Practical Workshop about Fertility in NZ Dr Sarah Wakeman Fertility Associates Christchurch Dr Mary Birdsall Fertility Associates Auckland Professor Wayne Gillett Otago Fertility Service and University of Otago
Individualised Fertility Assessment and Counselling Dr Sarah Wakeman FRANZCOG, CREI Medical Director Fertility Associates Christchurch
Who will come to see you? Couples heterosexual - same sex Single women After trying to conceive for a while Before trying to conceive Seeking contraception and future advice
Patient assessment female History How long trying for Previous pregnancies outcomes and how long to conceive Menstrual history Timing of intercourse Gynaecological history past surgery, STDs Medical/surgical history Family medical history Lifestyle ETOH, smoking, weight, exercise, work
Patient assessment female Examination Target history Ht Wt, BP Pelvic exam smear and swabs bimanual
Patient assessment male History Issues with sexual intercourse Pelvic or abdominal injuries or surgery Other medical history Family medical history Lifestyle ETOH, smoking, weight, exercise, work
Patient assessment male Examination HT, wt, BP Scrotum, testes, epididymis, vas deferens, penis Masses Testicular size Varicocele
Investigations Female Smear and swabs Day 3 FSH (plus AMH) Day 21 progesterone (or adjust to cycle length) Rubella status, Hep B, C, HIV, TSH, prl, FBE Perhaps pelvic USS Early in cycle, TV, antral follicle count, ovarian volume
Investigations AMH GP should only do if comfortable interpreting High levels -? PCOS Low levels for age Low ovarian reserve Earlier menopause May effect fertility
Investigations Male Semenalysis Count 15million/ml Motility more than 40% motile Morphology may not be available If available more than 4% normal using WHO 2010 criteria IF SA ABNORMAL PLEASE REPEAT
Density *10 6 /ml Fertile Man - Once/wk for 2 yrs
Investigations Specialist level Tubal patency HSG or SIS Laparoscopy and dye test and hysteroscopy
Management in General Practice Refer early if clear problem Eg infrequent periods Severe pelvic pain Abnormal semenalysis x2 Unexplained delay of less than 12-18 months could be managed in general practice
Chance of Pregnancy Drops with age Age < 30 years 37 years 40 years
Management in General Practice Improve lifestyle Smoking ETOH Caffeine Weight Sperm health loose underwear, frequency of ejaculation, avoid laptops on thighs Timing of intercourse/ expectant management Folic acid and iodine
Lifestyle and Fertility Smoking Females Longer to conceive reduces chances of pregnancy by half on treatment Earlier menopause Effects on fetus and newborn Males Longer for partner to conceive Effects sperm count, motility and morphology Increased risk of child having leukaemia Note passive smoking
Lifestyle and Fertility Alcohol Females Reduced fertility with heavy drinking Many studies showing effect even with low-mod amounts ETOH Safest advice is no alcohol Males Reduced fertility with 20 units or more a week
Lifestyle and Fertility Caffeine coffee, tea, soft drinks, chocolate Females Some evidence of fertility delay and lower chances of pregnancy with treatment with higher intakes Increased risk stillbirth with higher intakes Males Less evidence
Lifestyle and Fertility Weight Females Overweight greater BMI, less chance of pregnancy Increased risks in pregnancy Long term effects on child Underweight Males Ovulation disorders Lower chance of conceiving Overweight Effects sperm parameters Partner may have lower chance conceiving
Timing of intercourse Woman cycle length Mucous changes - Apps - Fertility Friend, Period Tracker - Regular intercourse every 2 nd day - From day 10 of cycle for a week
When to refer? Before a year if clear problem At a year if problem or if woman older than 35 yrs Definitely by 2 years for others Health Pathways criteria for public referral Fertility Associates Christchurch Christchurch Women s hospital Otago Fertility Service