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Consensus

Worldwide studies show that 10-15% of couples have a problem achieving conception despite regular unprotected sex for over one year. On average, only 56% of them seek medical aid. The biggest problem in most European countries is the early termination („dropout“) of the infertility treatment in up to 40% of the couples (Scheme 1). This means that the treatment is successful in only 10 out of the 56 pairs who seek medical aid. There are no data suggesting that the situation in Slovakia is different.

Goals of the practical consensus is make an appropriate and effective treatment available to couples with fertility problems by standardizing the diagnostic-therapeutic procedure and streamline the collaboration between primary care gynaecologists, urologists and assisted reproduction centers.

Consenus was approved by Slovak Society of Gyneacology and Obstetrics

Scheme 1 - Efficiency of the path to pregnancy

 Scheme 1 - Efficiency of the path to pregnancy

Screening

The primary care gynaecologist recommends the test to determine ovarian reserve – Anti-Müller hormone (AMH) to all women aged 30 years and over who intend to get pregnant in the future.

Interpretation of the test results:

Women aged 30 and over

AMH < 1 ng/mllow ovarian reserve

If the value of AMH is less than 1 ng/ml (low ovarian reserve), the primary care gynaecologist sends the couple to the assisted reproduction centre.

Women aged 25-29

AMH < 1,5 ng/mllow ovarian reserve

If the value of AMH is less than 1,5 ng/ml (low ovarian reserve), the primary care gynaecologist recommends to perform counting the number of antral follicles (AFC).

Diagnosis and treatment

Infertility is diagnosed and treated in 4 steps (Scheme 2)

  • STEP 1STEP 2STEP 3STEP 4Ovarian reservetestSpermiogramTubalpatencyverificationA maximum of3 cycles withclomiphene citrateor spontaneouslyLowovarianreservepathologicimpassablenon-successfulnormalnormalpassablesuccessfulAssisted reproduction centre
    Scheme 2 – Four steps in the diagnosis and treatment of couples with fertility problems by the primary care gynaecologist
  • STEP 1STEP 2STEP 3STEP 4Ovarian reservetestSpermiogramTubalpatencyverificationA maximum of3 cycles withclomiphene citrateor spontaneouslynormalnormalpassablesuccessful

    Step 1 – Ovarial reserve tests

    The primary care gynaecologist performs tests to determine ovarian reserve. (AMH, AFC).

    Next

    Women aged 30 and over

    AMH < 1 ng/mllow ovarian reserve

    If the value of AMH is less than 1 ng/ml (low ovarian reserve) or the AFC is in the range of 0-7, the primary care gynaecologist sends the couple to the assisted reproduction centre.

    If the value of AMH is higher than 1 ng/ml (normal ovarian reserve) or the AFC is higher than 8, the primary care gynaecologist sends the man to the urologist (andrologist) or to the assisted reproduction centre for spermiogram.

    Women aged 25–29 years

    AMH < 1,5 ng/mllow ovarian reserve

    If the value of AMH is less than 1,5 ng/ml (low ovarian reserve) or the AFC is in the range of 0-7, the primary care gynaecologist sends the couple to the assisted reproduction centre.

    If the value of AMH is higher than 1,5 ng/ml (normal ovarian reserve) or the AFC is higher than 8, the primary care gynaecologist sends the man to the urologist (andrologist) or to the assisted reproduction centre for spermiogram.

  • STEP 1STEP 2STEP 3STEP 4Ovarian reservetestSpermiogramTubalpatencyverificationA maximum of3 cycles withclomiphene citrateor spontaneouslynormalnormalpassablesuccessful

    Step 2 – Spermiogram

    The first care gynaecologist:

    carries out verification of tubal patency, if the spermiogram is normal,

    Next

    sends the couple to the assisted reproduction centre, if the spermiogram is pathologic.

    Scheme 3 – Reference values of normal spermiogram by WHO 2010:
  • STEP 1STEP 2STEP 3STEP 4Ovarian reservetestSpermiogramTubalpatencyverificationA maximum of3 cycles withclomiphene citrateor spontaneouslynormalnormalpassablesuccessful

    Step 3 – Examination of the patency of uterine tubes

    The primary care gynaecologist:

    performs 1-3 cycles of stimulation by clomiphene citrate (Clostlibegyt) in women trying to get pregnant, if at least one tube is passable, the ovarian reserve is normal and there is normospermy in man.

    Next

    sends the couple to the assisted reproduction centre, if both tubes are impassable.

  • STEP 1STEP 2STEP 3STEP 4Ovarian reservetestSpermiogramTubalpatencyverificationA maximum of3 cycles withclomiphene citrateor spontaneouslynormalnormalpassablesuccessful

    Step 4 – Stimulation by clomiphene citrate (Clostilbegyt)

    The primary care gynaecologist:

    sends the couple to the assisted reproduction centre after 3 non-successful cycles of stimulation by clomiphene citrate (Clostilbegyt).

    Final recommendations

    • Carry out ovarian reserve tests (AMH, AFC) and spermiogram without delay.
    • The primary care gynaecologist sends the couple to the assisted reproduction centre no later than after 6 months of unsuccessful attempts to become pregnant, if the woman is older than 35 years.
    • The primary care gynaecologist sends the couple to the assisted reproduction centre without delay, if the woman is older than 37 years.
    • For the first stimulation of ovulation, a dose of clomiphene citrate of 50 to 100 mg for 5 days is recommended. If no growth of the dominant follicle occurs during the first month, the dose of clomiphene citrate can be increased by 50 mg a day. The maximum recommended dose is 200 mg a day. Further increasing the dose of clomiphene citrate has no meaning in terms of increasing the likelihood of becoming pregnant. Continued stimulation in further cycles does not increase the chances of becoming pregnant.