1. Infertility New Issues

2. Yunus Tayob Clinical Lead in Reproductive Medicine and Reproductive Endoscopic Surgery

3. Referral Criteria BMI Eligibility for NHS treatment Investigations – primary care

4. BMI > 18 < 32-34

5. Ovulation Rates Reduced in both groups spontaneous and stimulated cycles

6. BMI < 18 Most likely to have hypothalamic hypogonadotrophic hypogonadism

7. BMI > 35 Most likely to have PCOS

8. Diagnosis Rotterdam criteria Acne, hirsutism, obesity Acne, hirsutism, obesity Hormonal imbalance Hormonal imbalance Ultrasound appearance of ovaries Ultrasound appearance of ovaries Requirement 2 of 3

9. Ovarian stimulation Study of 270 women receiving Clomid or Gonadotrophins Ovulation rates at 6 months 79% BMI 18 – 24 15.3% BMI 30 – 34 12% BMI > 35

10. IVF / PCOS / Obese Lower implantation rates Lower pregnancy rates Higher dose of drugs required Higher rate of miscarriage This extends to donor egg programmes

11. Primary Care Adopt the role of addressing the issues of BMI prior to referral to Secondary care

12. What lifestyle changes to support your patient Discuss BMI and move to low GI diet Caffeine reduction Advice both parties to stop smoking and reduce alcohol Start folic acid AND check they both want the referral! AND check they both want the referral!

13. Weight loss Obesity itself increases insulin levels Weight loss ↓ insulin concentrations Weight loss can restore ovulatory function Long-term effects DiabetesHypertension Heart disease Endometrial cancer

14. ELIGIBILITY FOR TREATMENT Concerns about IVF tourists to the NHS Non EEC countries Patients outside the East of England boundaries

15. Eligibility Living within East of England boundaries for a minimum of 12 months

16. East of England Very generous in offering 6 cycles of IVF This has encouraged movement from other parts of the country

17. Eligibility Who should adopt the policing role PCT’s opinion is that this should occur in Primary Care setting

18. Investigations

19. Significant proportion of Ix sent with referral letters are; Inappropriate e.g. LFT, U&E, Lipids Performed at wrong time of cycle e.g. FSH/LH at mid luteal phase Progesterone at Day 21 rather than mid- luteal phase Rubella not tested Sickle / haemaglobinopathies not screened for

20. IVF where are we ?

21. West Herts fertility Service Fund 3 IVF/ICSI cycles, 3 embryo transfer cycles Total of 6 possible cycles including private cycles 6 month wait from decision to treat for IVF Age 23-39 at time of treatment BMI 18 – 30 Neither partner has been sterilised No living children in the relationship Less than 3 NHS IVF cycles Registered with a west Hertfordshire GP

22. IVF Centres Hammersmith - within 18 weeks of referral Barts & London – within 10 weeks Bourne – within 18 weeks (3 satellite clinic Oxford – within for 4 weeks (2 satellite clin Leicester – in the next cycle

23. Egg Donation If 9 months amenorrhoea, elevated FSH and satisfy all other criteria

24. Sperm Donation No waiting time Must satisfy all other criteria

25. Single Sex Couples ?

26. Do we have enough money to continue funding IVF

27. Unlikely NHS Manchester and Wirral have withdrawn funding for treatment South of England have withdrawn funding for the current financial year

28. Expediency measures Miscarriage within waiting time renders you ineligible for IVF treatment Have to wait a further 3 years of trying to conceive

29. Thank you