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Infertility EpidemiologyEpidemiology Overview of fertility treatmentsOverview of fertility treatments.

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Presentation on theme: "Infertility EpidemiologyEpidemiology Overview of fertility treatmentsOverview of fertility treatments."— Presentation transcript:

1 Infertility EpidemiologyEpidemiology Overview of fertility treatmentsOverview of fertility treatments

2 Infertility Overview EpidemiologyEpidemiology Natural conceptionNatural conception IncidenceIncidence CausesCauses InvestigationInvestigation WhenWhen Which testsWhich tests

3 Key steps

4 Infertility - incidence IncidenceIncidence population based studiespopulation based studies 24 months unprotected intercourse24 months unprotected intercourse 1:6 overall1:6 overall Subfertility Azoospermia (No sperm) ovarian failure (No oocytes) extensive tubal damage (Gametes cannot meet)

5 Cumulative conception Normal couples prospect of conceptionNormal couples prospect of conception 33% first month33% first month 20-25% thereafter20-25% thereafter 84% conceive by 1 year84% conceive by 1 year 92% by 2 years92% by 2 years

6 Causes of infertility - diagnosis CauseFrequency (%) Sperm dysfunction30 Ovulation failure25 Tubal infective damage20 Unexplained25 Endometriosis5

7 Infertility investigations - general advice Check Rubella immunity (female)Check Rubella immunity (female) Smoking (both)Smoking (both) AlcoholAlcohol Folic acid (female)Folic acid (female) 0.4mg/d (reduces risk of spina bifida)0.4mg/d (reduces risk of spina bifida) Weight (female)Weight (female) BMI <30BMI <30 Kg/m2Kg/m2

8 Infertility investigations - primary care Develop local protocolsDevelop local protocols evidence basedevidence based MaleMale SFA x 2SFA x 2 FemaleFemale midluteal progesteronemidluteal progesterone >30nmol/l>30nmol/l

9 Infertility investigations - lack of evidence Not recommended routinelyNot recommended routinely Thyroid functionThyroid function ProlactinProlactin PCT/Sperm function testsPCT/Sperm function tests Endometrial biopsy or scanEndometrial biopsy or scan HysteroscopyHysteroscopy

10 When to refer early from primary care Female factorsFemale factors age > 35 yrs (biological clock)age > 35 yrs (biological clock) Oligo/amenorrhoeaOligo/amenorrhoea Previous pelvic surgeryPrevious pelvic surgery PID/STDPID/STD

11 Seminal Fluid Analysis

12 Sperm dysfunction History / ExaminationHistory / Examination genitourinary surgerygenitourinary surgery undescended testisundescended testis mumpsmumps InvestigationInvestigation SFASFA Azoospermia (check karotype)Azoospermia (check karotype) Spontaneous conceptionSpontaneous conception possiblepossible 20% over 2 yrs20% over 2 yrs ICSIICSI 30%/cycle30%/cycle

13 Ovulation Physiological indicators of ovulationPhysiological indicators of ovulation Cervical mucus thins and increasesCervical mucus thins and increases mid cycle pain (mittleschmertz)mid cycle pain (mittleschmertz) Rise in basal body temperatureRise in basal body temperature History suggestive of anovulationHistory suggestive of anovulation infrequent / absent periodsinfrequent / absent periods >35 days apart>35 days apart Mid luteal progesterone (<30mmol/l)Mid luteal progesterone (<30mmol/l) Day 21 028

14 Failure of Ovulation AnovulationAnovulation PolyCystic Ovarian Syndrome (PCOS)PolyCystic Ovarian Syndrome (PCOS) HyperprolactinemiaHyperprolactinemia drugsdrugs stressstress pituitary tumorpituitary tumor Premature ovarian failurePremature ovarian failure 1% <40 yrs1% <40 yrs 0.1% <30 yrs0.1% <30 yrs HypothalamicHypothalamic Low GnRH driveLow GnRH drive

15 Anovulation – management PCOSPCOS ClomifeneClomifene MetforminMetformin FSH injectionsFSH injections Ovarian drillingOvarian drilling HyperprolactinaemiaHyperprolactinaemia dopamine agonist (bromocriptine)dopamine agonist (bromocriptine) inhibits prolactin secretioninhibits prolactin secretion Premature ovarian failurePremature ovarian failure IVF donated oocytesIVF donated oocytes Hypothalamic causesHypothalamic causes GnRH pumpGnRH pump

16 Tubal infective damage AetiologyAetiology Chlamydia trachomatis commonestChlamydia trachomatis commonest Silent carriageSilent carriage Age <25 yr incidence increasingAge <25 yr incidence increasing TOP (7.5%)TOP (7.5%) 20-24yr (11.5%)20-24yr (11.5%) HistoryHistory nonenone Pelvic Inflammatory Disease (PID)Pelvic Inflammatory Disease (PID) infective complications following pregnancyinfective complications following pregnancy DiagnosisDiagnosis Hystero-SalpingoGram (HSG) or Hycosys (screen)Hystero-SalpingoGram (HSG) or Hycosys (screen) laparoscopylaparoscopy

17 Laparoscopy

18 Tubal infertility - hydrosalpinx Offer salpingectomy if hydrosalpinx present (NICE)

19 Tubal infective damage - management Tubal surgeryTubal surgery major operationmajor operation limited success (20%)limited success (20%) ectopic pregnancyectopic pregnancy Removal of tubeRemoval of tube Potentially seriousPotentially serious IVFIVF expensiveexpensive complicationscomplications success rates depend on female age (30%)success rates depend on female age (30%)

20 Cumulative conception in unexplained infertility

21 Unexplained infertility - management WaitWait <3 years<3 years reasonable prospect of conceptionreasonable prospect of conception >3 years>3 years IVF observe fertilisation occurringIVF observe fertilisation occurring IUI (intrauterine insemination)IUI (intrauterine insemination) Female age importantFemale age important

22 Endometriosis What is it ?What is it ? Endometrial cells at sites outwith the uterusEndometrial cells at sites outwith the uterus OvaryOvary PelvisPelvis Bowel/bladderBowel/bladder Lungs Lungs AetiologyAetiology ? retrograde menses? retrograde menses Familial associationFamilial association EmbolisationEmbolisation ImmunologicalImmunological

23 Endometriosis HistoryHistory pelvic painpelvic pain DysmenorrhoeaDysmenorrhoea deep dyspareuniadeep dyspareunia DiagnosisDiagnosis LaparoscopyLaparoscopy Why does it reduce fertility ?Why does it reduce fertility ? ? Sperm function? Sperm function ? Tubal motility? Tubal motility ? Oocyte quality? Oocyte quality

24 Endometriosis - management Laser or diathermyLaser or diathermy improves conception ratesimproves conception rates If pelvis anatomically distortedIf pelvis anatomically distorted IVFIVF laser to ovarian cystslaser to ovarian cysts

25 Intrauterine insemination IndicationsIndications UnexplainedUnexplained Mild male factorMild male factor 2y infertility2y infertility Minor endometriosisMinor endometriosis Tubal patencyTubal patency Natural cycleNatural cycle NICE guidance 6 unstimulated cyclesNICE guidance 6 unstimulated cycles Stimulated cycleStimulated cycle ClomifeneClomifene FSH injectionsFSH injections Multiple pregnancyMultiple pregnancy

26 Indications for IVF/ICSI IVFIVF TubalTubal Prolonged unexplainedProlonged unexplained Severe endometriosisSevere endometriosis Unexplained failure of ovulation inductionUnexplained failure of ovulation induction ICSIICSI Severe male factorSevere male factor Failed ferilisation with IVFFailed ferilisation with IVF

27 In vitro fertilisation (IVF) Pituitary densitisation (GnRHa nasal spray)Pituitary densitisation (GnRHa nasal spray) Stops ovulationStops ovulation Ovarian hyperstimulation (daily FSH injections)Ovarian hyperstimulation (daily FSH injections) Multiple follicles and eggsMultiple follicles and eggs Egg retrievalEgg retrieval Sedation TVUSSSedation TVUSS Embryo transferEmbryo transfer Max 2 embryos (UK)Max 2 embryos (UK) Luteal supportLuteal support Progesterone pessariesProgesterone pessaries IssuesIssues Welfare of the ChildWelfare of the Child Multiple pregnancy ratesMultiple pregnancy rates Success ratesSuccess rates NHS fundingNHS funding 3 cycles3 cycles Age 23-39Age 23-39 criteriacriteria

28 Long GnRHa 21 0 12 Cycle day IVF Stimulation cycle - overview Menses ORET Daily FSH injections hCG Luteal support

29 Risks in ART cycle n Poor ovarian response n Ovarian hyperstimulation syndrome iatrogenic PCOS pregnancy n Multiple pregnancy move to elective single embryo transfer

30 Impact of female age and basal FSH on IVF livebirth rate ( Impact of female age and basal FSH on IVF livebirth rate (Akande et al 2002) Proportion of all pregnancies to women >35 years

31 Can ART (IVF) compensate for the natural decline in fertility with age? Leridon 2004 Computer Model of Reproduction Combined the monthly probabilities of conceiving the risk of miscarriage probability of becoming age-dependently permanently sterile Delay 30 to 35 years IVFIVF Makes up for 50% of age related lossesMakes up for 50% of age related losses Delay 35 to 40 years Makes up for <30%Makes up for <30% More precise information required about risks of postponing childbirth

32 Infertility investigations - summary Common condition (1:6)Common condition (1:6) Sperm dysfunctionSperm dysfunction SFASFA AnovulationAnovulation historyhistory midluteal progesteronemidluteal progesterone TubalTubal HSG Hycosys or laparoscopyHSG Hycosys or laparoscopy EndometriosisEndometriosis laparoscopylaparoscopy UnexplainedUnexplained all of above are normalall of above are normal

33 Infertility treatment - summary Sperm dysfunctionSperm dysfunction Mild IUIMild IUI Severe ICSISevere ICSI AnovulationAnovulation PCOSPCOS ClomifeneClomifene MetforminMetformin FSH injections or Ovarian diathermyFSH injections or Ovarian diathermy HyperprolactinaemiaHyperprolactinaemia Bromocriptine/cabergolineBromocriptine/cabergoline Ovarian failureOvarian failure IVF Donor eggsIVF Donor eggs TubalTubal Surgery (mild)Surgery (mild) IVFIVF EndometriosisEndometriosis ablation improvesablation improves IUI or IVFIUI or IVF UnexplainedUnexplained Wait IUI IVFWait IUI IVF

34 www.rcog.org.uk Student & junior doctor section Careers Advice on applying for Obstetrics & Gynaecology


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