Fertility Flash - Issue 1

Highlights

Issue

F e Flash Successful IVF in a DiďŹƒcult Case of Uterine Didelphys Intrauterine Perfusion of Human Chorionic Gonadotropin Signi cantly Improves Pregnancy Rates Beta Subunit of Human Chorionic Gonadotropin Assay: Useful Diagnostic Tool for Prelabor Rupture of Membranes Assessment and Treatment of Fertility Problems: NICE Guidelines Association between Sperm DNA Methylation Patterns and Abnormal Semen Parameters among Infertile Couples Medico-Legal Case- Mrs. X vs. Infertility Centre

CASE STUDY Successful IVF in a Difficult Case of Uterine Didelphys

EVIDENCE UPDATE Intrauterine Perfusion of Human Chorionic Gonadotropin Significantly Improves Pregnancy Rates

CONTENTS

PREFACE

The field of infertility has undergone a complete revolution in the last few decades, both in terms of diagnostic capabilities to assess the infertile couple as well as unbelievable advances in overcoming the multitude of reasons why the process of conception fails to take place.

Ironically despite of expedited investigations for better diagnosis of these diseases and accelerated drug discovery, the world is still massively facing the outcomes of infertility.

Fertility Flash is an academic initiative from Corona Remedies to link medical fraternity with latest updated information in infertility. This will be a bi-Monthly series. Through this scientific information service to the Infertility specialists, we wish to contribute our part in fulfilling the dream of motherhood.

IMAGE OF THE MONTH DIAGNOSTIC UPDATE Beta Subunit of Human Chorionic Gonadotropin Assay: Useful Diagnostic Tool for Prelabor Rupture of Membranes

TREATMENT ALGORITHM Assessment and Treatment of Fertility Problems: NICE Guidelines

1 3 4 5 7

CONFERENCE UPDATE Association between Sperm DNA Methylation Patterns and Abnormal Semen Parameters among Infertile Couples Administration of GnRHa with Modified Luteal Support Improves Embryo Quality and Clinical Pregnancy Rates

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Co-administration of GnRH Agonist and hCG in IVF cycles Improves the Number of Oocytes and Oocyte Quality

MEDICO-LEGAL CASE Mrs. X vs. Infertility Centre on 26 September, 2011

CONFERENCE CALENDER

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April–October 2018

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QUIZ

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F e Flash CASE STUDY Successful IVF in a Difficult Case of Uterine Didelphys Contributed by:

Dr. Jatin P Shah MD, DGO (Gold Medallist), KEM Hospital, Mumbai University Currently Director of Mumbai Fertility Clinic & IVF Centre Founder Member of ASia Pacific Initiatives for Reproductive Endocrinology (ASPIRE) Performs close to 2500 IVF procedures per year and has more than 15000 IVF & ICSI live births to his credit Established some of the best IVF centres in Northern, Western and Southern India Numerous publications, contributions to leading infertility text books, presentations (National and International) www.drjatinshah.com

Case Presentation

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Mrs M, a 28-year-old nulligravida, presented with primary infertility of 5-year duration.

Her menstrual cycles were regular.

Hysterosalpingogram (HSG) revealed uterus didelphys with a well-developed right side horn (left horn being difficult to negotiate at the time of HSG).

Medical History

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She had previous history of vaginoplasty.

A diagnostic laparoscopy and hysteroscopy had confirmed these findings.

She also had a history of three failed intrauterine insemination (IUI) cycles and one failed in vitro fertilization (IVF) cycle with two frozen-thaw embryo transfers (all having been done in the right uterine horn).

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Her husband’s sperm parameters were within normal range.

Investigation

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On transvaginal ultrasound, both horns were found to be equally developed and well formed.

Her anti-mullerian hormone test (AMH) level was 2.1 ng/ml.

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IVF Procedure

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Controlled ovarian stimulation with IVF was carried out using a long down-regulation agonist protocol with highly purified-human menopausal gonadotropin (HP-hMG) 300 IU per day.

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On the day of egg retrieval, 15 oocytes were obtained and fertilized using routine IVF. On day 2, there were 10 embryos at the 4-cell stage of grade I quality, which were frozen by standard vitrification.

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The patient was then prepped with down regulation and exogenous estradiol valerate 8mg per day for the first 10 days and then increased to 12 mg per day for another 7 days.

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Intrauterine granulocyte - colony stimulating factor (G-CSF) was instilled into both uterine horns on day 21 in view of the previous two failed attempts.

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Optimal endometrial thickness was obtained in both uterine horns (7.6 mm in the right horn and 8.2 mm in the left horn).

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Injectable progesterone was administered on day 25 and two 8-cell embryos (thawed) were transferred into the right horn and one into the left horn under ultrasound guidance on day 29.

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Serum Beta human chorionic gonadotropin (hCG) was positive on day 14 after embryo transfer.

Subsequent ultrasound showed a twin pregnancy (singleton in each horn).

The pregnancy in the right horn miscarried at 7 weeks. nd

The pregnancy in the left horn is currently ongoing in the 32 week.

Discussion Uterus didelphys can be a challenging condition for IVF success. This is a classic case of an individualised approach using a combination of iCOS (Individualised controlled ovarian stimulation) and iFET (Individualised frozen embryo transfer). The agonist down regulation protocol was preferred in view of the previous two failures with the antagonist protocol. rFSH were replaced with HP-hMG for its hCG induced LH activity. Segmented IVF with iFET was preferred to gain time to build up the endometrium to its optimal capacity. High doses of estradiol valerate, vaginal sildenafil and intrauterine G-CSF were supplemented for optimising the endometrial receptivity.

An embryo was also transferred into the left horn in view of the previous two failed attempts in the right horn.

Conclusion Individualised controlled ovarian stimulation and individualised frozen embryo transfer are the need of the hour to tackle difficult IVF patients.

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F e Flash EVIDENCE UPDATE Intrauterine Perfusion of Human Chorionic Gonadotropin Significantly Improves Pregnancy Rates Objective A retrospective analysis was conducted to assess the effectiveness of the intrauterine perfusion of hCG before a frozen-thawed embryo transfer (FET) in women with different implantation failure numbers. A total of 225 patients undergoing FET who received an intrauterine injection hCG 1000 IU before embryo transfer were enrolled in the analysis. The groups included women with their first implantation failure (A group, n=26), second implantation failure (B group, n=122), and three or more failures (C group, n=77) and were compared with control groups (no infusion).

The pregnancy rates were compared among these groups.

Results Results from the study reported that the biochemical pregnancy rates and the clinical pregnancy rates after intrauterine injection hCG has been depicted in the Figure 1.

The biochemical pregnancy rates and the clinical pregnancy rates were significantly higher in the first failure group than in the other groups (P<0.05). The clinical pregnancy rates of the A and C groups were significantly higher (see Fig. 2) when compared to the corresponding (no infusion) control groups (P<0.05).

48.05

20

33.33

40

50.0

60

76.92

80

54.92

Clinical pregnancy rate Control group clinical pregnancy rate

100

Pregnancy rate (%)

48.05

20

49.02

40

54.92

76.92

60

92.3

Pregnancy rate (%)

80

63.11

Biochemical pregnancy rate Clinical pregnancy rate

100

Figure 2: Comparison of clinical pregnancy with corresponding control groups (no infusion).

56.81

Figure 1: Comparison of the pregnancy outcomes among the three groups.

0

0 First implantation failure

Second implantation failure

Three or more implantation failure

First implantation failure

Second implantation failure

Three or more implantation failure

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Conclusion Researchers of the study concluded that pregnancy rates decreased with the number of transplant failures. The pregnancy rates, especially after one and three or more implantation failures significantly improved with intrauterine administration of hCG before FET.

Source: Huang P, Wei L, Li X, et al. Effects of intrauterine perfusion of human chorionic gonadotropin in women with different implantation failure numbers. Am J Reprod Immunol. 2018;79(2). doi: 10.1111/aji.12809.

The intra uterine p erfusion of hCG ca n improv e the rate of pr egnancy in those pat ients with repeated implanta tion failures ( failure af ter three tim es).

Image of the month

The image depicts the ovaries in 24-year-old nulligravida, showing numerous peripheral antral follicles surrounding a rather hyperechoic central ovarian stroma. In both ovaries, numerous peripheral antral follicles were visualized surrounding a rather hyperechoic central ovarian stroma.

Source: W Froyman, D Van Schoubroeck and D Timmerman. Ultrasound Obstet Gynecol. 2018;51:147–149.

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F e Flash DIAGNOSTIC UPDATE Beta Subunit of Human Chorionic Gonadotropin Assay: Useful Diagnostic Tool for Prelabor Rupture of Membranes (PROM) Objective A study was conducted to assess the accuracy of the b-hCG test in vaginal washing fluid for diagnosis of prelabor rupture of membranes (PROM) in 100 pregnant women with unequivocal PROM. The pregnant women enrolled in the study from 17 to 38 weeks of gestation and were divided into two groups. The first group (PROM group) included 50 pregnant women with unequivocal PROM while the other group included 50 pregnant women with intact membranes.

In both groups, a sterile speculum examination was performed. If less than 5 cc was collected or no fluid found, 10 cc sterile saline was sprinkled on the vaginal wall and was 5 cc were recollected by aspiration in a sterile syringe. For qualitative testing of b-hCG, 2 drops of collected fluid were used. The remaining fluid was used for quantitative assessment of b-hCG.

Results Results from the study reported that the quantitative b-hCG test results were significantly higher in PROM group (median and range: 138.5 (23–475) versus 13 (1–55); the difference in medians and 95% CI: 105 (91–166); p value: <0.001) (see Table 1).

Table 1: Value of beta subunit of human chorionic gonadotropin (BhCG) in the two study groups.

ROM group (50 patients) Quantitative b-hCG test

138.5 (23–475)

Intact membranes group (50 patients) a

Difference between groups (95% CI)

p value

125 (91–166)

<0.001

a

13 (1–55)

Qualitative b-hCG test

0.84 (0.74-0.94)

Positive

42 (84%)b

0 (0%)b

Negative

8 (16%)

50 (100%)

c

<0.001

ROM=Rupture of membranes; CI=Confidence interval; b-hCG=beta subunit of human chorionic gonadotropin. a=Median (range); b=Count (percentage); c=Difference in proportion of women with positive test in the two groups.

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Table 2: Accuracy measures for quantitative and qualitative b-hCG for diagnosis of rupture of membranes (setting the unequivocal clinical diagnosis as the reference standard). a

AUC

p value

Cut-off value

Sensitivity

Specificity

PPV

NPV

Quantitative b-hCG test

0.967 (0.910–0.992)

<0.001

>32

94% 94% 94% 94% (83.5–98.7%) (83.5–98.7%) (83.5–98.7%) (83.5–98.7%)

Qualitative b-hCG test

0.920 (0.848–0.965)

<0.001

NA

84% 100% 100% 86.2% (70.9–92.8%) (92.9–100%) (91.6–100%) (74.6–93.9%)

Values are presented with their 95% CI. b-hCG=Beta subunit of human chorionic gonadotropin; ROC=Receiver operator characteristics; PPV=Positive predictive value; NPV=Negative predictive value; NA=Not applicable. a=p value for area under ROC curve. Difference between the areas under curve of the two index tests (95% CI), 0.0466 (-0.00247 to 0.0957), p value: 0.06.

In the PROM group, 84% of patients were positive when compared to 100% negative in the intact membranes group on performing qualitative b-hCG

Figure 1: ROC curves for the qualitative and quantitative b-hCG tests for diagnosis of PROM.

test. For both the quantitative and qualitative b-hCG

Conclusion Researchers of the study opined that b-hCG test (either

0.8

Sensitivity

tests, areas under receiver operating characteristics (AUC) were high (0.97, 95% CI: 0.91–0.99, p value: <0.001 and 0.92, 95% CI: 0.84–0.96, p value: <0.001, respectively) (see Table 2 and Fig. 1). The suggested cut-off of b-hCG for the quantitative test was 32 mIU/ml. The sensitivity of quantitative and qualitative tests are: 94, 95% CI: 83.5–98.7% and 84, 95% CI: 70.9–92.8%, respectively. The specificity of quantitative and qualitative tests are: 94, 95% CI: 83.5–98.7% and 100, 95% CI: 92.9–100%, respectively.

ROC curve 1.0

0.6

0.4 Source of the curve Quantitative BhCG 0.2

Qualitative BhCG Reference line

0.0 0.0

0.2

0.4

0.6

0.8

1.0

1-Specificity

quantitative or qualitative) in vaginal washing fluid can be used in the diagnosis of PROM in both preterm and term cases. Our suggested protocol can be used easily and safely to diagnose PROM with reduced cost.

Source: Eldaly A, Omran E, Youssef MA, et al. Use of beta subunit of human chorionic gonadotropin assay as a diagnostic tool for prelabor rupture of membranes. J Matern Fetal Neonatal Med. 2018 Jan 10:1-6. doi: 10.1080/14767058.2017.1422712.

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F e Flash TREATMENT ALGORITHM Assessment and Treatment of Fertility Problems: NICE Guidelines 2017 The NICE fertility guidelines deal with the diagnosis and treatment of infertility and subfertility, with the aim of incorporating advances in knowledge in this area, as well as the increased awareness of risks that are faced with this treatment. This will help to minimize practice-specific differences in investigation and management of this problem, and so improve overall excellence in fertility care.

Areas Covered The following are some of the areas included in the latest NICE fertility guidelines: Definition of infertility Recommended advice on delayed conception Principles to be followed in providing health care for infertile couples or patients: evidence-based, accessible, and informed care Diagnosis and treatment of infertility, including initial evaluation and guidelines for referral Information to be effectively transmitted to patients with treatable lifestyle factors contributing to infertility Medical and surgical management of common causes of infertility, such as male factor infertility, anovulation, or unexplained infertility, as well as cryopreservation of oocytes and sperm from patients who are about to undergo cancer therapy which may impair fertility Criteria and recommended procedures for frequently used techniques of assisted reproduction, such as intrauterine insemination and in vitro fertilization, including the use of donor sperm or oocytes, and intracytoplasmic sperm injection The safety of ART in the long term on the basis of available data

These statements seek to answer some frequently asked questions such as: The reliability of various tests used in infertility, such as tests of ovarian reserve which may dictate the decision to use donor oocytes What determines the number of embryos transferred or the timing of transfer in various patients?

How effective and safe are various ovarian hyperstimulation regimens when used in women with apparently normal ovarian function or with different grades of ovulation disorders?

The side effects of various medications used in infertility treatment, both on the women and the fetuses, over the short and long term?

The expected outcomes of various ART techniques

One notable outcome of the NICE guidelines is the reduction of multiple embryo transfers to single transfers, which now make up almost 17 percent (2011) up from 5 percent (2008).

This is largely the result of disseminating data about the advantages of transferring single embryos in all patients who would not experience the benefits of multiple embryo transfer. This includes a fall in the number of multiple pregnancies, without a corresponding decline in the pregnancy rate. Multiple gestation is the largest single source of risk for both mothers and fetuses following in vitro fertilization.

Source: Fertility problems: Assessment and treatment. Nice Guideline 2017. Accessed from https://www.nice.org.uk/guidance/cg156/resources/ fertility-problems-assessment-and-treatment-35109634660549 Accessed on: 4th Feb 2018.

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F e Flash CONFERENCE UPDATE Association between Sperm DNA Methylation Patterns and Abnormal Semen Parameters among Infertile Couples Objective A prospective, controlled, multi-institutional clinical trial of infertile couples was conducted to explain the new relations between routine semen parameters and sperm DNA methylation disruptions among infertile men, and seek to identify individual genes related to them.

Study Design Semen samples from 210 patients were used at more than 480,000 CpG sites in the sperm to assess DNA methylation levels using array technology. Samples were collected from couples with no identified female-factor infertility issues, and those with a minimum sperm concentration >2 millions/mL. The potential batch effects were used to normalize the data.

F-test was performed for each locus to measure the association between semen parameters and methylation to assess differentially methylated positions (DMPs) with a p-value cut-off of 0.05 for statistical significance. Results from the study reported that DMPs were observed in 7962 positions when compared sperm methylation patterns in men with high and low progressively motile sperms. Of 258 genes, at least 2 loci were significantly differentially methylated; 7 genes had more than 6 significant loci, including the ANKRD11 gene, known to be associated with male infertility, with 10 DMPs. A total of 4164 DMPs were observed in men with oligospermia (<15 millions/mL) vs. high sperm counts (>100 millions/mL). Of 112 genes, differential methylation was detected in 3 or more positions, and 10 genes showed 7 or more DMPs. Of about more than 20,000 DMPs, were observed in 45 men with 0% vs. >2% normal strict morphology. At least 4 significant DMPs were found in 548 genes and 13 genes had 8 or more DMPs, among which was the gene SLC9A3 with 9 DMPs. A significant association was found between loss of expression of SLC9A3 and abnormal sperm morphology.

Conclusion Researchers of the study opined significant relationships between sperm DNA methylation patterns and abnormal semen parameters among infertile couples. Many of the genes implicated by these data have known roles in male infertility in both humans and mice. Besides, its ability to associate with natural conception rates and IVF embryo quality, it was expected that sperm epigenetic profiles will be found to correlate closely to abnormal routine semen parameters.

Source: Abbasi M, Williamson L, Turek PJ, et al. Semen parameters are associated with alterations in the sperm epigenome of infertile men. Accessed from American Society for Reproductive Medicine-October 28-November 1, 2017, Abstract No: O-38.

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Administration of GnRHa with ModiďŹ ed Luteal Support Improves Embryo Quality and Clinical Pregnancy Rates Introduction Triggering of ďŹ nal oocyte maturation with GnRHa prevents ovarian hyperstimulation syndrome (OHSS), but it is associated with a poor clinical outcome and high rate of early pregnancy loss. A prospective randomized study was conducted with a rational approach to increase pregnancy rate and avoid OHSS in high OHSS risk patients. A total of 258 high responder patients with tubal infertility were enrolled in the study.

Concentrations of estradiol (E2, pmol/l ) and progesterone (P, nmol/l) in serum were evaluated with immunochemiluminometric assay.

Study Design Patients were randomized to three groups with patients in one group (n=91) receiving aGnRH trigger (triptorelin 0.2 mg) plus 1500 IU hCG support on the day of oocyte retrival (OR), second group (n=82) included women who received the dual trigger (triptorelin 0.2 mg+ 1500 UI hCG) and the third group (n=85) included patients who received the hCG trigger (10000 UI). Also all patients received micronized progesterone 600 mg/day and estradiol valerate 6 mg/day from next day after OR. On the day of the triggering ovulation and embryo transfer days (ET), plasma samples were obtained. Statistical analysis -ANOVA was applied with further t-test.

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Results Results from the study reported that clinical pregnancy rates per cycle is depicted in Figure 1. There was a tendency to increase the rate of early reproductive loss in group 2 (1 group-10.5% (4/38), 2 group-20.7% (6/29), 3 group-11.4% (4/35), p>0.05). Other results from the study are shown in Table 1.

Figure 1: Clinical pregnancy rate per cycle in three groups.

Clinical pregnancy rates (%)

-38

Group 1

Group 2

2 group (n=82)

3 group (n=85)

5.7±3.5

5.1±3.2

5.5±2.7

Peak E2

11085.1± 5127.2

10523.0± 5731.7

9855.9± 3144.4

E2, ET

7609.2± 4728.7

*4207.9± 3001.0

**6768.5± 2605.2

P, ET

290.5± 257.5

*151.3± 163.3

**338.2± 103.9

Retrieved oocytes

15.5±5.2

13.9±4.8

15.1±5.3

Blastocysts

5.9±3.4

*4.8±3.7

*4.8±3.1

7.7

11.0

***20.0

AMH -40.8

-40 -41 -42 -43

-44.3

-44

-46

1 group (n=91)

Group 3

-39

-45

Table 1: Value of beta subunit of human chorionic gonadotropin (BhCG) in the two study groups.

-45.2

OHSS, %

*p>0.05—differences are significant with 1 group, **p>0.05—differences are significant with 2 group; All other comparisons are not significantly different.

Conclusion Researchers of the study concluded that the embryo quality was better with improved clinical pregnancy rates with administration of GnRHa when combined with modified luteal support (1500 UI hCG support on OR, micronized progesterone 600 mg/day, estradiol valerate 6 mg/day). GnRHa triggering reduces OHSS in fresh transfer in vitro fertilization cycles, but doesn’t completely eliminate the risk of OHSS. Source: Martazanova B, Mishieva N, Komeeva I, et al. Triggering Ovulation With Gonadotropin-Releasing Hormone Agonist (Gnrha) and Modified Luteal Support: Hormonal Characteristics, Embryological And Clinical Outcome. Accessed from American Society for Reproductive Medicine- October 28-November 1, 2017, Abstract No: O-132.

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Co-administration of GnRH Agonist and hCG in IVF cycles Improves the Number of Oocytes and Oocyte Quality Objective A single center, prospective, randomized controlled, double blinded clinical trial was conducted to assess whether co-administration of GnRH agonist and hCG in IVF cycles would improve the number of oocytes and oocyte quality compared to hCG alone. A total of 108 patients were enrolled in the study and were randomized to two groups (54 in each group) to receive hCG or dual trigger for final oocyte maturation.

Data on patient’s age, BMI, AMH, number of follicles >10 mm and >15 mm on day of hCG administration, number of oocytes retrieved, MII, zygotes and blastocysts were assessed and compared between the dual trigger group 2 2 and the hCG group. The age (35.9 vs. 35.7), BMI (23.7 kg/m vs. 24 kg/m ), AMH (20.7 pmol/l vs. 19.5 pmol/l) and FSH (6.5 vs. 5.8) were comparable between the two groups.

Results Results from the study reported that the total amount of gonadotropins, the length of the stimulation and the number of follicles >10 mm and >15 mm in diameter on day of hCG administration were also similar in the two groups.

Figure 1: Clinical outcome in dual trigger group compared to the hCG group.

0

Clinical outcome (%) 5 15 10

Oocyte recovery rate (%) 0

12.9

Eggs retrieved

Number of MII

Figure 2: The oocyte recovery rate was significantly higher in the dual trigger group compared to the hCG group.

10.6 10.1

Dual trigger group

20 40 60 80 100 120

97

8.6

Dual Compared to the hCG group, the trigger hCG number of eggs retrieved, the number 7.9 group Number 78 group of zygotes of MII and the number of zygotes 6.3 hCG group were significantly higher in the dual trigger group (see Fig. 1). The oocyte recovery rate (oocytes/follicles R 11 mm) was significantly higher in the dual trigger group compared to the hCG group (see Fig. 2). The number of blastocysts (3.7 vs. 3.1), clinical pregnancy rate and the ongoing pregnancy rate were similar in both groups.

Conclusion Researchers of the study concluded that the dual trigger increases the number of oocyte, mature oocytes and the number of zygotes compared to triggering with hCG alone in normal responder patients. The increase in the number of mature oocytes may potentially improve the outcome of the IVF cycle.

Source: Haas J, Bassil R, Cadesky K, et al. Dual Trigger s. HCG for Final Oocyte Maturation. A prospective randomized controlled, double blinded study: Preliminary results. Accessed from American Society for Reproductive Medicine—October 28–November 1, 2017, Abstract No: O-322.

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F e Flash MEDICO-LEGAL CASE Mrs. X vs. Infertility Centre on 26 September, 2011 State Consumer Disputes Redressal Commission, Punjab, Dakshin Marg, Sector 37-A, Chandigarh. First Appeal No.817 of 2006.

Case Background

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Mrs. X was married with Mr. Y about 15 years ago but she was unable to conceive a child. Mrs. X was disappointed. She was consulting various doctors and specialists to ďŹ nd out the means for bearing the child but she could not succeed.

Mrs. X came across the advertisement got published by Infertility Centre several times that they could treat a woman suďŹ&#x20AC;ering from infertility. Mrs. X felt allured by this advertisement and accompanied by her husband, she travelled from Udaipur to Ludhiana on 23.10.2000 to the hospital of Infertility Centre.

Infertility Centre minutely examined the history of Mrs. X. The medical tests and scanning tests etc. of Mrs. X and of her husband were conducted

by Infertility Centre after charging a huge amount from them. She was told that she would be treated to her satisfaction and she will be helped to conceive. She was also told that her tumour would be removed and blockade would also be cleared with the help of medicines only and without conducting any operation.

The whole treatment would be painless.

Mrs. X was referred to Neuro Centre Pvt. Ltd., Ludhiana for MRI test.

Mrs. X companied by her husband went to Neuro Centre and got conducted the ultrasound of the whole abdomen and colour doppler of the pelvis on 13.11.2000. Separate MRI of the Sella and Pelvis were also got conducted on payment basis.

Thereafter she had again come to Infertility Centre for consultation.

Infertility Centre had charged a sum of Rs.500/- on 23.2.2001 as consultation fee. Certain medicines were given to Mrs. X and she was again asked to consult Infertility Centre after one month. Mrs. X started the medical treatment accordingly.

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F e Flash

!

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Infertility Centre had told Mrs. X that they would charge an amount of Rs.1,50,000/- only in cash and not by way of draft or cheque as medical fee for treating Mrs. X and for removal of blockade and tumour. Mrs. X and her husband made several visits to the hospital of Infertility Centre and they have paid in all a sum of Rs.3,00,000/- to Infertility Centre. The receipt was given by Infertility Centre on their letter head for this amount but later on they had over written the words 'private room please'. Mrs. X was referred to doctor directing him to charge Rs.10,000/- from her as the room charges and medicines/drugs.

It was further pleaded that neither the tumour was removed from the body of Mrs. X nor it was dissolved by Infertility Centre. Infertility Centre have charged a huge amount from Mrs. X running into lakhs of rupees and the promises made by Infertility Centre proved to be false. Mrs. X was willing to submit for medical examination to prove that she could not get any relief by the medical treatment given by Infertility Centre. Infertility Centre were liable to refund the amount of Rs.3,25,000/-. Hence the complaint for compensation amount of Rs.7,00,000/- along with the refund of Rs.3,25,000/-. Costs were also prayed.

A person who holds himself out as ready to give medical advice or treatment impliedly undertakes that he is possessed of skill and knowledge for the purpose. Such a person, whether he is a registered medical practitioner or not, who is consulted by a patient, owes him certain duties, namely, a duty of care in deciding whether to undertake the case; a duty of care in deciding what treatment to give; and a duty of care in his administration of that treatment.

A breach of any of these duties will support an action for negligence by the patient.

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!

Judgement

Since Infertility Centre had charged a sum of Rs.500/- initially from Mrs. X, therefore, Mrs. X is proved to be a consumer of Infertility Centre.

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Infertility Centre had given false advertisements assuring them of all medical reliefs while no relief could be given to Mrs. X and she was made to spend a huge amount for coming from Udaipur in Rajasthan frequently to Ludhiana and getting conducted numerous medical tests and treatment by spending a huge amount. It was only the false advertisement issued by Infertility Centre which persuaded Mrs. X to come from Udaipur to Ludhiana. She had come for the first time on 23.10.2000 and she filed the complaint on 28.4.2003. Till then she had achieved no result. Infertility Centre, therefore, have clearly committed deficiency in service and unfair trade practice by giving the false advertisements.

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Infertility Centre are directed to pay this amount of Rs.50,000/- to Mrs. X within a period of two months after the receipt of a copy of the order failing which Infertility Centre would be liable to pay interest on this amount at the rate of 9% per annum from today till the date of payment.

Upcoming Book Details Treatment Strategy for Unexplained Infertility and Recurrent Miscarriage

Recurrent Pregnancy Loss

Editors: Kuroda K, Brosens JJ, Quenby S, Takeda S. (Eds.)

Editors: Sumita Mehta, Bindiya Gupta (Eds.)

Comprehensive guide to treatment strategies for unexplained infertility and recurrent miscarriage. Offers recommendations on further examinations and more aggressive fertility treatments. Written by respected experts on implantation, fertilization and pregnancy loss.

The book covers all aspects of RPL in detail. Chapters cover the latest evidence based approach in diagnosis and management of RPL. Easy to follow algorithms and key points in each chapter. Chapters will be supplemented with ample illustrations and figures. Special section covers the controversies in RPL. Clinical approach to RPL will be discussed with case scenarios. A separate section titled beyond convention covers special aspects related to RPL.

14

F e Flash CONFERENCE CALENDER th

Indian Society for Assisted Reproduction (ISAR) 2018

14 Asia Pacific Congress in Maternal Fetal Medicine 2018

Date: April 19–22, 2018 Venue: Kolkata, India

Date: May 18–20, 2018 Venue: Hong Kong, Hong Kong SAR, China

Begin Before Birth 2018

17 World Congress in Fetal Medicine 2018

Date: June 14 2018 Venue: London, United Kingdom

Date: June 24–28, 2018 Venue: Athens, Greece

European Society of Human Reproduction and Embryology (ESHRE) th 34 Annual Meeting 2018

American Society for Reproductive Medicine (ASRM) th 74 Annual Meeting 2018

Date: July 1–4, 2018 Venue: Barcelona, Spain

Date: October 6–10, 2018 Venue: Denver, Co, USA

th

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*For the use of a registered medical practitioner only