2/14/2017. Pre Pregnancy Tune Up: Predicting Success and Avoiding Liability. Objectives. Disclosure. Participant will be able to:

Transcription

1 Pre Pregnancy Tune Up: Predicting Success and Avoiding Liability February 9, 2017 G. Wright Bates, Jr., M.D. Professor and Director Reproductive Endocrinology and Infertility Objectives Participant will be able to: Describe pre pregnancy counseling and lifestyle modification Describe optimization of natural fertility Describe the history and age based evaluation Describe appropriate genetic screening prior to pregnancy Provide overview of fertility treatment options Disclosure I have no relevant financial interest 1

2 Patient Centered Family Planning Care Am J Obstet Gynecol Feb Do you like the children that you have? 2

3 Pre conception Risk Stratification Borowski, etal, Fertil Steril (1):28 31 Pre conception Risk Stratification 3

4 Lifestyle and Reproductive Health Marijuana Testosterone supp ASRM Practice Committee, 2016 Tobacco and Fertility Increased risk of 50 miscarriage and ectopic 40 Hastens menopause % 30 Damages sperm 20 REDUCED chance of success with IVF 10 (regardless of who 0 smokes in the household) Successful Pregnancy nonsmoker Female Smokes Male Smokes 4

5 Obesity and Birth Defects ACOG Obesity in Pregnancy, April 2016 Stothard, KJ, et al., JAMA : Getting Pregnant Diet Avoid raw meat, fish, etc. Carefully wash vegetables and fruits Limit process meats, fish, soft cheeses Limit refined sugars Avoid Alcohol once pregnant Limit Caffeine OB, obesity and litigation Walking the fine line between frank counseling of risk and discrimination because of disability 5

6 Lifestyle Modification Recommend losing 7% of body weight with Increase exercise to 150 minutes of moderate activity such as brisk walking Reduce caloric intake by kcal/day (composition of diet may not be crucial) Multi-disciplinary approach with support structure (UAB s PCOS Eat Right Clinic) Obesity and Reproduction: A Committee Opinion. Fertil Steril (5) PCOS and Exercise Aerobic Exercise 30 minutes 3 4 x week ( kcal) 40% improvement in insulin sensitivity lasting 48 hours Defronzo RA, Diabetes 1997:36,1379 Segar KR, J Appl Physiol 1991; 71; month exercise regimen (92 min / week) 5% reduction in BMI and improved glucose dynamics 60% had return of menstrual cycle Vigorito C, et al, JCEM (online) February 2007 Realities Only 20% of patients lose 10% of body weight 60 86% of lost weight regained at 3 years % of lost weight regained at 5 years Obesity and Reproduction: A Committee Opinion. Fertil Steril (5)

7 Starbucks Baby?? Starbucks Baby?? KEEP IT SHORT (<180) Tll Tall up to 280 mg Grande up to 375 mg Venti up to 475 mg Optimizing Natural Fertility Age Sexual Activity Coital Practices Frequency Lubricants Timing or Fertility Window 7

8 Age and Fertility ASRM, 2013 Timing of Intercourse Probability of Conception 221 patients, a total of 625 normal menstrual cycles Days Wilcox AJ, et al. N Engl J Med 1995;333:517 Dunson DB, et al, Hum Reprod 2002;1399 Day of Conception ASRM,

9 Myths of Male Reproduction More Sex is better (abstinence interval) Boxers versus brief Hot tub / Baths (temperature matters??) Consider male pre natal vitamins Avoid common TOXINS: tobacco, THC, Testosterone I am fine I have kids, a great libido, no ED, etc so I am FERTILE Health and Age doesn t matter Coital Frequency and Conception 221 healthy fertile couples Attempted Daily Intercourse: Increased stress Decreased sexual esteem Decreased satisfaction Decreased frequency Fecundity Daily QOD Q 3 day J Endo Invest, 2003 Abstinence Interval and IUI Pregnancy Rate Retrospective study of 929 cycles Abstinence positively correlated with count and negatively with motility days >10 0 Abstience Interval Jurema MW, Fertil Steril 2005;84:678 9

10 Coital Practices and Conception No position or practice (resting supine) increases fecundity Organism decreases transit time Lubricants must be chosen carefully Most Bad for sperm Pre Seed or ConceivEase Pre pregnancy Thyroid Screening Universal screening not recommend Screen with risk factors: Family or personal history of thyroid disease Symptoms or Signs of hypothyroidism Type 1Diabetes Infertility (if irregular cycles and prolactin) History of miscarriage or preterm delivery History of autoimmune conditions History of upper body radiation ASRM Practice Committee, 2016 ACOG Committee Opinion, 2007 Pre Pregnancy Screening: Glucose Intolerance PCOS Family History African American, Latino/Hispanic or American Indian History of Gestational Diabetes or baby greater than 9 pounds Hypertension Hyperlipidemia Physical Inactivity Metabolic Phenotype? Endocrine Society, Screening for Type 2 Diabetes, Hormone.org 10

11 Pre pregnancy Screening: Ovarian Reserve Infertility and older than 35, amenorrhea,?menopausal symptoms AMH Basal FSH AND Estradiol Basal Antral follicle count (ovarian volume) CCCT Inhibin Response to medication Recommended Screening: Genetics or Carrier Status Screen for Fragile X With premature ovarian failure (POI) OR elevated FSH before 40 screen for Fragile X Unexplained MR, autism or developmental delays Ethnicity?? and family history based screening Only 27 33% correctly identified their ethnicity African American: Sickle Cell OFFER to ALL ethnic groups: Cystic Fibrosis Greek, Italian, Southern Asians: Thalassemia Eastern Europeans Jews, (French Canadians): Tay Sachs, Canavan, CF, Familial dysautonomia Offer carrier status screening (genetic counselors) Recommended Screening: Genetics or Carrier Status Offer Genetic Counseling and/ screening if personal or family history of: 11

12 Failure to Screen Awards $600K failure to screen African American for SC $1 million for Thalassemia did not take family history $1.25 million failure to screen Ashkenazi Jewish family for Canavan Disease $1.2 million did not test for Fragile X with family history of mental retardation and autism $14 million claim by CF carrier for wrongful life Defense Verdict (patient given a pamphlet) Systematic Approach Treatment Approaches Timing Lifestyle modification CC or Letrozole 3 cycle with OPK and TI 3 with ultrasound monitoring and IUI IUI earlier in unexplained or mild male factor Consider adjuctive therapy Metformin Dexamethasone Gonadotropins / IUI Ovarian Drilling IVF 12

13 Conclusions: All counseling, evaluations and treatment should be AGE sensitive and tailored to the individual patient s circumstances Diet and Lifestyle Modification Pre conceptual counseling and risk Assessment is crucial Systematic genetic screening 13