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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

“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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

Infertility is a marker for medical disease For men For women www.fertility-info.co.uk

Initial Investigations UK guidelines Guidelines from other countries Local guidelines Medical textbooks Medical journals Internet www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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” www.fertility-info.co.uk

But my hormone levels are normal! www.fertility-info.co.uk

Female Fertility: Baseline TV Scan Assess Ovarian size and morphology Any cysts? Hydrosalpinges Free fluid Fibroids Congenital uterine malformations www.fertility-info.co.uk

Female Fertility: Extra lab tests for PCO Fasting cholesterol Fasting blood glucose Testosterone www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

Primary and Secondary Care: Effective Interfacing Working together Couples will rely on primary care professionals for support during complex investigations and treatments www.fertility-info.co.uk

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 www.fertility-info.co.uk

Secondary Care: Principles Further investigations: Cycle monitoring, tubal patency testing, hysteroscopy, laparoscopy Establishing a diagnosis Planning treatment www.fertility-info.co.uk

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 www.fertility-info.co.uk

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 www.fertility-info.co.uk

Thank you for your attention! www.fertility-info.co.uk