PRETREATMENT ASSESSMENT & MANAGEMENT (MODULE 1 B) March, 2018

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1 PRETREATMENT ASSESSMENT & MANAGEMENT (MODULE 1 B) March, 2018

Clinical Assessment A thorough clinical evaluation is a

detailed in the female and male infertility modules Assure

manage factors that can impact on treatment risks, success,

and/or preconceptual counselling 2 Perinatal Risks Associated

2 Clinical Assessment A thorough clinical evaluation is a prerequisite for ART A thorough clinical evaluation as detailed in the female and male infertility modules Assure co-morbidities are being effectively managed Identify and manage factors that can impact on treatment risks, success, and obstetric & neonatal prognosis Consider need for genetic and/or preconceptual counselling 2 Perinatal Risks Associated With Assisted Reproductive Technology. Committee Opinion. ACOG. Number 671, September 2016.

3 Clinical Assessment Some causes of infertility can impact on treatment outcomes. Appropriate management of these conditions before ART optimizes success rates Age Ovulatory Dysfunction Female Reduced Ovarian Reserve Pelvic Disease Lifestyle Male Other Unexplained Male and female factors are both present in 30-40% of couples Tubal Occlusion Fibroids Endometriosis Adenomyosis Uterine Other Asherman's Congenital anomaly Endometrial polyps Infection (endometritis) Foreign body STDs BMI Exercise Smoking Stress Employment Environment al factors Systemic illness Celiac disease Thyroid Immune Genetic When an abnormality is found in one partner, the other partner should still be investigated 3 Patel Z and Niederberger C, Med Clin N Am, 2011; 95:

Clinical Assessment Clinical features can be associated with patient response to ovarian stimulation and should be considered when selecting medication regimes

Ovaries Ovarian Reserve (AMH and/or Antral Follicle Count) 4 1. Farquhar et al., Reprod Biomed Online, 2017; 35:3-16 2. Fertility problems: assessment and treatment.

4 Clinical Assessment Clinical features can be associated with patient response to ovarian stimulation and should be considered when selecting medication regimes Identifying women likely to have excessive response to stimulation & increased risk of OHSS Response in a prior stimulated cycle Age, Body Mass Index (BMI) Polycystic Ovaries Ovarian Reserve (AMH and/or Antral Follicle Count) 4 1. Farquhar et al., Reprod Biomed Online, 2017; 35: Fertility problems: assessment and treatment. NICE Clinical guideline, 2013; International Federation of Fertility Societies Global Standards of Infertility Care Standard 16 Ovarian Hyperstimulation Syndrome (OHSS) June, 2016

Clinical Assessment Uterine and tubal pathology may reduce ART success rates and treatment should be offered for relevant conditions before commencing ART Approximately 25% have uterine

5 Clinical Assessment Uterine and tubal pathology may reduce ART success rates and treatment should be offered for relevant conditions before commencing ART Approximately 25% have uterine factors that could impact IVF outcome Cervical stenosis Endometrial polyp, submucous fibroid, septum, Asherman s syndrome Adenomyosis Hydrosalpinx 5 1. Taskin et al. Fertil Steril, 2011; 96: e2

6 Clinical Assessment Evidence suggests that treating hydrosalpinges before IVF improves success rates Normal Fallopian tube Ovary Fluid filled and blocked tube (Hydrosalpinx) Uterus Cervix Vagina 6

7 Risks and potential adverse outcomes Informed consent includes advising patients of the risks and potential adverse outcomes of ART Cycle outcomes (cancelled, no eggs, failed fertilization, no embryo(s) to transfer) Bleeding, infection, trauma Anaesthetic complications Thrombo-embolic events Moderate or severe Ovarian Hyperstimulation Syndrome (OHSS) Pregnancy (ectopic, cervical, heterotopic, multiple) 7 1. Safety Monitoring for Assisted Reproductive Technology (IVF, ICSI) Recommendations for Practice. IFFS 2015; Perinatal risks associated with assisted reproductive technology. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e61 8.

including Absolute indications where no chance spontaneous pregnancy (eg.

8 Patient preparation Informed consent also includes discussing indications for treatment, therapeutic alternatives, and factors affecting the prognosis Consider and discuss therapeutic alternatives Review indications for treatment including Absolute indications where no chance spontaneous pregnancy (eg. bilateral salpingectomy) Relative indications (multiple) Obtain informed consent including discussing potential prognosis and risks 8 1. Photo by Matheus Ferrero on Unsplash

jurisdictions 9 1. ESHRE Psychology and Counselling Guidelines 2.

9 Patient preparation Access to counselling is an essential component of providing ART services Counselling Roles ART Regulation & Legislation Support Implications & decision-making Information gathering & analysis Therapeutic Counselling is mandated in many jurisdictions 9 1. ESHRE Psychology and Counselling Guidelines 2. Human Fertilization and Embryo Authority Code of Practice, 8 th Edition, October 2017; 3A. Photo by Beatriz Pérez Moya on Unsplash

Conclusions Patients should be thoroughly evaluated before ART, identifying and managing conditions that could negatively impact on outcome Medication regimes for ovarian stimulation should be

10 Conclusions Patients should be thoroughly evaluated before ART, identifying and managing conditions that could negatively impact on outcome Medication regimes for ovarian stimulation should be tailored to the patient s clinical profile Appropriate patient preparation for ART includes detailed informed consent and access to counselling services 10 GBPMLR/NONF/1217/0071

Dr Manuela Toledo - Procedures in ART -

Dr Manuela Toledo - Procedures in ART - Fertility Specialist MBBS FRANZCOG MMed CREI Specialities: IVF & infertility Fertility preservation Consulting Locations East Melbourne Planning a pregnancy - Folic