Fertility Assessment The Reproductive Medicine Unit UCLH

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Fertility AssessmentThe Reproductive Medicine
UnitUCLH

• Rehan Salim MD MRCOG
• Consultant Gynaecologist

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Infertility definition

• Failure to conceive after regular unprotected
  sexual intercourse for 2 years in the absence of
  known reproductive pathology

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Prevalence

• 15 of couples
• related to age of female partner
• related to history of sexually-transmitted
  disease

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Probability of pregnancy

• 84 in 1st year
• 92 in 2nd year

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Age, fertility miscarriage
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Risk of Downs syndrome birth by maternal age
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Assisted conception
HFEA 2007
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Mean age of mother at birth, England and Wales,
1970-2006office of national statistics
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Age at referral
HFEA 2007
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(No Transcript)
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Infertility general advice

• Sexual intercourse every 2-3 days
• Stop smoking reduce caffeine intake
• Alcohol
• lt1-2 units/week for women
• lt3-4 units/week for men
• Folic acid
• BMI 19-29

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Obesity

• BMI lt 30 (ideal 28) kg/m2
• Reduces fertility
• Increased risk of
• Anovulatory cycles
• Miscarriage
• Gestational diabetes
• Hypertension
• Thromboembolism
• Obstetric delivery problems

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Underweight

• BMI lt20
• Anovulatory Amenorrhoeic
• Increased risk of
• Miscarriage
• Preterm delivery
• Growth restricted baby
• Fetal programming

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Management

• treat couple
• refer to specialist clinic
• systematic investigation
• appropriate treatment
• recognise emotional impact
• Welfare of the child

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When to refer

• one year unprotected intercourse
• earlier if
• woman over 35
• oligo- or amenorrhoea
• significant history
• eg previous ectopic pregnancy, PID, endometriosis

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Investigations

• General health
• BMI
• Rubella immunity
• Hepatitis B,C HIV
• (cervical screening)
• Triple swabs

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Fertility tests semen analysis

• use lab of referral unit
• operator-dependent
• WHO criteria
• count gt20 million/ml
• motility gt50
• morphology gt50 normal

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Investigations
Ovarian function
Ovulation
Progesterone

• 1 14 21
  28
• Day of cycle

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Investigations
Ovarian function
Progesterone

• 1 21 28
  35
• Day of cycle

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Investigations
Ovarian function
Progesterone

• 1 11 18
  25
• Day of cycle

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Ovarian function

• Ovarian reserve
• The capacity of the ovary to provide eggs that
  are capable of fertilization resulting in a
  healthy and successful pregnancy
• Measure of
• Fertility
• Risk of miscarriage
• Chances of success with treatment

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Ovarian function

• FSH and oestradiol early in the cycle
• ovarian ultrasound for antral follicle count

FSH
Oestradiol
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Antral follicle count
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AFC and age
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Fertility tests ultrasound
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Ovulation

• Mid luteal phase progesterone
• 28 day cycle
• Day 21

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Tubal patency
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Tubal patency
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Laparoscopy
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Summary of investigations

• Day 1 5
• FSH, LH, Oestradiol
• Ultrasound
• Day 7-10
• HSG
• HyCoSy
• Day 21 (or 7 days after ovulation)
• Progesterone

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Summary of investigations

• Rubella immunity
• Hepatitis B,C HIV
• (cervical screening)
• Triple swabs
• Semen analysis

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Treatment options

• Reassure and wait
• Ovulation induction
• Anovulation
• Superovulation intrauterine insemination
• Mild male factor
• Unexplained
• Mild endometriosis

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Treatment options

• IVF
• tubal damage
• severe male factor
• severe endometriosis
• unexplained infertility
• if prolonged or older woman
• failure of simple treatment

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The Reproductive Medicine Unit

• Out-Patient Clinics
• Superovulation
• Intrauterine Insemination (IUI)
• Ovulation Induction (OI)
• IVF
• Ultrasonography (USS)
• Oncology Storage
• Fertility and Psycho-sexual counselling

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Success Rates 2007IUI
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RMU - IVF

• Full range of IVF treatments
• (IVF, ICSI, Surgical sperm retrieval)
• Collaboration with The Assisted Conception Unit
• PCT contracts
• Haringey
• Kensington Chelsea
• ?Barnet

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ACU IVF success rates
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Fertility AssessmentThe Reproductive Medicine
UnitUCLH

• Rehan Salim MD MRCOG
• Consultant Gynaecologist