NaProTechnology® A Family Physician’s Protocol

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NaProTechnologyA Family Physicians Protocol
Toronto July 03

• Dr. Phil Boyle
• MICGP MRCGP CNFPMC

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• Fertility CareTM
• Taking Care of your fertility
• NaProTechnology
• A New Reproductive Science that works by
  co-operating with the natural procreative cycle

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NaProTechnology

• Physiology before Pathology
• A Disease Based approach to infertility
• If not.why not?

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IVF- Diagnosis before Treatment
42 Unexplained
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NaProTechnology

• Consistent with accepted medical principles
• History (standardised medical form)
• Symptoms
• Signs
• Investigations
• Diagnosis
• Targeted Medical / Surgical Treatment

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The FertilityCareTM System(History)

• Unable to conceive
• Previous miscarriage
• Previous Ectopic Pregnancy
• Prematurity
• Low Birth Weight
• Placental Abruption
• Pregnancy induced Hypertension (Not PET)

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The FertilityCareTM System(Symptoms)

• Premenstrual Tension
• lasting for 5 days or more
• relieved with menses
• Record Average
• Symptoms,
• Days,
• Duration,
• Severity out of 10

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The FertilityCare Chart(Clinical Signs)

• Dry Cycles
• Limited Mucus
• Premenstrual Spotting
• Intermenstrual spotting
• Tail-end brown bleeding
• Short luteal phase
• Long luteal phase
• Long cycles

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Targeted Hormone EvaluationInvestigation Level
1.
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Targeted Hormone Evaluation(Investigation Level
1.)

• Peak Plus 7
• Progesterone (18.5 - 31.0 ng/dl) (60 - 100
  nmol/L) Oestradiol (145 300 pg/l) (400
  800 pmol/l)
• Peak Plus 3,5,7,9,11
• Pre Peak P-3, P-1, P1
  Oestradiol only - Over 370 pg/l (1000
  nmol/l)

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Ultrasound Studies (Investigation Level 2.)

• Structural Assessment
• Uterus - Fibroids, Polyps, Retroverted
• Tubes - Hydrosalpinx
• Ovaries - Cysts, Endometrioma

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Ultrasound Studies (Investigation Level 2.)

• Follicular Tracking

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Ultrasound Studies (Investigation Level 2.)

• Follicular Tracking
• Small Follicles
• Incomplete (Partial) Rupture
• Luteinised Unruptured Follicle
• Normal Rupture
• Endometrial Response

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Surgical Evaluation (Investigation Level 3.)

• Lap and Dye
• Hysteroscopy
• Transcervical Catheterisation of Fallopian Tube.
  USA
• Laparotomy and Microsurgery

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Diagnosis

• FUNCTIONAL
• Hormone deficiency - Follicular or Luteal?
• Ovulatory defect - Anovulation, Luteinised
  Unruptured Follicle Syndrome, Partial follicular
  rupture.
• Limited cervical Mucus Flow
• Male Factor
• STRUCTURAL
• Surgical - Endometriosis, PCOD, Fibroids, Polyp,
  Uterine Septum, PID.

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Treatment

• FUNCTIONAL
• Luteal Phase Support - HCG, Progesterone
• Mucus Enhancers - Vitamin B6, Mucolytics,
  Antibiotics
• Stress Management
• Male Treatment
• Ovulation Induction - Clomiphene, HCG, FSH, GnRH
• STRUCTURAL
• Surgical - Endometriosis, Ovarian Diathermy,
  Fibroids, Polyp, Uterine Septum, PID.
• AIM is to restore normal Function over 12
  effective cycles

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NaProTechnology

• Co-operates with the couples natural procreative
  potential to achieve optimum function.
• Creighton Model FertilityCareTM System
• Medical Treatments
• Surgical Treatments
• Counselling - Stress Management
• Spiritual Support - prayer for couples

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The Creighton Model FertilityCareTM System

• The FertilityCareTM system is the cornerstone to
  evaluation and treatment with NaProTechnology
• Everything is built on or around the fertility
  chart

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The Creighton Model FertilityCareTM System

• Charting abnormalities are just the tip of a very
  large patho-physiologic iceberg!

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Charting abnormalities

• Are associated with
• Hypothalamic-pituitary-gonadal Dysfunction
• Poor Follicular Function
• Abnormal levels of Oestradiol 17 Beta,
  Progesterone
• Endometriosis
• Pelvic Adhesions
• Polycystic Ovaries

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Not Suitable

• Established Menopause
• Zero Sperm count / Motility
• Completely Blocked Fallopian Tubes despite
  surgical reconstruction

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Creighton Model NaProTracking

• Important for the initial evaluation
• Timing of Hormone Blood Tests
• To Monitor the response to treatment - cycle by
  cycle
• Mucus
• Hormones
• Timing for Intercourse
• Effects of stress

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Infertility Protocol -Family Physician

• Initial Medical Consultation
• NaProTracking for 2 cycles
• Blood Tests Seminal fluid analysis (using
  seminal fluid collecting device) - 2nd cycle
• Medical Review - 3rd cycle
• Ultrasound Evaluation
• Ultrasound Follicle Tracking
• Diagnostic Laparoscopy and Hysteroscopy - 6th
  cycle
• 12 effective cycles of medical treatment

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45 MINUTES per CONSULTATION
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The Couple manage their own fertility under
supervision by their FertilityCare Physician
and Teacher-Practitioner
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Case Presentations

• 1. Case 1
• 2. Case 2
• 3. Case 3

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Case 1

• Married 8 years, Both Aged 35years.
• 7 Pregnancy Losses 1993- 1999
• 10w, 18w, 31w, 26w, 26w, 17w, 17w
• 2 miscarriages, 3 Stillbirths, 2 miscarriages.
• Nurse
• Attended 3 different Specialists,
• Locally, Dublin, London

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Case 1

• Lupus Anticoagulant,
• anticardiolipin Antibodies,
• b2 glycoprotein 1,
• Rheumatoid factor,
• ANA, CRP, ALL NORMAL
• Chromosomes,
• TORCH
• Hysteroscopy

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Case 1
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Case 1

• Low Progesterone
• Low Oestradiol 17 Beta
• Raised TSH 8.5

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Case 1

• Corrected Hormonal Deficiencies Preconception
  with
• Clomid 50mg od x 3/7
• Eltroxin 50ug daily
• HCG 2000, P3,5,7,9.

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Case 1

• Conceived with optimum hormone levels
• Took Prog 200mg x2 /w, HCG 5000 x2 /w Aspirin,
  Heparin.
• Prog. Support for 30 weeks
• Delivered Healthy Baby Girl, Eilís
• Induced at 39 weeks, Nov 00.
• NVD Weight 7lb 11oz.

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Case 1

• Conceived with same Rx 14 months later
• Delivered live female in March 02
• Elective LSCS at 41 weeks, Weight 9 lbs. 1 oz

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Case 2

• Primary Dx Fibroids
• Myomectomy 1996
• Female infant 1997 NVD
• Unable to conceive since then

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Case 2

• Age 37 yrs. G1 P1
• Secondary Infertility 1999
• LAP Adhesions secondary to myomectomy
• Laparotomy repair
• Rx Clomid x 3/12, FSH x 3/12
• IVF - Oct. 00, and again frozen transfer Feb. 01
  ( 1 IVF 2 Embryo T/F)
• ??Suitable for NaPro

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Case 2

• FertilityCare Chart
• Normal in appearance

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Case 2

• Peak 7
• Peak 3,5,7,9,11

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Case 2
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Case 2

• Ultrasound Follicle Tracking

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Case 2

• Repeat Laparoscopy Apr 02
• Laparotomy and Microsurgery Dec 02
• Mucus enhancers
• Stress management
• FFI
• No Hormonal Treatment

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Case 2

• Conceived May 2003
• Excellent initial hormone levels
• Dramatic drop at 6-7 weeks
• Bleeding in pregnancy
• Miscarried 8 weeks gestation
• Probable Embryo factor

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Case 3

• Feb 99
• 37 yrs. Female, and Male
• G 1 P 3 6 yr. Old Boy
• SA 2 (12 and 13 weeks)

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Case 3
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Case 3 First Attempt

• HCG 2000 P3,5,7,9
• P7 P 66.6 nmol/l (20.7)
• E2 301 pmol/l (82.0)
• ADD Clomid 100mg daily x 5 days

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Case 3 First Attempt

• P7 P 89.8 nmol/l (28.2)
• E2 290 pmol/l (79.0)
• P17 P 61.8 nmol/l (19.4)

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Case 3 Second Attempt

• Clomid 150 mg daily x 5 days
• HCG 2000 P3,5,7,9
• Add prednisolone 5mg daily
• P7 P Usually normal
• E2 Usually low

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Case 3 Ultrasound series
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Case 3 Blood Test Results

• E2 - Pre Peak - 544 pmol/L (148 pg/ml)
• aim gt 1,000 nmol/l ( 370 g/ml)
• P7 - Prog - 99.1 nmol/L (31.1 ng/dl)
• E2 - 341 pmol/L (92.9 pg/ml)
  

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Case 3 Outcome

• Renal Agenesis
• Baby Boy RIP 26 weeks approx.

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Case 3 3rd Attempt

• Puregon (FSH) 100 iu sc daily for 10 days, start
  day 3 of cycle
• HCG 5,000 sc on day 12
• Cyclogest (Progesterone) PV 400mg for 10 nights
• STRESS MANAGEMENT
• 6th cycle ready to try

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Case 3 Blood Test Results

• Ultrasound 2 follicles, one 22 x 20mm
• E2 - Pre Peak - Not available
• P7 - Prog - 122.1 nmol/L (38.3 ng/dl)
• E2 - 899 pmol/L (245 ng/dl)
  

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NaProTechnologyA Family Physicians Protocol
Toronto July 03

• Dr. Phil Boyle
• MICGP MRCGP CNFPMC

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The Irish NaPro Statistics

• Approx. 1200 couples over 4 years
• Average Female age - 36yrs.
• Average time trying to conceive - 5yrs.
• Approx. 25 - history of unsuccessful IVF

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Estimated Success

• Approx. 340 successful Pregnancies
• Approx. 25 - 30 success overall
• Substantially higher with lifetable analysis,
  accounting for dropouts
• still in preparation for publication

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Questions
Toronto July 03

• Dr. Phil Boyle
• MICGP MRCGP CFCMC