infertility new issues. yunus tayob clinical lead in reproductive medicine and reproductive...
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InfertilityInfertilityNew IssuesNew Issues
Yunus TayobYunus Tayob
Clinical Lead in Reproductive Clinical Lead in Reproductive
Medicine and Reproductive Medicine and Reproductive
Endoscopic SurgeryEndoscopic Surgery
Referral CriteriaReferral Criteria
BMI BMI
Eligibility for NHS treatmentEligibility for NHS treatment
Investigations – primary careInvestigations – primary care
BMIBMI
> 18> 18
< 32-34< 32-34
Ovulation RatesOvulation Rates
Reduced in both groups Reduced in both groups spontaneous and stimulated cyclesspontaneous and stimulated cycles
BMI < 18BMI < 18
Most likely to have hypothalamic Most likely to have hypothalamic hypogonadotrophic hypogonadismhypogonadotrophic hypogonadism
BMI > 35BMI > 35
Most likely to have PCOSMost likely to have PCOS
DiagnosisDiagnosis
Rotterdam criteria Rotterdam criteria
Acne, hirsutism, obesityAcne, hirsutism, obesity
Hormonal imbalanceHormonal imbalance
Ultrasound appearance of Ultrasound appearance of ovaries ovaries
Requirement 2 of 3 Requirement 2 of 3
Ovarian stimulationOvarian stimulation
Study of 270 women receiving Clomid or Study of 270 women receiving Clomid or GonadotrophinsGonadotrophins
Ovulation rates at 6 monthsOvulation rates at 6 months
79% BMI 18 – 2479% BMI 18 – 24
15.3% BMI 30 – 3415.3% BMI 30 – 34
12% BMI > 3512% BMI > 35
IVF / PCOS / ObeseIVF / PCOS / Obese
Lower implantation ratesLower implantation rates
Lower pregnancy ratesLower pregnancy rates
Higher dose of drugs requiredHigher dose of drugs required
Higher rate of miscarriageHigher rate of miscarriage
This extends to donor egg This extends to donor egg programmesprogrammes
Primary CarePrimary Care
Adopt the role of addressing the issues of Adopt the role of addressing the issues of BMI prior to referral to Secondary careBMI prior to referral to Secondary care
What lifestyle changes to support What lifestyle changes to support your patientyour patient
Discuss BMI and move to low GI dietDiscuss BMI and move to low GI diet
Caffeine reductionCaffeine reduction
Advice both parties to stop smoking and Advice both parties to stop smoking and reduce alcohol reduce alcohol
Start folic acidStart folic acid
AND check they both want the referral!AND check they both want the referral!
Weight lossWeight loss
Obesity itself increases insulin levels Obesity itself increases insulin levels
Weight loss Weight loss ↓↓ insulin concentrations insulin concentrations
Weight loss can restore ovulatory functionWeight loss can restore ovulatory function
Long-term effects Long-term effects DiabetesDiabetes
HypertensionHypertension
Heart disease Heart disease
Endometrial cancerEndometrial cancer
ELIGIBILITY FOR TREATMENTELIGIBILITY FOR TREATMENT
Concerns about IVF tourists to the NHSConcerns about IVF tourists to the NHS
Non EEC countriesNon EEC countries
Patients outside the East of England Patients outside the East of England boundariesboundaries
EligibilityEligibility
Living within East of England boundaries Living within East of England boundaries for a minimum of 12 monthsfor a minimum of 12 months
East of EnglandEast of England
Very generous in offering 6 cycles of IVFVery generous in offering 6 cycles of IVF
This has encouraged movement from This has encouraged movement from other parts of the countryother parts of the country
EligibilityEligibility
Who should adopt the policing roleWho should adopt the policing role
PCT’s opinion is that this should occur in PCT’s opinion is that this should occur in Primary Care settingPrimary Care setting
InvestigationsInvestigations
Significant proportion of Ix sent with Significant proportion of Ix sent with referral letters are;referral letters are;
Inappropriate e.g. LFT, U&E, Lipids Inappropriate e.g. LFT, U&E, Lipids
Performed at wrong time of cycle e.g. Performed at wrong time of cycle e.g. FSH/LH at mid luteal phaseFSH/LH at mid luteal phase
Progesterone at Day 21 rather than mid-Progesterone at Day 21 rather than mid-luteal phaseluteal phase
Rubella not testedRubella not tested
Sickle / haemaglobinopathies not Sickle / haemaglobinopathies not screened forscreened for
IVF where are we ? IVF where are we ?
West Herts fertility ServiceWest Herts fertility Service
Fund 3 IVF/ICSI cycles , 3 embryo transfer Fund 3 IVF/ICSI cycles , 3 embryo transfer cyclescyclesTotal of 6 possible cycles including private Total of 6 possible cycles including private cyclescycles6 month wait from decision to treat for IVF6 month wait from decision to treat for IVF
Age 23-39 at time of treatmentAge 23-39 at time of treatmentBMI 18 – 30BMI 18 – 30Neither partner has been sterilisedNeither partner has been sterilisedNo living children in the relationshipNo living children in the relationshipLess than 3 NHS IVF cycles Less than 3 NHS IVF cycles Registered with a west Hertfordshire GPRegistered with a west Hertfordshire GP
IVF CentresIVF Centres
Hammersmith - within 18 weeks of referralHammersmith - within 18 weeks of referral
Barts & London – within 10 weeksBarts & London – within 10 weeks
Bourne – within 18 weeks (3 satellite clinicBourne – within 18 weeks (3 satellite clinic
Oxford – within for 4 weeks (2 satellite clinOxford – within for 4 weeks (2 satellite clin
Leicester – in the next cycleLeicester – in the next cycle
Egg DonationEgg Donation
If 9 months amenorrhoea, elevated FSH If 9 months amenorrhoea, elevated FSH and satisfy all other criteriaand satisfy all other criteria
Sperm DonationSperm Donation
No waiting timeNo waiting time
Must satisfy all other criteriaMust satisfy all other criteria
Single Sex CouplesSingle Sex Couples
??
Do we have enough money to Do we have enough money to continue funding IVFcontinue funding IVF
UnlikelyUnlikely
NHS Manchester and Wirral have NHS Manchester and Wirral have withdrawn funding for treatmentwithdrawn funding for treatment
South of England have withdrawn funding South of England have withdrawn funding for the current financial yearfor the current financial year
Expediency measuresExpediency measures
Miscarriage within waiting time renders Miscarriage within waiting time renders you ineligible for IVF treatmentyou ineligible for IVF treatment
Have to wait a further 3 years of trying to Have to wait a further 3 years of trying to conceiveconceive
Thank youThank you