The Academy of Medicine (AMS) and Ministry of Health (MOH) have developed the clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level to provide doctors and patients in Singapore with evidence-based treatment for infertility. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the AMS-MOH clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2013/cpgmed_infertility.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Evidence-Based Medicine ; Female ; Guidelines as Topic ; Humans ; Infertility ; diagnosis ; therapy ; Male ; Practice Guidelines as Topic ; Primary Health Care ; methods ; standards ; Public Health ; standards ; Singapore

INTRODUCTIONSuperovulation-intrauterine insemination (SO-IUI) is the most common assisted reproductive technique (ART) in the world, with good evidence of efficacy and cost-effectiveness. However, parameters affecting its success have not been consistently reported. So in this study, we aim at determining the parameters influencing the success rate of SO-IUI.

MATERIALS AND METHODSWe conducted a retrospective cohort study of 797 SO-IUI cycles from 606 patients, performed between 2007 and 2009 in a single centre. These women received clomiphene citrate (CC), recombinant FSH (rFSH) or both.

RESULTSThere were 127 clinical pregnancies with a pregnancy rate (PR) of 15.9% (127/797) per treatment cycle. Factors associated with higher PR included maternal age <38 (P = 0.02), subfertility diagnoses of ovulatory disorders, unexplained infertility, sexual dysfunction and unilateral tubal obstruction (P = 0.02), an endometrial thickness ≥8 mm (P = 0.03), total number motile spermatozoa (TNMS) of ≥1 million (P = 0.03), and spermatozoa normal forms (NF) ≥4% (P <0.01) on bivariate analysis. When CC is used, the endometrial thickness is more likely to be suboptimal (<8 mm). All the above parameters remained significant except the subfertility diagnoses on multivariate analysis.

CONCLUSIONPatients' selection with women <38 years old and preferably with ovulation disorders and unexplained infertility is associated with the highest PR in SO-IUI. Cycle parameters such as the use of rFSH alone, with the avoidance of CC, TNMS ≥1 million and NF ≥4% is likely to result in the best outcomes and reduce the high order multiple pregnancy risk.

Adult ; Age Factors ; Clomiphene ; therapeutic use ; Cohort Studies ; Female ; Fertility Agents, Female ; therapeutic use ; Humans ; Infertility, Female ; etiology ; Insemination, Artificial ; methods ; Pregnancy ; Pregnancy Rate ; Prognosis ; Retrospective Studies ; Superovulation

INTRODUCTIONWe aimed to develop and implement a short tandem repeat (STR) polymerase chain reaction alternative to fluorescence in situ hybridisation (FISH) for the preimplantation genetic diagnosis (PGD) of chromosomal translocations.

METHODSSelected informative STRs located on translocated arms of relevant chromosomes were used to discriminate between normal and unbalanced chromosome states in each embryo.

RESULTSPGD cycles were performed on five couples where one spouse carried a balanced translocation. 27 embryos were analysed, of which 12 were normal/balanced, 12 were abnormal/unbalanced and three were indeterminate. Four PGD cycles proceeded to embryo transfer, of which two led to pregnancy. The first pregnancy showed a normal male karyotype, and a healthy baby was delivered at term. A second pregnancy unexpectedly miscarried in the second trimester from unknown causes.

CONCLUSIONSTR analysis is a simple and suitable alternative to FISH for detecting unbalanced chromosomal states in preimplantation embryos.

Female ; Fertilization in Vitro ; Humans ; Male ; Microsatellite Repeats ; genetics ; Polymerase Chain Reaction ; methods ; Polymorphism, Genetic ; genetics ; Pregnancy ; Pregnancy Outcome ; Preimplantation Diagnosis ; methods ; Translocation, Genetic ; genetics

INTRODUCTIONWomen with previous tubal sterilisation seeking fertility are faced with treatment options of reconstructive tubal surgery or in vitro fertilisation (IVF) techniques. The aim was to assess the current viability of tubal anastomosis in a local clinical practice.

MATERIALS AND METHODSA retrospective cohort review of all sterilisation reversal cases from January 1998 to January 2008. The main outcome measures included fi rst pregnancy success and live birth after surgery. Subsequent live births, ectopic pregnancies, miscarriages, duration of surgery and hospitalisation within the study period were also reported. We included cases aged less than 40 years, without any known semen abnormalities, and performed by only one operator. Cases with only unilateral reversal were excluded.

RESULTSNineteen cases with previous Filshie clip ligation (9 laparoscopic/10 open) were reviewed. Cumulative pregnancy rates with surgery were 47.4% (<6 months), 57.9% (6 to 12 months), 68.4% (12 to 48 months) and 73.7% (>48 months). Pregnancy (77.8% vs 70.0%) and live birth rates (66.7% vs 60.0%) were similar between laparoscopy and open surgery. The mean interval to pregnancy was marginally lower via laparoscopy (11.3 vs 13.6 months). Hospitalisation stay was significantly halved (1.43 vs 3.00 days) but ectopic pregnancies were increased 3-fold (3 vs 1) with laparoscopy. Compared with IVF, the estimated average cost per delivery for laparoscopic reversal was reduced for laparoscopic reversal with no multiple pregnancies.

CONCLUSIONOur results favour surgical reversal after sterilisation for patients younger than 40 years old. It avoids hyperstimulation risks and the economic burdens associated with multiple pregnancies. Where expertise is available, laparoscopic reversal should be performed.

Adult ; Age Factors ; Cohort Studies ; Female ; Fertilization in Vitro ; Humans ; Laparotomy ; adverse effects ; Microsurgery ; methods ; Pregnancy ; Pregnancy Rate ; Pregnancy, Ectopic ; etiology ; Retrospective Studies ; Sterilization Reversal ; adverse effects ; Sterilization, Tubal