Manual of Infertility SN Tripathy, Nandita Palshetkar, KC Mahapatra, SK Giri, Babitaq Panda
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fm1Manual of Infertility
fm2fm3Manual of Infertility
Editors SN Tripathy KC Mahapatra SK Giri Nandita Palshetkar Babita Panda
fm4
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Manual of Infertility
First Edition: 2018
9789352703715
Printed atfm5
Contributors
Anuradha Tibrewal
Consultant
Raipur, India
Babita Panda MD
Professor and Head
Department of Infertility unit
IMS and Sum Hospital
Bhubaneswar, Odisha, India
Kamini Rao DGO DORCP DCh FRCOG (UK) MCh (UK) FICOG PGDMLE (Law) FNAMS
Medical Director
Milann—The Fertility Center
A Unit of BACC Healthcare Pvt Ltd
Bengaluru, Karnataka India
Kanchana Devi
Senior Consultant
Department of Reproductive Medicine
Cloud Nine Hospital
Chennai, Tamil Nadu, India
Lilavati Guru
Cuttack, Odisha, India
Raju Nair
Medical Director
Department of Reproductive Medicine
Mitera Hospital
Kottayam, Kerala, India
Saubhagya Kumar Jena
Additional Professor
All India Institute of Medical Sciences
Bhubaneswar, Odisha, India
Siddhartha Chatterjee
Subhashree Rout
Sujata Pradhan MD
Associate Professor
IMS and Sum Hospital
Bhubaneswar, Odisha, India
Supriya Pani MD
Bhubaneswar, Odisha, India
Taswin Kaurfm6
fm7Message
Rishma Dhillon Pai
MD DNB FCPS DGO FICOG
President, FOGSI—2017
Consultant Gynecologist
Jaslok Hospital, Lilavati Hospital and Hinduja Healthcare (Khar),
Bloom IVF Centre,
The Every Woman Clinic,
Mumbai, Maharashtra, India
   “Wisdom…. comes not from age, but from education and learning.”
Anton Chekhov
Life is a continuous process of learning. Especially in the field of medicine, which is constantly changing, it is very important to keep oneself abreast with the latest developments. It is heartening to note that academic workshop manuals are being released at the AICOG, Bhubaneswar, Odisha, India, for the benefit of the participating delegates and present varied updates in the field. Many different Manuals are being released on important subjects such as 3D Laparoscopy and Operative Oncology, Genetics, Fetal Medicine and Color Doppler, Postpartum Hemorrhage and High-Risk Pregnancy, Hysteroscopy, etc.
I thank all the authors, for their immense contributions in building up the content for the manuals for Federation of Obstetric and Gynaecological Societies of India (FOGSI) by sharing their rich experiences in the field. These will be a big help to young gynecologists, who are still acquiring skills in various aspects of obstetrics and gynecology and a quick update for the seniors.
I extend congratulations to the organizing team of the AICOG 2018 and the editors of these manuals and wish you all success for this mega event.
   “You cannot open a book without learning something.”
Confucius
fm8Message
Jaideep Malhotra
MD FICMCH FICS FMAS FRCOG FlCOG FRCPI FIAJAGO
Consultant ART (IVF)
President Elect, FOGSI—2018
Director, Rainbow IVF
Agra, Uttar Pradesh, India
   “Education is greatest gift of life, it should never stop.”
The subject of obstetrics and gynecology needs extreme proficiency as it deals with the medical specialties that focus on two different aspects. First one includes the care of pregnant women, the unborn baby, labor and delivery, as well as the immediate period following childbirth. Second aspect includes dealing with any ailment concerning the female reproductive organs. Hence, the manuals will help all those who are looking forward to gain excellence in the field of woman health. The manuals have tried to address all the issues a doctor needs.
With increasing expertise in all fields, the surgeon therefore while exercising a choice needs to follow the Hippocratic dictum—“First, do no harm.”
We are thankful to all those who have incorporated their contribution by providing chapters from their research and collected scientific material and have shared their fruitful experiences for the delegates of the workshop.
As a part of my agenda for 2018, I as FOGSI President 2018, plan to work actively on QED (Quality, Ethics and Dignity) among our profession and also work towards HER (Health, Empowerment and Respect) towards our patients.
   “Knowledge is of no value unless you put it into practices.”
fm9Message
Hrishikesh Pai
Secretary General, FOGSI
It is my proud privilege to invite and welcome all delegates to the 61st All India Congress of Obstetrics and Gynaecology (AICOG) from 17th–21st January, 2018 at the Temple City of India, Bhubaneswar, Odisha, India.
It is propitious to note that the academic workshop manuals are being released which will reap beneficial reward to all the participating delegates.
I thank all the authors, for their immense contributions in building up the content for the manuals for Federation of Obstetric and Gynaecological Societies of India (FOGSI) by sharing their rich experiences in the field. These will be a big help to young gynecologists, who are still acquiring skills in various aspects of obstetrics and gynecology and a quick update for the seniors.
I forward my heartiest congratulations to all the contributors, the editors and the delegates of the workshop.
fm10Message
PC Mahapatra
Professor Department of Obstetrics and Gynecology
SCB Medical College, Cuttack, Odisha, India
President, FOGSI—2011
Organising Chairperson
It is my proud privilege to invite and welcome all delegates to the 61st All India Congress of Obstetrics and Gynaecology (AICOG) from 17th–21st January, 2018 at the Temple City of India, Bhubaneswar, Odisha, India.
The five days of academic extravaganza will certainly enrich the scientific knowledge of all participating delegates and faculty. The precongress workshop on various aspects of this specialty will be held on 17th January 2018.
A quote by Edwin Louis Cole says that “Winners are not those who never fail but those who never quit” is apt for all the clinicians who are determined enough to see and overcome all the difficulties that are faced in the field of obstetrics and gynecology.
Today, with the advancement in the field of obstetrics and gynecology, everyone requires an in-depth knowledge of the complex subjects associated with the field so as to gain excellence in it.
This manual will prove to be a boon to all those who are associated with the field and wants to gain more knowledge in the subject matter.
fm11Message
HP Pattanaik
Head
Department of Obstetrics and Gynecology
City Hospital
Cuttack, Odisha, India
Vice President, FOGSI—2009
Organising Secretary
Greetings from 61st AICOG 2018!
It is a matter of great pleasure to invite you all to 61st AICOG, from 17th–21st January, 2018 at the Temple City of India, Bhubaneswar, Odisha, India. The 11th Precongress workshops will be held on 17th January, 2018 in three medical colleges of Bhubaneswar.
It is propitious to note that the academic workshop manuals are being released which will reap beneficial reward to all the participating delegates.
It will also prove to be beneficial to the members of Federation of Obstetric and Gynaecological Societies of India (FOGSI), those who were unable to register themselves for the academic workshops.
I forward my heartiest congratulations to all the contributors, the editors and the delegates of the workshop.
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fm13Preface
‘To get and beget’ is the basic human driving force. Hence infertility is a problem of immense magnitude. Infertility affects 10–15 % of couples trying to conceive. In India, one out of five couples is childless. Having a child for most individuals is an important milestone; and being unable to do so represents a major disaster.
The etiology of female infertility can be broken down into ovulation disorders, uterine abnormalities, tubal obstruction and peritoneal factors. Cervical factors are also thought to play a minor role.
The investigation of the infertile patient must begin with adequate history taking and physical examination and diagnostic evaluation of both the partners simultaneously. If the initial evaluation shows any abnormality, further investigations should be suggested according to the individual case. Proper evaluation as per guidelines helps in diagnosing cause of majority of cases. A target-oriented approach maximizes the chances of conception while minimizing the time to achieve pregnancy and treatment-related adverse effects.
At present in infertility work-up, the most neglected area is uterus, Research is necessary in the area of endometrial receptivity and on the molecular factors of the endometrium. Dilatation and curettage or endometrial aspiration should be done to exclude endometrial tuberculosis and to stimulate the good molecules of the endometrium. In 300 BC Aristotle has told, ‘The womb is the field of generation; and if this field be corrupted it is invain to expect any fruit though it be ever so well sown.’
Tubal factor accounts for 25–35% of female infertility. In addition to that a large proportion of post-sterilized females contribute to tubal factor infertility. Evaluation of the fallopian tubes is an essential part of a fertility work-up. Several non-surgical and surgical methods have been used since decades to evaluate the tubal patency. HSG has been used for a long time for assessment of tubal patency. In ultrasonography various methods like SIS, HyCoSy and HyFoSy are used for evaluation of the fallopian tube. HyFoSy allows a more accurate diagnosis of tubal patency compared with HyCoSy. Laparoscopy and dye test remains the gold standard among tubal patency tests until a suitable non-invasive test is available. In most of the infertility evaluation guidelines, tubal evaluation is the last step. The guidelines are not in agreement on the most effective diagnostic scenario for tubal evaluation.
The decision for managing a case of tubal factor infertility should be taken considering all other possible factors leading to infertility. Presently ART is widely used for treatment of tubal factor infertility, but the role of tubal reconstructive surgeries for selected cases in the hand of experts cannot be fm14completely ignored. Tubal reconstructive surgery avoids the complications associated with ART ie. OHSS, multiple pregnancies, high risk of obstetric and perinatal complications. Surgery is less costly than ART and in the hand of experts tubal reconstruction carries a reasonable success rate for pregnancy. Surgery performed once offers the opportunity of pregnancy for multiple times.
Several treatment options have been used to overcome male infertility. Intrauterine insemination (IUI) is one of the easy, affordable and widely practiced treatment for many infertile couples. Intrauterine insemination (IUI) aims to make a reasonable fraction of motile spermatozoa available close to the oocyte around the time of ovulation. Presently global success rate for IUI has been up to 10–15%. Hence various strategies have been tried to optimize the outcome of IUI. With the advent of ICSI, severe male factor which was considered untreatable became treatable and with the parallel improvement in knowledge about genetics and advancement in molecular biology, understanding of the genetic aspect of male fertility and infertility emerged. This has opened new vistas in the assessment and treatment of male factor infertility. In any male with severe oligozoospermia or azoospermia, genetic testing must be done and it is important to continue research in this subject.
Infertility is a very sensitive social issue. The graduation in status through motherhood is so marked that barrenness is a dreaded condition. These stigmatized couples spend all their money by traveling to every nook and corner of the country where they hope to realize their dream. These childless couples use a variety of traditional, religious and herbal treatments in addition to the evidence-based medicine hoping for a miracle. There are many phages and modality of treatment for infertility, but nothing gives a good success rate, We, who are infertility specialists should take a very sympathetic attitude towards them and guide them properly, for anovulation, ovulation stimulating drugs, for tubal factor infertility, ART or tubal reconstructive surgery, for uterine factor, surrogacy or adoption and for male factor infertility IUI or ICSI.
We hope this workshop will help you a lot in infertility management.
Blessed trinity, have pity
You can give the blind man sight
Fill the barren rocks with grass
Grant this house a child tonight’
Irish Proverb