Fertility Issues Dr Jane Stewart Newcastle Fertility Centre at LIFE

Fertility  Who to refer  When to refer  How to refer  Secondary care provision and changes  Tertiary care  Licensed treatments  Primary care support

1 in 7 couples will experience a problem with conception in their reproductive lifetime.

Who/when to refer – primary care  Reassurance as appropriate  Referral as appropriate  Other options

Normal Cumulative Pregnancy Rate

Factors important to fertility  Eggs  Sperm  Tubes  Sex

Primary Care Assessment  Fertility Risk factors Ovulation Sperm [Tubes] Sexual function NICE 2004  General General health and wellbeing Sexual health Weight, smoking, alcohol Folic acid Smear [FBC, TSH], rubella

Who/when to refer  Immediately Significant risk factors Identified cause  Early Significantly anxious Female age >35 years  Otherwise At 1-2 years trying  Issues Female age Relationship Welfare of the child Medical/psychiatric problems Desire to proceed

Old Technologies  Acceptance of childlessness  Adoption  Fostering  Extended families

Unexplained subfertility  2 years failure to conceive with regular intercourse and normal investigations

Ideal Referral  Details of both partners  Relationship  Duration of trying  Salient risk factors  Significant medical/psychiatric history  Previous pregnancies/children  WoC issues  Confirmation of ovulation  FBC, rubella (TSH)  Semen analysis (x2 if relevant)  [Tubal patency if access]  With results in the letter.

Referral Pathways  PCT directed 2y/3y services Patient choice Choose and book Treatment availability There are no eligibility requirements for fertility assessment.

Secondary Care Provision  Investigation More detailed investigation Tubal patency testing  Unlicensed treatments  Licensed treatments Overlap with tertiary centres

Aims of Process WITHOUT UNDUE DELAY  Diagnose a cause where possible  Reassure if appropriate  Give an estimate of chance of conceiving without treatment  Offer appropriate treatment options  Provide timely access to appropriate treatment

Unlicensed treatment  Ovulation induction Clomifene Gonadotrophins GnRH  Scanning facilities  Sperm prep facilities  IUI-H  [GIFT]  Changing profiles

EUTCD  HFEA Bring under licence from April 2007 (now June 2007) Sperm prep IUI-H GIFT  EU directive Stringent tissue handling conditions

Tertiary Referral  “2y care” facilities  Unlicensed treatments  Licensed treatments Non- ART ART  GP support for tertiary treatment Welfare of the child Pregnancy support

GP support for 2y/3y treatment  Prompt appropriate referral  Welfare of the child  Ongoing medical/psychiatric management  Weight management  Counselling  Pregnancy support  Shared prescribing

PCT Support  Facilitate access to pathway of care  Provide appropriate funding to comply with the NICE Guidelines and the associated DoH targets allowing treatment to be provided in a timely fashion  Determine local criteria for application of limited funding  To apply funding criteria equitably  Remain open to new developments

NFCL - What do we do?  Clinics  Trans-vaginal ultrasound scanning  Andrology  Embryology  Treatment  Counselling  Education  Multidisciplinary links  Research

Clinics  Fertility Accept 1y, 2y and 3y referrals Investigation, results review, treatment options discussed  Gynae-endo Investigation endocrine related fertility problems Management ovulatory dysfunction  Young peoples clinic Advice on fertility for future Oncology/endocrinology/ urology etc.  IVF clinics Investigated patients arranging treatment Follow-up following unsuccessful treatment  PP clinic

Trans-vaginal Ultrasound  Diagnostic  Natural cycle follicle tracking for DI/IUI  Ovulation induction  Ovarian stimulation for IVF  Early pregnancy  Up to 30 scans/morning 5 days/week and Sat am limited facility

Andrology  Diagnostic service Semen analysis Newcastle  Pre-treatment assessment semen  Epididymal/testicular sperm processing  Sperm storage Pre-treatment/post retrieval Oncology  Sperm donor bank

Embryology  IVF  ICSI  Embryo freezing  Embryo culture  [PGD]  Research

Treatments  Ovulation induction Clomiphene/gonadotrophins/GnRH  IVF ICSI, sperm retrieval, embryo freezing  Donor gametes/ embryos  Surrogacy  Fertility preservation Sperm storage Embryo storage

Counselling  Treatment implications counselling  Fertility therapeutic counselling  Psychosexual counselling  Fertility awareness

Other activities  Well established clinical links with other specialties  Education  Research

Future Fertility Issues  Fertility preservation  PGD  Donor recruitment strategies  New technologies