Fertility Assessment The Reproductive Medicine Unit UCLH

1. Fertility AssessmentThe Reproductive Medicine UnitUCLH Rehan Salim MD MRCOG Consultant Gynaecologist

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

3. Prevalence • 15% of couples • related to age of female partner • related to history of sexually-transmitted disease

4. Probability of pregnancy • 84% in 1st year • 92% in 2nd year

5. Age, fertility & miscarriage

6. Risk of Down’s syndrome birth by maternal age

7. Assisted conception HFEA 2007

8. Mean age of mother at birth, England and Wales, 1970-2006office of national statistics

9. Age at referral HFEA 2007

11. Infertility general advice • Sexual intercourse every 2-3 days • Stop smoking & reduce caffeine intake • Alcohol • <1-2 units/week for women • <3-4 units/week for men • Folic acid • BMI 19-29

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

13. Underweight • BMI <20 • Anovulatory & Amenorrhoeic • Increased risk of • Miscarriage • Preterm delivery • Growth restricted baby • Fetal programming

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

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

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

17. Fertility tests: semen analysis • use lab of referral unit operator-dependent • WHO criteria: count >20 million/ml motility >50% morphology >50% normal

18. Investigations 1 14 21 28 Day of cycle Ovarian function Ovulation Progesterone

19. Investigations 1 21 28 35 Day of cycle Ovarian function Progesterone

20. Investigations 1 11 18 25 Day of cycle Ovarian function Progesterone

21. 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

22. Ovarian function • FSH and oestradiol early in the cycle • ovarian ultrasound for antral follicle count FSH Oestradiol

23. Antral follicle count

24. AFC and age

25. Fertility tests: ultrasound

26. Ovulation • Mid luteal phase progesterone • 28 day cycle • Day 21

27. Tubal patency

28. Tubal patency

29. Laparoscopy

30. Summary of investigations • Day 1 – 5 • FSH, LH, Oestradiol • Ultrasound • Day 7-10 • HSG • HyCoSy • Day 21 (or 7 days after ovulation) • Progesterone

31. Summary of investigations • Rubella immunity • Hepatitis B,C & HIV • (cervical screening) • Triple swabs • Semen analysis

32. Treatment options • Reassure and wait • Ovulation induction • Anovulation • Superovulation & intrauterine insemination • Mild male factor • Unexplained • Mild endometriosis

33. Treatment options • IVF • tubal damage • severe male factor • severe endometriosis • unexplained infertility – if prolonged or older woman • failure of simple treatment

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

35. Success Rates 2007IUI

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

37. ACU – IVF success rates

38. Fertility AssessmentThe Reproductive Medicine UnitUCLH Rehan Salim MD MRCOG Consultant Gynaecologist