Fertility Assessment

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Fertility Assessment

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  • Fertility AssessmentThe Reproductive Medicine UnitUCLHRehan Salim MD MRCOGConsultant Gynaecologist

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

  • Prevalence15% of couplesrelated to age of female partnerrelated to history of sexually-transmitted disease

  • Probability of pregnancy84% in 1st year92% in 2nd year

  • Age, fertility & miscarriage

  • Risk of Downs syndrome birth by maternal age

  • Assisted conception HFEA 2007

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

    Chart1

    26.7193413009

    26.6189674364

    26.5207226104

    26.4140286877

    26.3624310617

    26.4359317332

    26.5214602062

    26.6343954229

    26.7222948819

    26.8292784763

    26.8859129075

    27.007114933

    27.1047450212

    27.2074643284

    27.2851258588

    27.3272923962

    27.3829714811

    27.4536238124

    27.4534403257

    27.5639235448

    27.6524961692

    27.7150699121

    27.8515978552

    27.9469858293

    28.1162862506

    28.1771274717

    28.1837314163

    28.275166221

    28.342139314

    28.387587467

    28.5036227713

    28.5848327019

    28.7013234098

    28.8342773929

    28.9375117144

    29

    29.1

    p

    Year

    Figure 2

    Figure 2:Standardised mean age of mother at birth, 1970-2006

    YearMean age

    197026.7

    197126.6

    197226.5

    197326.4

    197426.4

    197526.4

    197626.5

    197726.6

    197826.7

    197926.8

    198026.9

    198127.0

    198227.1

    198327.2

    198427.3

    198527.3

    198627.4

    198727.5

    198827.5

    198927.6

    199027.7

    199127.7

    199227.9

    199327.9

    199428.1

    199528.2

    199628.2

    199728.3

    199828.3

    199928.4

    200028.5

    200128.6

    200228.7

    200328.8

    200428.9

    200529.0

    200629.1

    Figure 2

    p

    Year

  • Age at referralHFEA 2007

  • Infertility general adviceSexual intercourse every 2-3 daysStop smoking & reduce caffeine intakeAlcohol
  • ObesityBMI < 30 (ideal 28) kg/m2Reduces fertilityIncreased risk ofAnovulatory cyclesMiscarriageGestational diabetesHypertensionThromboembolismObstetric delivery problems

  • UnderweightBMI
  • Managementtreat couplerefer to specialist clinic systematic investigationappropriate treatmentrecognise emotional impactWelfare of the child

  • When to referone year unprotected intercourseearlier ifwoman over 35oligo- or amenorrhoeasignificant historyeg previous ectopic pregnancy, PID, endometriosis

  • InvestigationsGeneral healthBMIRubella immunityHepatitis B,C & HIV(cervical screening)Triple swabs

  • Fertility tests: semen analysisuse lab of referral unitoperator-dependentWHO criteria: count >20 million/mlmotility >50%morphology >50% normal

  • Investigations 1 14 21 28 Day of cycleOvarian functionOvulationProgesterone

  • Investigations 1 21 28 35 Day of cycleOvarian functionProgesterone

  • Investigations 1 11 18 25 Day of cycleOvarian functionProgesterone

  • Ovarian functionOvarian reserveThe capacity of the ovary to provide eggs that are capable of fertilization resulting in a healthy and successful pregnancyMeasure ofFertilityRisk of miscarriageChances of success with treatment

  • Ovarian functionFSH and oestradiol early in the cycleovarian ultrasound for antral follicle count

    FSHOestradiol

  • Antral follicle count

  • AFC and age

  • Fertility tests: ultrasound

  • OvulationMid luteal phase progesterone28 day cycleDay 21

  • Tubal patency

  • Tubal patency

  • Laparoscopy

  • Summary of investigationsDay 1 5FSH, LH, OestradiolUltrasound Day 7-10HSGHyCoSyDay 21 (or 7 days after ovulation)Progesterone

  • Summary of investigationsRubella immunityHepatitis B,C & HIV(cervical screening)Triple swabs

    Semen analysis

  • Treatment optionsReassure and waitOvulation inductionAnovulationSuperovulation & intrauterine inseminationMild male factorUnexplainedMild endometriosis

  • Treatment optionsIVFtubal damagesevere male factorsevere endometriosisunexplained infertility if prolonged or older womanfailure of simple treatment

  • The Reproductive Medicine UnitOut-Patient ClinicsSuperovulationIntrauterine Insemination (IUI)Ovulation Induction (OI)IVFUltrasonography (USS)Oncology StorageFertility and Psycho-sexual counselling

  • Success Rates 2007IUI

  • RMU - IVFFull range of IVF treatments(IVF, ICSI, Surgical sperm retrieval)Collaboration with The Assisted Conception UnitPCT contractsHaringeyKensington & Chelsea?Barnet

  • ACU IVF success rates

  • Fertility AssessmentThe Reproductive Medicine UnitUCLHRehan Salim MD MRCOGConsultant Gynaecologist