Infertility

1. Infertility New Issues

2. Yunus Tayob Clinical Lead in Reproductive Medicine and Reproductive Endoscopic Surgery

3. Referral Criteria • BMI • Eligibility for NHS treatment • Investigations – primary care

4. BMI • > 18 • < 32-34

5. Ovulation Rates • Reduced in both groups spontaneous and stimulated cycles

6. BMI < 18 • Most likely to have hypothalamic hypogonadotrophic hypogonadism

7. BMI > 35 • Most likely to have PCOS

8. Diagnosis • Rotterdam criteria Acne, hirsutism, obesity Hormonal imbalance Ultrasound appearance of ovaries Requirement 2 of 3

9. Ovarian stimulation • Study of 270 women receiving Clomid or Gonadotrophins • Ovulation rates at 6 months 79% BMI 18 – 24 15.3% BMI 30 – 34 12% BMI > 35

10. IVF / PCOS / Obese • Lower implantation rates • Lower pregnancy rates • Higher dose of drugs required • Higher rate of miscarriage • This extends to donor egg programmes

11. Primary Care • Adopt the role of addressing the issues of BMI prior to referral to Secondary care

12. What lifestyle changes to support your patient • Discuss BMI and move to low GI diet • Caffeine reduction • Advice both parties to stop smoking and reduce alcohol • Start folic acid • AND check they both want the referral!

13. Weight loss • Obesity itself increases insulin levels • Weight loss ↓ insulin concentrations • Weight loss can restore ovulatory function • Long-term effects • Diabetes • Hypertension • Heart disease • Endometrial cancer

14. ELIGIBILITY FOR TREATMENT • Concerns about IVF tourists to the NHS • Non EEC countries • Patients outside the East of England boundaries

15. Eligibility • Living within East of England boundaries for a minimum of 12 months

16. East of England • Very generous in offering 6 cycles of IVF • This has encouraged movement from other parts of the country

17. Eligibility • Who should adopt the policing role • PCT’s opinion is that this should occur in Primary Care setting

18. Investigations

19. Significant proportion of Ix sent with referral letters are; • Inappropriate e.g. LFT, U&E, Lipids • Performed at wrong time of cycle e.g. FSH/LH at mid luteal phase • Progesterone at Day 21 rather than mid-luteal phase • Rubella not tested • Sickle / haemaglobinopathies not screened for

20. IVF where are we ?

21. West Herts fertility Service • Fund 3 IVF/ICSI cycles , 3 embryo transfer cycles • Total of 6 possible cycles including private cycles • 6 month wait from decision to treat for IVF • Age 23-39 at time of treatment • BMI 18 – 30 • Neither partner has been sterilised • No living children in the relationship • Less than 3 NHS IVF cycles • Registered with a west Hertfordshire GP

22. IVF Centres • Hammersmith - within 18 weeks of referral • Barts & London – within 10 weeks • Bourne – within 18 weeks (3 satellite clinic • Oxford – within for 4 weeks (2 satellite clin • Leicester – in the next cycle

23. Egg Donation • If 9 months amenorrhoea, elevated FSH and satisfy all other criteria

24. Sperm Donation • No waiting time • Must satisfy all other criteria

25. Single Sex Couples ?

26. Do we have enough money to continue funding IVF

27. Unlikely • NHS Manchester and Wirral have withdrawn funding for treatment • South of England have withdrawn funding for the current financial year

28. Expediency measures • Miscarriage within waiting time renders you ineligible for IVF treatment • Have to wait a further 3 years of trying to conceive

29. Thank you