Fertility assessment and assisted conception

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1 Fertility assessment and assisted conception Dr Geetha Venkat MD FRCOG Director Pulse Learning Women s health 14 September 2016

2 Disclosure statement Dr Venkat is a director of Harley Street Fertility Clinic. As such, she has an affiliation with and a financial interest in Harley Street Fertility Clinic. Harley Street Fertility Clinic 2016 All rights reserved 2

3 Assessment: the fertility check-up What are we checking? To achieve a pregnancy you need: Eggs assess ovarian reserve and hormone profile Sperm semen analysis Implantation assess endometrial development Harley Street Fertility Clinic 2016 All rights reserved 3

4 Female investigations D2-5 Scan to visualise the ovaries Blood test for FSH, LH, E2 (baseline levels) Midcycle (D10-12/28) Scan to visualise development of endometrium Midluteal (D21/28) [not performed as routine] Scan to confirm ovulation Blood test for P4 (progesterone) Other bloods: AMH assess ovarian reserve Thyroid function (Free T4, TSH) controls fertility Prolactin inhibits FSH and GnRH Harley Street Fertility Clinic 2016 All rights reserved 4

5 Male investigations Semen analysis 2-5 days abstinence for optimum sample Vitamin D level Harley Street Fertility Clinic 2016 All rights reserved 5

6 Initial investigations at GP FSH, LH, Oestradiol (Day 2-5) AMH key for ovarian reserve Thyroid function (TSH, Free T4) Prolactin Vitamin D Harley Street Fertility Clinic 2016 All rights reserved 6

7 Further investigations Day 21 Progesterone Should be mid-luteal Timing is important, especially for women with irregular cycles e.g. PCOS => No need to perform ultrasound scans prior to referral. Harley Street Fertility Clinic 2016 All rights reserved 7

8 Further investigations Tubal testing Hysterosalpingogram (HSG) visualised by X-ray HyCoSy visualised by ultrasound => When: after bleeding and before ovulation Harley Street Fertility Clinic 2016 All rights reserved 8

9 When to refer Female age Duration of infertility <35 2 years year > months Other criteria for immediate referral: Family history of premature ovarian failure: FSH alone is not enough, test AMH Low ovarian reserve (AMH < 5 pmol/l) Severe male factor Harley Street Fertility Clinic 2016 All rights reserved 9

10 Treatment options Try naturally Timed Sexual Intercourse (TSI) Ovulation induction Intrauterine insemination (IUI) In Vitro Fertilisation (IVF) Egg Freezing Harley Street Fertility Clinic 2016 All rights reserved 10

11 In Vitro Fertilisation (IVF) Stimulate ovaries to produce multiple follicles Eggs are retreived and mixed with sperm in vitro Embryos cultured in the laboratory and transferred a few days later Chance of success: 5-50% Harley Street Fertility Clinic 2016 All rights reserved 11

12 ICSI Process of injecting individual sperm into individual egg Good for: Male factor (poor sperm) Previous failure of fertilisation with IVF Surgically retreived sperm Cryopreserved eggs Harley Street Fertility Clinic 2016 All rights reserved 12

13 Egg freezing New technique of vitrification: >90% survival rate Egg freezing is only PLAN B ICSI will be required to fertilise No guarantee of pregnancy w/ frozen eggs Storage period: up to 10 years (extendable to 55 years) Harley Street Fertility Clinic 2016 All rights reserved 13

14 Education and planning Encourage: Women in their 20s to have a check-up Social egg freezing if not ready yet Harley Street Fertility Clinic 2016 All rights reserved 14

15 Summary Know your patient: family history is important (e.g. premature ovarian failure) When to investigate Investigations: Mid-luteal progesterone AMH ovarian reserve Don t forget the male partner! Discuss options, e.g. fertility preservation Refer as appropriate Harley Street Fertility Clinic 2016 All rights reserved 15

16 Thank you Questions? Harley Street Fertility Clinic 2016 All rights reserved 16