1. Assessment & Treatment for Subfertility Treatment pathway Jayaprakasan K Consultant Subspecialist in Fertility Honorary Associate Professor & Consultant Gynaecologist

2. Fertility Overview Tests and Treatment offered Our approach (Philosophy) Couple’s/ Woman’s Perspective Informal Conversation Plan for this evening

4. Fertility Overview Tests and Treatment Our Core values Couple’s/ Woman’s Perspective Informal Conversation Plan for this evening

5. Natural Fertility

6. - Realistic Chances - Age dependant - Frequency of Intercourse - 2 to 3 per week - 5 days before up to ovulation day - LH kit/ BBT no use (stressful intervention) - Healthy Life style - Optimise weight/ healthy diet - No smoking - Limit Alcohol intake

7. Natural Fertility - Folic acid around conception time - continue up to 12 weeks - 0.4 mg generally (5 mg for some) - Measures to reduce scrotal temp - Loose fitting underwear - Avoid hot baths - Laptops etc

8. Defining subfertility Failure to conceive after 1 year of unprotected intercourse in the absence of known reproductive abnormalities Early referral for specialist consultation - Woman’s age > 35 yrs - Infrequent or No periods - Pelvic infection - Undescended testes - Known reason (chemotherapy/ radiotherapy) - HIV/ Hep B/ Hep C - HIV/ Hep B/ Hep C C

9. Prevalence 80% conceive within 12 months 90% conceive within 24 months 1 in 7 couples

10. Causes Sperm Egg Tubes Male 30% Ovulation 25% Tubal 20% Endometriosis/ Fibroids 5-10% Unexplained 25%

11. Initial assessment History Examination Investigation

12. History- Female Egg Production: Menstrual regularity, ovulation awareness, PCOS, thyroid or prolactinoma symptoms, weight changes, exercise Tubal disease: PID, pelvic surgery, ectopic pregnancy Endometriosis: Dysmenorrhoea, dyspareunia, dyschezia Previous contraception/ Obstetric history/ surgical or medical illness/ Medicines/ cancer treatment Lifestyle: smoking, alcohol, recreational drugs, job Hepatitis B & C and HIV – Proper CounsellingHepatitis B & C and HIV – Proper Counselling

13. History - Male Sexual history: coital frequency, erectile or ejaculatory dysfunction Past medical illness (mumps), surgery (varicocele, hernia, hydrocele) Occupation, current medical illness (diabetes, hypertension), smoking, alcohol, recreational drugs

14. Examination BMI Physical examination if indicated

15. Investigation 1. Semen assay 2. Ovulation (Day2/21) 3. Tubal Patency 4. Referral Sperm Egg Tubes patent Check Rubella status/ Chlamydia screening/ Cervical smear

16. Treatment pathway (Primary care) - Baseline FSH & LH/ Mid-luteal progesterone - Prolactin/ TSH, free T4/ Testosterone, SHBG - Chlamydia/ Rubella screen/ Cervical smear - Advise on funding criteria - Advise both couple should attend the clinic

17. Investigation 1.Semen assay 1.Semen assay 2.ovulation 2.ovulation 3.tubal patency endometriosis/ uterine pathology Sperm Egg Tubes patent Check Rubella status/ Chlamydia screening/ Cervical smear

18. Tubal patency Low risk High Risk HysteroSalpingoGraphy OPD

19. Tubal patency Low Risk High Risk Laparoscopy & Dye More information Adnexae Endometriosis Treatment

20. Ultrasound scan (TVS)

21. Clinical assessment Management options & Tx pathwayIVF/ICSIConclusions Plan

22. Management of male subfertility Male factor - Lifestyle - Vitamin, Selenium, Zinc, supplements - IUI/IVF - Hormonal drugs (if appropriate) Ovulation Problem (PCOS/ Other Hormonal problems) - Lifestyle - Clomiphene tablets/ Metformin tablets - Hormonal Injections Tubal Problems - IVF - Surgery Unexplained - IUI/ IVF Fibroids/Polyps Endometriosis - Surgery - IUI/ IVF

23. Purpose built Unit Andrology Laboratory/Scan/Surgery Treatment offered 7 day a week Staffs 3 Specialist nurses, 3 Andrologists, 4 Admin, 1 Quality manager 2 Consultants,1SR Derby Fertility Unit: Current status

24. All appropriate investigations are offered Derby Fertility Unit: Current status Sperm Egg Tubes patent

25. Most treatment options can be offered Derby Fertility Unit: Current status Ovulation InductionLaparoscopy Hysteroscopy Intra-uterine Insemination IUI Derby IUI success rates: 12.3% per cycle/ 18% in <35 years

26. Satellite IVF offered Satellite with Nottingham IVF Unit Pre-treatment assessment/ Start IVF cycle/ Ovarian stimulation/monitoring Follow up IVF Derby Fertility Unit: Current status

27. IVF/ICSI Plan

28. Criteria for NHS funding

29. IVF/ ICSI

30. Egg collection

31. Egg Collection

32. IVF

33. ICSI

34. Fertilisation/ Embryo development

35. Embryo transfer

36. Progesterone Luteal support Progesterone Started two days after egg collection Progesterone pessaries (Vaginal) or Injection (IM) Continued for 14-16 days until pregnancy test Continued up to10-12 weeks if pregnant

37. Live birth rates per cycle started: 2013 data Age range (years) IVF/ICSI <3551% 35-3739.7% 38-3927% 40-429.2% 43-444% Success rates

38. Initiate investigation at one year/ or earlier if any co-morbidities Referral with relevant investigations and information on funding criteria Both couple should ideally attend the clinic Treatment depending on the cause, age, duration of subfertility and ovarian reserve Conclusions

39. Assessment & Treatment for Subfertility Treatment pathway Jayaprakasan K Consultant Subspecialist in Fertility Honorary Associate Professor & Consultant Gynaecologist