Assisted Reproductive Treatment Clinical Practice Guidelines (2020)

German Society of Gynecology and Obstetrics (DGGG), Swiss Society of Gynecology and Obstetrics (SGGG), and Austrian Society of Gynecology and Obstetrics (OEGGG)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

January 31, 2020

The German Society of Gynecology and Obstetrics (DGGG), in cooperation with the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG), have developed guidelines for counselling, diagnostic workup, and treatment of infertility.[1]

Infertility Consultation and Workup

The initial history should include an inquiry concerning risk factors relevant to infertility, such as age, smoking status, alcohol intake, eating disorders, drug use, and intensive physical exercise. The patient must understand that such factors may not only adversely affect the treatment outcome but also potentially damage gametes and embryos. Patients must also understand that a body mass index (BMI) over 30 kg/m2 or under 19 kg/m2 may predispose to ovulation disorders, which may cause infertility.

Before fertility treatment is initiated, women must be informed that folic acid substitution is required.

Appropriate psychotherapy or counseling should be recommended to patients whose fertility disorder is related to behavior (eg, eating disorder, drug addiction).

Sexuality and sexual disorders

Patients should be asked about sexual issues in the couple’s relationship. Sexual therapy should be recommended to couples who feel that their sexual behavior and experience require treatment.

Psychological factors

Screening tools for psychological vulnerability may be considered, if relevant. In these cases, a psychosomatic diagnosis should be offered; routine psychopathological diagnosis is unnecessary. Psychosocial counseling or psychotherapy is generally not recommended in these cases unless the fertility disorder has a behavioral etiology or the patient has a mental illness that requires treatment.

Diagnosis and Treatment of Congenital and Acquired Genital Anomalies

Following the gynecological examination, vaginal ultrasonography must be performed to rule out congenital malformation. Three-dimensional vaginal ultrasonography with or without hysteroscopy, possibly combined with laparoscopy, should be performed if a congenital malformation is suspected.

Fibroids must be diagnosed with vaginal ultrasonography. Before fertility treatment is initiated, submucosal fibroids (Federation of Gynecology and Obstetrics [FIGO] type 0 and 1) must be removed hysteroscopically. Laparoscopy may be performed for intramural and subserous fibroids.

Suspected intrauterine polyps and/or adhesions should be evaluated with hysteroscopy. Hysteroscopy should be used to remove intrauterine polyps and adhesions.

If tubal patency evaluation is indicated, either laparoscopy with chromopertubation or hysterosalpingo contrast ultrasonography must be performed. Laparoscopy used to investigate tubal patency must be combined with hysteroscopy.

Women with a septate or subseptate uterus should undergo hysteroscopic septum dissection before fertility treatment is initiated. Bicornuate uterus, duplex uterus, and unicornuate unicollis uteri should not be corrected surgically in women with primary infertility.

Hydrosalpinx must be treated with laparoscopic salpingectomy or laparoscopic proximal tubal occlusion before assisted reproductive treatment (ART) is initiated.

Diagnosis and Treatment of Endometriosis

Infertile women with suspected endometriosis should undergo laparoscopic diagnostic workup with histological confirmation, chromopertubation, and hysteroscopy.

Peritoneal foci of endometriosis should be removed surgically.

Patients with ovarian endometriosis should be counseled regarding the procedural risks (reduced ovarian reserve) and possible benefits of surgery preoperatively.

Deep infiltrating endometriosis may be treated with surgical resection.

Diagnosis and Treatment of Vaginal Infections

Asymptomatic women should not undergo screening for bacterial vaginosis with vaginal smears, nor should patients undergo acute chlamydia infection screening if asymptomatic. However, screening for chronic chlamydia infection may be performed with serology.

Clindamycin or metronidazole is suggested as treatment for bacterial vaginosis.

Infection prophylaxis is unwarranted in asymptomatic women and in the absence of pathogen confirmation.

Diagnosis and Treatment of Endocrine Factors

The basic hormonal diagnostic workup in women with infertility consists of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, testosterone, dehydroepiandrosterone (DHEAS), sex hormone–binding globulin (SHBG), free androgen index, estradiol, and anti-müllerian hormone (AMH) on days 3-7 of the menstrual cycle (or when no follicle has a diameter >10 mm). Vaginal ultrasonography and thyroid evaluation are performed along with the basic diagnostic workup. Any additional testing is based on specific findings.

Progesterone levels may be assessed at approximately 7 days following presumed ovulation to determine ovulatory cycle.

Primary or secondary amenorrhea

A pregnancy test is the first step in evaluating for amenorrhea. After a basic diagnostic endocrine workup is performed, additional examinations are based on symptoms.

Women with a high BMI (>30 kg/m2) should be advised to lose weight.

Hyperprolactinemia

Confirmed hyperprolactinemia in women should be treated with dopamine agonists.

Polycystic ovary syndrome or hyperandrogenemia

If polycystic ovary syndrome (PCOS) is suspected, diagnostic criteria for PCOS must be evaluated clinically. Rotterdam criteria include abnormal periods with oligoovulation or anovulation, laboratory-confirmed or clinical hyperandrogenemia, and characteristic PCO sonomorphology findings.

Drug therapy to induce ovulation should be monitored with ultrasonography, especially in women with PCOS, to reduce the likelihood of multifollicular growth, multiple pregnancy, and overstimulation.

In women with PCOS and oligo-ovulation or anovulation, clomiphene stimulation or letrozole stimulation (off-label) is first-line therapy to induce ovulation.

Adrenogenital syndrome and congenital adrenal hyperplasia

If androgenital syndrome (AGS) is suspected, molecular-genetic testing must be performed. Partners with confirmed AGS must be provided with genetic counselling.

Glucocorticoid treatment should be administered to women with classic AGS. An endocrinologist must be consulted for treatment and monitoring.

Anti-müllerian hormone, age, and oocyte quality

Although the AMH level may be used to estimate ovarian activity and responsiveness to hormone stimulation treatment, it is not used for fertility evaluation.

Anovulatory cycle and luteal phase insufficiency

In women with a regular and unremarkable menstrual cycle duration, endometrial biopsy to evaluate the luteal phase is unwarranted.

Cyclical progestogens should not be given to women with spontaneous menstrual cycles.

Diabetes mellitus

Before conception, hemoglobin A1c (HbA1c) testing must be performed in women with diabetes. A planned pregnancy is appropriate only when blood sugar levels are within the reference range or near the reference range.

Thyroid dysfunction

All women who want children should undergo thyroid-stimulating hormone (TSH) testing. A TSH value exceeding 2.5 mU/L should prompt testing of anti-thyroid antibodies.

At least 100-150 µg iodine supplementation/day should be given to women before conception.

L-thyroxine should be used in women with a TSH level of 2.5 mU/L or more to decrease the TSH level to less than 2.5 mU/L.

Definitive thyroid treatment must be completed in women with hyperthyroidism before ART is initiated and prior to conception.

Treatment of Immunological Factors

Women with antiphospholipid syndrome or systemic lupus erythematosus (SLE) must undergo treatment by an interdisciplinary team prior to conception. Antibody status, disease activity, comorbidities, and an updated treatment approach are components of management.

Rheumatoid arthritis, chronic inflammatory bowel disease (IBD), multiple sclerosis (MS), and other autoimmune or immune disorders must be closely managed by an interdisciplinary team, with treatment initiated before conception.

Vaccination Status

The patient’s vaccination status should be evaluated. Rubella and varicella zoster immunity status must be confirmed and vaccination recommended, if necessary. Tetanus, diphtheria, and pertussis vaccinations should be given to women of childbearing age.

For more information, please go to Infertility and Assisted Reproduction Technology.

For more Clinical Practice Guidelines, please go to Guidelines.

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