Attention has been focused on In Vitro Maturation of oocyte followed by IVF-ET which will certainly reduce the treatment cost and incidence of OHSS. These aspects have been elaborately discussed through question – answer format presented in this book.

Advanced endometriosis is a major dilemma in the treatment of infertility. In addition to anatomical distortion of pelvic organs, biochemical and immunomodulatory changes in the reproductive tract of women suffering from endometriosis create challenging problems for all types of infertility treatment including IVF. The experts through their own experience backed up by literature survey have provided valuable informations regarding various treatment options including surrogacy and adoption for some women with advanced endometriosis where IVF is not possible or affordable.

There is a continuous ongoing effort for advancement in andrology specially at the molecular level, related to male infertility. This aspect has been dealt in detail by some eminent andrologists in the country.

A cost effective ovarian stimulation protocol for IVF and IUI which will be easy to use with optimum outcome should be formulated. These have been adequately covered up in sections dealing with “stimulation protocol made easy, IUI lab details and results”.

Recurrent pregnancy loss, like infertility is also a challenging problem. Though in 50% of cases, the cause is unknown, thrombophilic disorder has been 8identified as a significant etiological factor. The different modalities of current management protocols have been addressed in the chapter of Recurrent Pregnancy Loss.

Recently attention has been focused on the mechanism involved for “endometrial receptivity” at the molecular level. Knowledge acquired from these works will help us to understand the complex embryo-endometrial implantation mechanism. It is now generally accepted that several biochemical, physiological, immunomodulatory and genetically expressed molecules participate in generating endometrial receptivity. These endometrial molecules or ‘markers’ are induced by estrogen in the follicular phase and activated by progesterone in the luteal phase. Since receptivity is regulated by genetic coding of the endometrium, it varies from woman to woman and in the same woman from cycle to cycle. Few receptivity markers like integrin, ‘pinopodes’, proadhesive members of interleukins super family, TNFα etc have already been identified. These markers are poorly expressed in endometriosis and tubercular endometritis leading to poor endometrial receptivity in these women. These points have been highlighted in the chapter of this book dealing with endometrium, endometriosis and genital tuberculosis.

This book ends with discussion of 9 extraordinary case reports which are thought provoking. To summarize, the scientific material provided in this book are very practical and will be of immense help for day-to-day practice for those who are already committed and also for those who are aspiring to specialize in the sub-specialty of reproductive medicine and infertility.

Martin Luther King once said “When you are right you could be too radical and when you are wrong you could be too conservative”. Every clinician in his/her day to day practice some time stands at such cross roads and has to decide the right approach in treating the patients.

A Ready Reckoner like this will be handy. The experts have worked very hard to address such dilemmas in treating infertility.

I congratulate Dr. Prakash Trivedi for compiling this Ready Reckoner.

It's truly said that the world doesn't recognize you by your skill, knowledge, intelligence but on your ability to use all this aspects to deliver your best only in the interest of the fellow Gynaecologists and the infertile patients. The only skill an editor needs is to pick up the Gems and Jewels from our country who have contributed towards the field of Infertility, IVF, Sonography, Color Doppler, Andrology, Infertility laboratory and fertility enhancing endoscopic surgery. I was blessed by the almighty to serve FOGSI as an Infertility Committee Chairperson from 2003 to 2007. After the Genius like Prof. Mehroo Hansotia, Prof Sadhana Desai and our highly respected Prof BN Chakravarty.

The vastness of Infertility field may need few lifetime commitments and rebirth, but with the team of the Expert Contributors the best on this planet I could make it possible. I will remain obliged to them for ever. “Your Infertility Dilemmas ~ The experts final verdict” a FOGSI publication from the Infertility committee chairperson is a ready reckoner, a guide, a thought provoking stimulating book with answers from the experts is impossible to miss on your practicing table. I have immense satisfaction to release this book at the end of my tenure as FOGSI Infertility Committee Chairperson exactly at the time when in the heart of India Delhi you have elected me as the FOGSI Senior Vice President ~ 2008. May 22000 FOGSI members gain from this book in day to day treatment of the most deserving Infertile couples.