1 NaProTechnology ® A Family Physician’s Protocol Dr. Phil Boyle MICGP MRCGP CNFPMC Toronto July ‘03
2 Fertility Care TM Taking Care of your fertility NaProTechnology® A New Reproductive Science that works by co-operating with the natural procreative cycle
3 NaProTechnology ® s Physiology before Pathology s A Disease Based approach to infertility s If not……….why not?
4 IVF- Diagnosis before Treatment 42% Unexplained
5 NaProTechnology ® s Consistent with accepted medical principles –History (standardised medical form) –Symptoms –Signs –Investigations –Diagnosis –Targeted Medical / Surgical Treatment
6 The FertilityCare TM System ( History ) s Unable to conceive s Previous miscarriage s Previous Ectopic Pregnancy s Prematurity s Low Birth Weight s Placental Abruption s Pregnancy induced Hypertension (Not PET)
7 The FertilityCare TM System (Symptoms) s Premenstrual Tension u lasting for 5 days or more u relieved with menses s Record Average u Symptoms, u Days, u Duration, u Severity out of 10
8 The FertilityCare Chart (Clinical Signs) s Dry Cycles s Limited Mucus s Premenstrual Spotting s Intermenstrual spotting s Tail-end brown bleeding s Short luteal phase s Long luteal phase s Long cycles
12 Ultrasound Studies (Investigation Level 2.) s Follicular Tracking
13 Ultrasound Studies (Investigation Level 2.) s Follicular Tracking u Small Follicles u Incomplete (Partial) Rupture u Luteinised Unruptured Follicle u Normal Rupture u Endometrial Response
14 Surgical Evaluation (Investigation Level 3.) s Lap and Dye s Hysteroscopy s Transcervical Catheterisation of Fallopian Tube. USA s Laparotomy and Microsurgery
15 DiagnosisFUNCTIONAL s Hormone deficiency - Follicular or Luteal? s Ovulatory defect - Anovulation, Luteinised Unruptured Follicle Syndrome, Partial follicular rupture. s Limited cervical Mucus Flow s Male FactorSTRUCTURAL s Surgical - Endometriosis, PCOD, Fibroids, Polyp, Uterine Septum, PID.
16 TreatmentFUNCTIONAL s Luteal Phase Support - HCG, Progesterone s Mucus Enhancers - Vitamin B6, Mucolytics, Antibiotics s Stress Management s Male Treatment s Ovulation Induction - Clomiphene, HCG, FSH, GnRHSTRUCTURAL s Surgical - Endometriosis, Ovarian Diathermy, Fibroids, Polyp, Uterine Septum, PID. AIM is to restore normal Function over 12 effective cycles
17 NaProTechnology Co-operates with the couple’s natural procreative potential to achieve optimum function. s Creighton Model FertilityCare TM System s Medical Treatments s Surgical Treatments s Counselling - Stress Management s Spiritual Support - prayer for couples
18 s The FertilityCare TM system is the cornerstone to evaluation and treatment with NaProTechnology® s Everything is built on or around the fertility chart The Creighton Model FertilityCare TM System
19 s Charting abnormalities are just the tip of a very large patho-physiologic iceberg! The Creighton Model FertilityCare TM System
20 Are associated with: u Hypothalamic-pituitary-gonadal Dysfunction u Poor Follicular Function u Abnormal levels of Oestradiol 17 Beta, Progesterone u Endometriosis u Pelvic Adhesions u Polycystic Ovaries Charting abnormalities
21 Not Suitable s Established Menopause s Zero Sperm count / Motility s Completely Blocked Fallopian Tubes despite surgical reconstruction
22 Creighton Model NaProTracking s Important for the initial evaluation s Timing of Hormone Blood Tests s To Monitor the response to treatment - cycle by cycle u Mucus u Hormones u Timing for Intercourse u Effects of stress
23 Infertility Protocol -Family Physician s Initial Medical Consultation s NaProTracking for 2 cycles s Blood Tests & Seminal fluid analysis (using seminal fluid collecting device) - 2nd cycle s Medical Review - 3rd cycle s Ultrasound Evaluation s Ultrasound Follicle Tracking s Diagnostic Laparoscopy and Hysteroscopy - 6th cycle s 12 effective cycles of medical treatment
25 The Couple manage their own fertility under supervision by their “FertilityCare Physician” and Teacher-Practitioner
26 Case Presentations 1. Case 1 2. Case 2 3. Case 3
27 Case 1 s Married 8 years, Both Aged 35years. s 7 Pregnancy Losses 1993- 1999 u 10w, 18w, 31w, 26w, 26w, 17w, 17w u 2 miscarriages, 3 Stillbirths, 2 miscarriages. s Nurse s Attended 3 different Specialists, –Locally, Dublin, London
28 Case 1 s Lupus Anticoagulant, s anticardiolipin Antibodies, s b2 glycoprotein 1, s Rheumatoid factor, s ANA, CRP, ALL NORMAL s Chromosomes, s TORCH s Hysteroscopy
30 Case 1 s Low Progesterone s Low Oestradiol 17 Beta s Raised TSH 8.5
31 Case 1 s Corrected Hormonal Deficiencies Preconception with –Clomid 50mg od x 3/7 –Eltroxin 50ug daily –HCG 2000, P+3,5,7,9.
32 Case 1 s Conceived with optimum hormone levels s Took Prog 200mg x2 /w, HCG 5000 x2 /w Aspirin, Heparin. s Prog. Support for 30 weeks s Delivered Healthy Baby Girl, Eilís s Induced at 39 weeks, Nov ‘00. s NVD Weight 7lb 11oz.
33 Case 1 s Conceived with same Rx 14 months later s Delivered live female in March ‘02 s Elective LSCS at 41 weeks, Weight 9 lbs. 1 oz
34 Case 2 s Primary Dx Fibroids – Myomectomy 1996 s Female infant 1997 NVD s Unable to conceive since then
35 Case 2 s Age 37 yrs. G1 P1 s Secondary Infertility 1999 u LAP – Adhesions secondary to myomectomy u Laparotomy repair s Rx Clomid x 3/12, FSH x 3/12 s IVF - Oct. 00, and again frozen transfer Feb. 01 ( 1 IVF 2 Embryo T/F) u ??Suitable for NaPro
36 Case 2 s FertilityCare Chart – Normal in appearance
48 Case 3 Blood Test Results s E2 - Pre Peak - 544 pmol/L (148 pg/ml) –aim > 1,000 nmol/l ( 370 g/ml) s P+7 - Prog - 99.1 nmol/L (31.1 ng/dl) E2 - 341 pmol/L (92.9 pg/ml)
49 Case 3 Outcome s Renal Agenesis s Baby Boy RIP – 26 weeks approx.
50 Case 3 3rd Attempt s Puregon (FSH) 100 iu sc daily for 10 days, start day 3 of cycle s HCG 5,000 sc on day 12 s Cyclogest (Progesterone) PV 400mg for 10 nights s STRESS MANAGEMENT s 6th cycle ready to try
51 Case 3 Blood Test Results s Ultrasound 2 follicles, one 22 x 20mm s E2 - Pre Peak - Not available s P+7 - Prog - 122.1 nmol/L (38.3 ng/dl) E2 - 899 pmol/L (245 ng/dl)
52 NaProTechnology ® A Family Physician’s Protocol Dr. Phil Boyle MICGP MRCGP CNFPMC Toronto July ‘03
53 The Irish NaPro Statistics s Approx. 1200 couples over 4 years s Average Female age - 36yrs. s Average time trying to conceive - 5yrs. s Approx. 25% - history of unsuccessful IVF
54 Estimated Success s Approx. 340 successful Pregnancies s Approx. 25 - 30% success overall u Substantially higher with lifetable analysis, accounting for dropouts u still in preparation for publication
55 Questions Dr. Phil Boyle MICGP MRCGP CFCMC Toronto July ‘03