Brighton & Hove CCG PLS CONFERENCE 2016 Dr Carole Gilling-Smith Medical Director
FERTILITY CHALLENGES IN THE NHS A TERTIARY CARE PERSPECTIVE
LEARNING OBJECTIVES Understand the pathways through assisted conception Understand what patients will be going through Managing disappointment Managing early pregnancy and beyond Routes to care when the NHS won t fund Not eligible Donor sperm (single women, same sex couples) Male infertility(non-obstructive azospermia) Fertility preservation Cancer (oncofertility) Gender re-asignment
BEYOND INVESTIGATIONS NHS TREATMENT OPTIONS Ovulation induction Intrauterine insemination (IUI) IVF ICSI
OVULATION INDUCTION 6 cycles Clomifene PCOS diet & exercise + Metformin (Ovarian Diathermy) 2-3 cycles Low Dose FSH injections Hypogonadotrophic Hypogonadism
FOLLICLE TRACKING Day 8 Day 11 Day 13 18mm Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
INTRAUTERINE INSEMINATION Uterus Cervix Prepared Sperm Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
IVF TREATMENT Exponential rise in IVF babies over 35 years: 1990: 90,000 2000: 900,0000 2007: 2.5 million 2013: 5 million Accounts for 2% of all babies born in the UK So far no long terms risks associated with treatment to mother or child
FROM REFERRAL TO TREATMENT CCG Funding approval to first appointment 2-4 weeks Patient called and initial appointments booked Baseline pelvic ultrasound scan (antral follicle count) Dr s consultation Nurse s consultation +/- semen analysis IVF injection treatment start 6-8 weeks after CCG approval received unless patient defers
AT INITIAL MEDICAL CONSULTATION Couple complete a Patient History Booklet prior to consultation Couple elect to disclose their information to third parties or not (HFEA disclosure form) Detailed medical history taken and results of all investigations reviewed Powerpoint slides used to explain every step of the treatment to couple, risks and success rates Final treatment plan agreed and documented Counselling offered
CONFIDENTIALITY
AT NURSE CONSULTATION Couple go through medication plan and learn how to do self-injections Talk about possible side effects (headaches, tiredness, mood swings) Dates are agreed for treatment Couple complete HFEA consent forms for IVF including embryo freezing Welfare of the Child forms completed Referred for anaesthetic review if necessary NOTES taken to MDT where indicated
CONSENT FORMS
NATURAL CONCEPTION: FERTILISATION AND EMBRYO FORMATION Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
IVF: TYPICAL PROGRAM Phone to book 1 st scan HCG FSH injections Buserilin Injections Egg Collection Embryo transfer Oral Contraceptive Pill (daily) 1 14-21 6 10 12 37h 48-72h Scan Scan Scan Scan Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
FOLLICLE TRACKING FOR IVF Day 5 Day 7 Day 10 18mm Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
VAGINAL EGG COLLECTION Fallopian Tube Egg collection needle Ovary Vaginal probe Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
EGG COLLECTION: FINDING THE EGG Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
INSEMINATION (3 HOURS) Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
ISCI (3 HOURS) Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
CULTURING EMBRYOS IN INCUBATORS
TWO PRONUCLEAR STAGE (24 HOURS) Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
EIGHT CELL EMBRYO (72 HOURS) Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
DAY 5: BLASTOCYST STAGE AND EMBRYO HATCHING) Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
EMBRYO TRANSFER (ET) Bladder Ovary Embryo Transfer Catheter Uterus Speculum Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
AGORA RESULTS / NATIONAL AVERAGE: HFEA PUBLISHED DATA IN THE YEAR ENDING 2 ND QUARTER 2013 LIVE BIRTH RATE (%) PER FRESH IVF/ICSI TREATMENT CYCLE STARTED 40 35 30 25 20 15 10 5 0 37.1 32.5 34.2 28.5 23.9 21.1 7.3 14 16.7 under 35 35-37 38-39 40-42 43-44 Agora National Average 6
AGORA LATEST RESULTS: CLINICAL PREGNANCY RATE (%) PER FRESH IVF/ICSI TREATMENT D2,D3 ET VS D5 ET July 14- July 15 60 50 54 49 45 40 30 20 30 33 26 18 24 25 10 0 0 under 35 35-37 38-39 40-42 43-44 D2 or D3 ET D5 ET
COMMON FEARS OF IVF
How do I know you are mixing the right sperm with my eggs? IVF Mix up in 2002 prompted double witnessing
OVARIAN HYPERSTIMULATION SYNDROME
USEFUL INFO FOR GPS Vaginal egg collection is done under IV sedation so patient needs to take the day off work They are given a discharge letter for GP/A & E Agora has an on-call mobile for all out of hours emergencies Embryo transfer is 2-5 days after treatment Some ask for a sick note to take a few days off work (stressed++) Pregnancy test is done 10 12 days after embryo transfer by the patient
USEFUL INFO FOR GPS If pregnancy test is negative: follow up consultation booked Important to remember the stats IVF is a treatment program not just one cycle If pregnancy test is positive: Early pregnancy scan done at 7 weeks Report issued and given to patient for GP Progesterone supplements continued to 8 weeks Discharged to normal antenatal care
USEFUL INFO FOR GPS If there is no fetal heart/bleeding: Referred to EPAC If there is OHSS: Managed as out patients by the Agora Referred for admission if concerns
MANAGING MALE INFERTILITY [FSH] + [LH] + Bilaterally small testes Non obstructive azospermia (NOA) (testicular failure) Chromosome abnormalities Y chromosome micro deletions [FSH] + [LH] + or normal [testosterone] Pre-testicular Hypothalamic disorders Pituitary tumor? Imaging Normal [FSH] + [LH] Non obstructive azospermia or obstructive azospermia? Testicular biopsy
SURGICAL SPERM RETRIEVAL Copyright Agora Fertility Clinic 2014 - www.agoraclinic.co.uk
SPERM CRYOPRESERVATION
WHEN THE NHS WON T FUND TREATMENT Patients wishing to use donor sperm can only access this as self-paying (private) patients Single women Same-sex couples Couples where the male has untreatable azospermia Patients wishing to egg donation can only access this as self-paying (private) patients Altruistic or known egg donors Egg sharing
TREATMENT OPTIONS WITH DONOR SPERM Natural Cycle intrauterine insemination (IUI) Stimulated cycle IUI IVF or ICSI Donor eggs + donor sperm with IVF or ICSI
EGG DONATION OR EGG SHARING Partner 1 donates eggs Option to egg share Eggs and donor sperm mixed to form embryos Receives embryo (s) and carries baby Partner 2
Surrogacy; A legal minefield They need to adopt the child when he/she is born A commercial venture in the USA (50K)
CCG FUNDING OF FERTILITY PRESERVATION Rapid access service to store sperm, gametes and eggs is available locally Patient seen by oncologist and options discussed Referral letter faxed over Viral screening complete Consultant assessment booked within 24 hours Egg or embryo freezing offered if timescales allow Sperm can be collected in the hospital or hospice setting
AN EVOLVING CHALLENGE: FERTILITY PRESERVATION IN YOUNG ADULTS Cancer & chronic disease associated with loss of sperm or eggs Increasing numbers of young patients seen prior to gender reasignment hormone treatment or surgery Difficulties with obtaining samples and consent In cancer cases dilemmas can arise if the child dies? Can the parents use the sperm or eggs to re-create their lost child? Can the mother or father can store eggs or sperm for their child s future use?
Thank You