Message from the Organizing Committee Chairperson Dr.Deepthi Jammi (Chennai Women’s Clinic and Scan Centre)

On behalf of Chennai Women’s Clinic and Scan Centre, I thank the

panel moderators, expert panellists, sponsors and attendees who

were part of the inaugural DIALOGUE conference on April 22nd 2018.

Your presence and participation made the conference as engaging,

informative and thought-provoking as it was designed to be.

I also convey my deep appreciation to Dr.Nirmala Jayashankar and

Dr.Shanthi Sanjay for doing us the great honour of taking time from

their busy schedules to receive the first copies of the newsletter.

The primary goal of the conference was to bring together experts

across various disciplines to exchange views on the best practices of

today. As intended, what ensued was an open dialogue that delved

into the best possible approaches on the engagement of patients,

management of pregnancies and treatment of anomalous conditions.

Each of the topics chosen for discussion is vast yet the diverse and

dynamic group of moderators and panellists were able to dissect key

slivers of their area of expertise to provide thought provoking

comments and in-depth insight.

We have received very positive feedback on the discussions and

even inquiries on how to best take the said discussions forward in a

digital setting. We will work towards this and I hope that you continue

to be engaged with Chennai Women’s Clinic.

To those invitees who could not be a part of this edition, I eagerly look

forward to welcoming you personally in the next.

Stay tuned for DIALOGUE 2019. We are already working on

enhancements to the conference format and would be thrilled if it

receives the same level of acceptance and accommodation as this

inaugural edition did.

- Dr.Deepthi Jammi

This conference is useful especially because of its

format, having been structured to bring people

together and encourage discussion.

Chennai Women’s Clinic firmly believes that continual inclusive discussions bring fetal medicine

specialists and obstetricians ever closer to offer enhanced services

to the patient.

Dr.Anitha Parthasarathy welcomed the audience before Dr.Deepthi set the ball rolling.

Dr.Nanditha Thakkar deftly moderates the panel on infertility

MALE INFERTILITY

• Indications for Ultrasound scrotum / Transrectal (TRUS)

• Severe Oligoasthenoteratospermia (OATS)

• Azoospermia (to rule out obstruction. Most common cause is Tuberculosis)

• The presence of dilated seminal vesicles with normal FSH and LH levels along with Azoospermia

indicates an obstructive cause

• To rule out infection (Prostatitis / Genito Urinary Tract)

• To rule out varicocoele / undescended testis

• In suspected cases of congenital absence of Vas Deferens (bilateral)

• Morphological abnormalities of the sperm identified in semen analysis are not a routine indication for ultrasound

scrotum

• Surgical indications for varicocoele

• Only for Grade IV

• Abnormal semen analysis (motility / morphology)

• Severe pain during intercourse

• Indications for penile Doppler

• To rule out ejaculatory / erectile dysfunction

KEY TAKEAWAYS - PANEL DISCUSSION ON INFERTILITY

Female Infertility

• Why perform a baseline day 2 scan

• For ovarian reserve – antral follicular count (more than 5 to 9 mm respond better)

• Pelvic anatomy- to rule out follicular cyst

• Serum estradiol levels more than 60pg, then it is advisable to defer ovulation induction for that cycle).

• How to measure a follicle?

• If the follicle is circular - two measurements – inner wall to inner wall

• If the follicle is oval – three measurements – and take the mean value

• Is ovarian volume important for all patients?

• Yes. To rule out PCOS in reproductive age-group women

• In elderly age group patients with borderline AMH and few antral follicle count

• Why is ovarian stromal flow important?

• If the blood flow increases, the yield is better

• RI less than 0.4 and PI less than 0.7, risk of OHSS is high

• How to differentiate bicornuate and septate uterus?

• Fundal indentation is the most important differentiating factor

• What is the most desirable endometrial thickness for conception?

• 8mm to 12mm, triple line pattern has recorded the best pregnancy rate

• When does a hydrosalphinx require surgery?

• When the dilated tube is more than 3 cms

• Presence of endometrial vascularity

• More than Zone 2,3,4 – pregnancy rates more than 80% successful

It is extremely important to study the motility of the sperm -

levels A,B and C defined by the WHO

criteria.

One of the most common cause of dilated epididymis is

Tuberculous obstruction

To rule out vasculogenic Erectile Dysfunction, a penile Doppler is done.

Resistive index and Peak Systolic Velocity are the

important parameters assessed.

Selection of patients for varicocoelectomy is

important. It is indicated In cases of persistent Grade

IV varicocoeles with abnormal parameters in

semen analysis.

AF count -In case of round follicle, 2

measurements [inner to inner wall] are enough

while in an oval follicle, 3 are required

Some key moments during the discussion

With regard to the role of Doppler in endometrial

thickness, as an IVF professional what do you look for in an Ultrasound

report, prior to Embryo transfer ?

Average endometrial line thickness of 8–12 mm and triple line (good morphologic texture) are good

prognostic values if good quality embryos are transferred.

The endometrial blood flow beyond zone 2,3 and 4 is used as a good

predictor for successful implantation rate in IVF/ICSI cycles.

Dr.Uma Ram and the panelists drive home key messages using various case scenarios

1. IUGR – If estimated fetal weight (EFW) / abdominal circumference (AC) less than 3rd centile then the prognosis of the fetus is

worse when compared to fetuses with EFW between 3rd to 10th centile.

2. When to involve the neonatologist?

1. At the earliest, extensive counselling with the entire neonatology team

2. In fetuses with early onset growth restriction the decision of delivery before 32 weeks is based on venous Doppler i.e.

ductus venosus PI more than 95th percentile. This indicates that the fetal hypoxia has progressed to fetal acidemia.

3. In fetuses with late onset IUGR, at term beyond 36-37 weeks with absent end diastolic flow in the umbilical artery is a

better indicator for delivery than expectant management.

KEY TAKEAWAYS - PANEL DISCUSSION ON HIGH RISK OBSTETRICS

Gratacos Staging /

management protocol for

SGA / IUGR fetuses

Placental failure

Early

Nutrition affected

Long latency to demise

Time for SGA to develop

Late

?Respiration affected

Short latency to demise

No time for SGA to develop

Assessment of neurodevelopmental

outcome

Early

Check for hypoglycaemia

Rule out Retinopathy of Prematurity (ROP) at 4

to 6 weeks of birth

Auditory testing at day 7 of life

Late

4 weekly review for developmental

milestones

Review with the occupational

therapist

IUGR Fetuses with EFW or AC less than 3rd centile

have poorer prognosis when compared with fetuses

whose EFW or AC between 3rd-10th %centile

Low risk primi at 20weeks with structurally normal fetus with low profile growth –check for dating scan / parentral BMI/regularity of cycles/hyperemesis in first

trimester/ uterine artery doppler

In fetuses with early onset IUGR, the decision of

delivery before 32 weeks is based upon the venous

doppler [ DV PI> 95th%le]

The involvement of neonatologist team at the earliest is important.

Early neurodevelopmental outcome is assessed by ruling out hypoglycemia / opthal check at 4-6weeks and hearing assessment

at day 7 of life. Late neurodevelopmental outcome

is by 4 weekly check with occupational therapist

Increasing incidence of environmental pollution and

smoking also is a major cause for IUGR

Some key moments during the discussion…

Sections of the audience

Prof.Suresh

Seshadri

Dr.Indrani

Suresh

Dr.Uma

Ram

Prof.Jaya

Vijayaraghavan

Prof.Cynthia

Alexander

NEWSLETTER LAUNCH The inaugural edition of the “DIALOGUE” newsletter was launched and received much positive feedback from the audience. I sincerely

thank the authors for having put pen to paper and drafting such high-quality contributions.

Right from the ideation stage, the newsletter was conceived not just as a communication tool but as a platform for doctors across

multiple disciplines to share their thoughts and opinions on trending topics.

From the conversations I have had with doctors since the conference, I have gained deeper insights into the expectations of the

audience. I look forward to engaging with contributors and the target audience to best orient the content to satisfy those expectations.

As I had said during the conference, this initiative was made possible only by the constructive feedback of and guidance from the

editorial advisory board (below). I once again thank them deeply for their time thus far and going forward in advising me on the

nuances of stitching together various articles into a compelling reading experience.

- Dr.Deepthi Jammi

Editorial Advisory Board

Dr.Suresh, a member of the editorial board, presents a copy of the newsletter to Dr.Nirmala Jayashankar

Dr.Indrani Suresh and Dr.Jaya Vijayaraghavan (Left and Centre), members of the editorial board, present a copy of the newsletter to Dr.Shanthi Sanjay

Some of the members of the editorial board and honourable chief guests share their thoughts on the initiative to publish a periodical newsletter

Dr.Padmapriya Vivek fields questions on the latest development in the practice – uterine transplants

KEY TAKEAWAYS - CONVERSATION ON UTERINE TRANSPLANTS

Uterine Factor Infertility

Non-functioning Uterus

Intrauterine Adhesions

Radiation Damage

Uterine Malformations

Absent Uterus

MRKH Syndrome

Previous Hysterectomy

Obstetric Bleeding

Myoma

Uterine/Cervical Cancer

DONOR RECIPIENT

EX

CL

US

ION

CR

ITE

RIA

• Donor over the age of 60 years

• Subject with pre-existing clinical or medical condition that would

pose the subject at an increased risk

• Subject with an active infection

• Subject who is sero-positive for HIV, HBSAG, HCV

• Subject who has history of cancer in last five years

• Subject unwilling or unable to comply with study requirements

• Sex within the past 6 months with a male who is known to have

any of the risk factor listed in exclusion criteria

• Subject with DM type 1 or type 2 by medical history or elevated hba1c test

• Subject who has known hypersensitivity to tacrolimus, thymoglobulin or cellcept

• Subject with existing hypertension

• Subject who have history of solid organ or bone marrow transplant

• Subject who has history of cancer in last five years

• Subject with bmi>30

• Subject with active infection

• Subject who is sero-positive for HIV, HBSAG, HCV

• Subject not cleared for transplant

• Subject who has alcohol or drug abuse or has smoked within 12 months of

screening.

INC

LU

SIO

N C

RIT

ER

IA

• Women must be between 40-60 years of age

• Women younger than 40 years of age, who have had successful

pregnancies and have undergone permanent sterilization

• Subjects who are HPV negative or received vaccination for HPV

• Subject with h/o HPV in the past must show negative history and

test negative at screening

• A subject who is negative for gonorrhea, chlamydia and syphilis

• A subject with past h/o hsv-2 with no current symptoms

• A subject with normal uterus on sonogram and CT

• A subject who meets psychological donor criteria

• A subject who has had at least one prior full term live birth

• Women diagnosed with absolute uterine factor infertility and intact native ovaries

• Women of child bearing age

• Subjects who are HPV negative or received vaccination for HPV.

• Subject with h/o HPV in the past must show negative history and test negative at

screening

• A subject who is negative for gonorrhea, chlamydia and syphilis

• A subject with past h/o hsv-2 with no current symptoms

• Subject who have received counseling regarding infertility alternative to uterine

transplant such as adoption or surrogate pregnancy

• Subject who are willing to undergo in vitro fertilization and medically cleared for IVF

• Subject who have been evaluated by a fertility specialist and found to have good

ovarian reproductive potential

• Subject must have the ability to fund either through third party coverage or through

their own personal financing

The main contraindication for a donor is more than 2 surgeries (caesarean,

myomectomy) performed.

Apart from ruling out infection in the donor,

what are the other contraindications?

The most common indication is absolute

uterine factor infertility either due to congenital

absence of uterus or presence of a non-functioning uterus.

What are the most common

indications for uterine

transplant?

Some key moments during the discussion…

Dr.Indrani Suresh and Dr.Beena elaborate on the best practices and protocols in genetic testing.

KEY TAKEAWAYS - CONVERSATION ON THE ROLE OF GENETICS

In case of a previous child with

chromosomal abnormality

Do Karyotype (KT)

Numerical abnormality

Recurrence is low Indirect / direct

testing

Structural abnormality

Do parental KT

If parent is a carrier, then

recurrence risk is high

If parent is not a carrier than

recurrence risk is low

In case 22q microdeletion is detected in a fetus with complex

cardiac anomaly

Check parents for specific genetic mutation

If negative, recurrence risk is lower than 1%

If affected, recurrence risk is 50%

Protocols for various scenarios encountered

In case of a previous child with an Autosomal Dominant (AD)

condition

Check parents for specific genetic mutation

If negative, recurrence risk is low (<1%)

If affected, then the recurrence risk is at least 50%

In case of a previouschild with X-linked recessive

condition

Check if the mother is a carrier

Yes

50% males would be affected

50% females would be a carrier

No

Recurrence risk is low

Prenatal testing can be offered to rule out Germline Mosaicism

In case of structural chromosomal abnormality, a

parental karyotype is indicated to look for carrier status, which would determine the recurrence risk in subsequent pregnancies.

Cases diagnosed with Down syndrome need complete evaluation of Karyotype to ascertain whether it is pure Trisomy or translocation type of Down syndrome. In case of

translocation type, parental karyotyping must be offered.

Some key moments during the discussion…

Dr.Suresh raises thought provoking questions on prenatal testing during the panel discussion

KEY TAKEAWAYS – PANEL DISCUSSION ON FETAL MEDICINE

PRENATAL SCREENING

• It was pointed out that while prenatal screening should be offered to all patients, there is no written rule to do so. A

majority of the patients are not offered prenatal screening at all.

• All the panelists agreed that the screening should be offered as a mandatory procedure accompanied by pre- and

post-test counseling.

• Recently there has been considerable thought given to non-invasive testing that provides a higher predictive value vis-

à-vis combined first-trimester screening. This eliminates the risks of miscarriage brought about by invasive testing.

Combined First-Trimester Screening Non-Invasive Prenatal Screening

Methodology

Brings together maternal serum screening

and a measurement of the nuchal

translucency to give a risk score for trisomy

21.

Uses a simple draw of the mother’s blood to

measure the risk.

Detection Rate

Lower compared to NIPT which might prompt

a need for invasive testing.

Very high which is sometimes taken as

confirmatory thereby eliminating the need for

invasive testing.

Chance of miscarriage Higher incase of an invasive procedure done

to rule out a false positive.

Nil as the test is confirmatory.

Specificity for Trisomy 21 ~90% ~99.9%

CONGENITAL HEART DEFECTS

• There was an energetic discussion about cardiac anomalies and the appropriate course of management.

• The Paediatric Cardiologist and the Neonatologist on the panel provided a lot of experts comments.

• Congenital Heart Defects is much more common than chromosomal anomalies and neural tube defects.

• It is key that antenatal detection of CHD is done at the right stage so that,

• Adequate counseling may be provided to the parents

• Screening for other malformations is conducted

• Preparation for post-delivery procedures are done as required

• Routine cardiac evaluation followed by a Fetal Echo (if required) helps reduce the post-delivery mortality rates.

• However, it is important to note that the ideal gestational age for a Fetal Echo is before 20 weeks of gestation.

• If this protocol is adhered to, outcomes relate to cardiac anomalies can be optimized.

What is the goal of prenatal screening?

Should it be offered to all pregnant mothers?

Ideally screening should be offered to all pregnant mothers with pre & post-test

counseling.

The ideal time for a fetal echo is between 18 to 20 weeks of

gestation. Effective communication between the

paediatric cardiologist, obstetrician and fetal medicine

consultant is essential to manage cardiac anomalies.

The goal of any prenatal screening test is to achieve

highest detection rate with the least false

positive rate possible.

The most common cardiac anomalies identified at birth

for a baby with normal prenatal ultrasound are

Ventriculoseptal defects. Rarely TAPVC (Total Anamolous Pulmonary Venous Connection).

Some key moments during the discussion…

Trade Marks

Chennai Women’s Clinic and Scan Centre, DIALOGUE and their respective logos are trademarks of Chennai

Women’s Clinic and Scan Centre used under licence.

Copyright

Materials available in the DIALOGUE 2018 post-event summary is owned by Chennai Women’s Clinic and Scan

Centre. No part of the said materials available may be copied, photocopied, reproduced, translated or reduced

to any electronic medium or machine-readable form, in whole or in part, without the prior written consent of the

author. Any other reproduction in any form without the permission of Chennai Women’s clinic and Scan Centre

is prohibited.

CHENNAI WOMEN’S CLINIC AND SCAN CENTRE

Address: No.13, Soundarajan Street, T Nagar, Chennai-17.

Mobile : +91 733 8771 733

Landline: +44 4359 4620

E-mail: ChennaiWomensClinic@gmail.com

Web: www.ChennaiWomensClinic.com

Appointments based on patients request and convenience. Appointments available on Sundays on prior notification