1. Case History

2. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband good health s No STDs or GYN surgeries s Normal exam

3. Case #1 s Previous evaluations –Normal FSH and LH –Low progesterone level on “day 21” –Normal semen analysis and HSG s Previous treatments –6 cycles of clomid, hCG injections, AIHS, luteal PG u Resulted in one pregnancy with SAB –IVF was recommended as next step

4. Case #1 s Recommended: –CrM NaPro Tracking –optimal timing of intercourse –Vitamin B6 to enhance mucus production –Timed hormonal evaluation, based on charting –Fasting serum insulin and glucose –Follicular ultrasound series

5. Case #1 s Results –NaPro Tracking- limited mucus pattern –Good timing of intercourse –Severe PG and E2 deficiency in luteal phase –Fasting serum insulin- normal –Follicular ultrasound series- slightly small follicle prior to rupture, no PCO on US

6. Case #1 s Recommended –Support of luteal phase with postpeak hCG injections, 2000 Units IM on peak +3, 5, 7, 9 –Continue vitamin B6 –Continue fertility-focused intercourse –Reassess after 2 cycles of hCG support

7. Case #1 s Results –On second cycle of postpeak hCG injections, she conceived –At 5 weeks EGA, she felt like she was going to miscarry. The progesterone level was very low. Human-identical progesterone was given IM twice a week and tapered as her levels returned to normal. –She delivered a healthy baby girl at 39.5 wks EGA

8. Comments s NPT cohort pregnancy rates (crude and lifetable) similar to IVF cohort studies. –Crude rates underestimate success; lifetable rates overestimate s NPT takes more time than IVF, but is far less costly, and has much lower rates of prematurity and neonatal morbidity.

9. Comments s With confirmatory studies, NPT should become a mainstream approach to infertility. –NPT does require additional training. s International multi-practice studies are in planning.

11. Case Presentations Dr. Phil Boyle MICGP MRCGP CNFPMC 1.40 year old Female – implantation? 2.Failed fertilisation with IVF – Egg Quality? 3.FSH Above 20 IU/L 4.100% Antisperm Antibodies 5.Very Low Sperm Count

12. 1. 40 year old Female –implantation? s Dx: Unexplained infertility for 5 years s Hx: Gravida 1 para 0 Misc 1 s 3 Failed IVF – 3 embryos replaced each time s Problem with Implantation?

13. 40 year old Female – implantation? s NPT Dx: Corpus Luteum insufficiency s Conceived 3 rd Cycle HCG s Healthy Girl born, 9lb 5 oz. Mum aged 40yrs s Tried again age 42yrs. s Conceived 12 th Cycle HCG s Healthy Boy, 8lb 6 oz. Mum aged 43yrs

14. 2. Failed fertilisation with IVF – Egg Quality? s Dx: Moderately severe Endometriosis Trying to conceive for 5 years s Female Age 40 Yrs. s Hx: Gravida 1 para 0 Misc 1 s 1 Failed IVF – 3 eggs, None fertilised s Had successful adoption s Egg Problem?

15. Failed fertilisation with IVF – Egg Quality? s NPT Dx: Poor Follicular Fx / LTD Mucus s Rx: Clomiphene, B6, Carbocisteine, Amoxicillin s Conceived 10 th Cycle NPT s Healthy baby girl 6lb 8 oz Full term. Mum aged 41 at delivery.

16. 3. FSH Above 20 IU/L s Dx: Secondary infertility for 5 years, s Hx: Gravida 2 para 1 Misc 1, Female Age 40 Yrs. s 1Failed IVF – No follicular development s FSH – 23 IU/L s Problem – Perimenopause

17. FSH Above 20 IU/L s Rx: Clomiphene 50mg x 5 days, B6. s Long Irregular cycles s Conceived Day 50 of second Rx cycle s Healthy Boy 5lb 13 oz at 38 weeks s Never Menstruated again!

18. 4. 100% Antisperm Antibodies s Dx: Infertility for 8 years, Female Age 37 s 100%Antisperm Antibodies s Hx: Gravida 0 para 0 Misc 0, s s 2 Failed ICSI – 3 embryos each time s Problem – Male Factor

19. 100% Antisperm Antibodies s NPT Additional Dx: Low Prog. And Low E2 s Conceived 12 th Cycle NPT, (5 th Cycle Male Prednisolone Rx) s Healthy Girl born, 8lb 1 oz. Mum aged 39yrs s Spontaneously conceived again age 39yrs, but miscarried. s Spontaneously conceived 3 rd time age 40yrs, again miscarried. s How significant were the antibodies?

20. 5. Very Low Sperm Count s Dx: Infertility for 5 years, Female Age 34yrs Count 50,000 per ml 10,000 per ml 200,000 per ml 4,000,000 per ml 800,000 per ml s Hx: Gravida 1 para 0 Misc 1, (ICSI Pregnancy) s 3 Failed ICSI, 2 – 3 embryos each time s Problem – Male Factor

21. Very Low Sperm Count s NPT Additional Female Dx: Low Prog. And Low E2 s Conceived 8 th Cycle NPT, s 8 th Cycle Male Tamoxifen, L carnitine, Pycnogenol s Volume4 mls s Count4 Million/ ml s Motility45% s Morphology 4% Normal s Healthy Girl born, 8lb 8 oz. June 2004 s Mum aged 35yrs s Progesterone support during pregnancy until 28 wks s Very important to treat the female…often combined problem

22. IVF - UK. Declining success with increased age