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Specialist in Reproductive Surgery &

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1 Specialist in Reproductive Surgery &
Assessment & Treatment for Fertility Problems: The Role of Primary Care Michael Booker Consultant OB / GYN Specialist in Reproductive Surgery & Fertility Treatment

2 When will couples first seek advice?
If no conception within 1 year, or earlier:- If the woman is older (>36yrs) Infertile in a previous relationship Significant past history, eg - Previous ectopic pregnancy - Previous gynae surgery - Undescended testicles

3 “It must be remembered that infertility is often a reversible state”
“When those who desire children are unsuccessful in conceiving, their frustration can turn to despair, helplessness, and the need to seek advice from any source” “It must be remembered that infertility is often a reversible state” Gary M Horowitz 2007

4 Female Fertility: Lifestyle Factors
Alcohol: max 4 units/wk Excess alcohol reduces fertility & causes fetal alcohol syndrome Smoking reduces fertility (lowers AMH) Smoking increases pregnancy complications Obesity BMI>30 :- Delays conception Increases risk of miscarriage & pregnancy complications Underweight BMI<20 - causes anovulation Excessive alcohol reduces fertility and increases risk of fetal alcohol syndrome

5 Female Fertility: Lifestyle Factors
Eat a well balanced diet Have a sensible BMI Exercise regularly Role of supplements Folic acid 400mcg Adjustments to reduce stress

6 Male Fertility: Lifestyle Factors
Obesity BMI>30 impairs fertility Smoking increases reactive oxygen species Tobacco contains cadmium (heavy metal) Excessive alcohol damages sperm production Heart disease is associated with male infertility and erectile dysfunction Anabolic steroids damage sperm production Other environmental toxins Avoid tight underpants

7 Male Fertility: Lifestyle Factors
Eat a well balanced diet Have a sensible BMI Exercise regularly Adjustments to reduce stress Role of anti-oxidants and supplements

8 Coital Frequency Enquire about coital difficulties
Coitus every 2-3 days Detecting LH surge for women with regular cycles Effects of lifestyle, long hours at work, travelling

9 Female Fertility: Medical History
Review details of past medical / surgical history Optimise treatment of any ongoing health problems Review medications PID / STI history Previous pregnancies Menstrual history Any gynaecological symptoms? Physical examination

10 Male fertility: Medical History
Review details of past medical history Optimise treatment of any ongoing health problems Review medications STI history Heart disease risk Previous pregnancies Surgery for undescended testes Inguinal hernias Testicular torsion ops Mumps Physical exam if indicated

11 Infertility is a marker for medical disease
For men For women

12 Initial Investigations
UK guidelines Guidelines from other countries Local guidelines Medical textbooks Medical journals Internet

13 Semen analysis (WHO 2010) Volume >1.5mls pH >7.2
Sperm concentration >15 x 10/6 per ml Total sperm count > 39 x 10/6 Motility >40 %, >32% progressive motility Morphology >4% by strict criteria WBC <1 x 10/6 per ml

14 Male Fertility Assessment: Lab Tests
If count is less than 5 x 10/6 on two semen analyses: FSH, LH Testosterone TSH, Prolactin And if any erectile dysfunction: Fasting lipids

15 Female Fertility: Initial Lab Tests
FSH LH (Day 2 – 5) Oestradiol (Day 2 – 5) TSH Prolactin Full Blood Count Hb Electrophoresis Rubella Status Cervical smear Endocervical swabs - bacteriology - chlamydia

16 Female Fertility: Thyroid disease
Ovarian function … and in pregnancy Even quite subtle thyroid disease can affect ovarian function Concept of “crosstalk” between thyroid hormones and FSH & LH Family history provides clues Review by an endocrine physician For hypothyroid women, dose of thyroxine needs to increase

17 Ovarian Reserve Assessment
FSH LH Oestradiol (Day 2 – 5 of cycle) Transvaginal Ultrasound of Ovaries - Antral Follicle Count Anti Mullerian Hormone (AMH) Past medical / surgical history Past reproductive history Age

18 Ovarian Reserve Assessment
Fluctuating levels of FSH; The high levels are more significant than the low levels Oestradiol should be low normal at day 2 – 5; paradoxically high levels signify ovarian/pituitary dysynchrony Low AMH can be the only biochemical marker for diminished ovarian reserve Careful TVUSS assessment of ovaries

19 Anti Mullerian Hormone
Rises in adolescence Reaches a peak in early 20’s Followed by an initial steep fall and then a long slow further decline Reported in centiles:- 75 – 100% “Optimal fertility” 50 – 75% “Satisfactory fertility” 25 – 50% “Low fertility” 0 – 25% “Very low / undetectable”

20 But my hormone levels are normal!

21 Female Fertility: Baseline TV Scan
Assess Ovarian size and morphology Any cysts? Hydrosalpinges Free fluid Fibroids Congenital uterine malformations

22 Female Fertility: Extra lab tests for PCO
Fasting cholesterol Fasting blood glucose Testosterone

23 PCO: Endocrine Markers
Reversed FSH:LH ratio Raised testosterone Type II diabetes (x7 risk) High cholesterol LDL chol higher than HDL chol Raised triglyceride Also look for - Hyperprolactinaemia - Thyroid disease

24 Male fertility: Effect of Ageing
Little change with age up to age 40yrs Over 40, decline in testosterone levels (Leydig cells) Decline in spermatogenesis (Sertoli cells) Testosterone supplements don’t help

25 When to refer? “People who experience fertility problems should be treated by a specialist team because this is likely to improve the effectiveness and efficiency of treatment and is known to improve people’s satisfaction with treatment” NICE 2013

26 Primary and Secondary Care: Effective Interfacing
Working together Couples will rely on primary care professionals for support during complex investigations and treatments

27 Primary care to Secondary Care
“The purpose of the basic infertility workup is to (1) identify the likely basis of the underlying obstacle or obstacles and suggest the best evidence-based therapies, and (2) bring understanding and identity to our patients. This regard for the psychological well-being of our patients will help guide them toward successful closure regardless of the success or failure of their treatment” Gary M Horowitz

28 Secondary Care: Principles
Further investigations: Cycle monitoring, tubal patency testing, hysteroscopy, laparoscopy Establishing a diagnosis Planning treatment

29 Fertility Treatment Male Female Treatment for endocrine disease
Optimising cardiovascular health Varicocelectomy Vasovasostomy Vasoepididymostomy Treatment for endocrine disease and PCO Surgery for endometriosis Myomectomy Tubal microsurgery Correction of congenital uterine malformations Hysteroscopic surgery Ovulation induction

30 Fertility Treatment: Male & Female
Ovulation induction with intrauterine insemination Donor sperm treatments IVF IVF + ICSI Donor oocyte IVF IVF with Pre-implantation genetic diagnosis Oncofertility

31 Thank you for your attention!

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