Fertility Issues

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Fertility Issues

• Dr Jane Stewart
• Newcastle Fertility Centre at LIFE

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Fertility

• Who to refer
• When to refer
• How to refer
• Secondary care provision and changes
• Tertiary care
• Licensed treatments
• Primary care support

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• 1 in 7 couples will experience a problem with
  conception in their reproductive lifetime.

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Who/when to refer primary care

• Reassurance as appropriate
• Referral as appropriate
• Other options

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Normal Cumulative Pregnancy Rate
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Factors important to fertility

• Eggs
• Sperm
• Tubes
• Sex

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Primary Care Assessment

• Fertility
• Risk factors
• Ovulation
• Sperm
• Tubes
• Sexual function
• NICE 2004

• General
• General health and wellbeing
• Sexual health
• Weight, smoking, alcohol
• Folic acid
• Smear
• FBC, TSH, rubella

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Who/when to refer

• Immediately
• Significant risk factors
• Identified cause
• Early
• Significantly anxious
• Female age gt35 years
• Otherwise
• At 1-2 years trying

• Issues
• Female age
• Relationship
• Welfare of the child
• Medical/psychiatric problems
• Desire to proceed

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Old Technologies

• Acceptance of childlessness
• Adoption
• Fostering
• Extended families

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Unexplained subfertility

• 2 years failure to conceive with regular
  intercourse and normal investigations

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Ideal Referral

• Details of both partners
• Relationship
• Duration of trying
• Salient risk factors
• Significant medical/psychiatric history
• Previous pregnancies/children
• WoC issues

• Confirmation of ovulation
• FBC, rubella (TSH)
• Semen analysis (x2 if relevant)
• Tubal patency if access
• With results in the letter.

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Referral Pathways

• PCT directed
• 2y/3y services
• Patient choice
• Choose and book
• Treatment availability
• There are no eligibility requirements for
  fertility assessment.

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Secondary Care Provision

• Investigation
• More detailed investigation
• Tubal patency testing

• Unlicensed treatments
• Licensed treatments
• Overlap with tertiary centres

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Aims of Process

• WITHOUT UNDUE DELAY
• Diagnose a cause where possible
• Reassure if appropriate
• Give an estimate of chance of conceiving without
  treatment
• Offer appropriate treatment options
• Provide timely access to appropriate treatment

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Unlicensed treatment

• Ovulation induction
• Clomifene
• Gonadotrophins
• GnRH
• Scanning facilities

• Sperm prep facilities
• IUI-H
• GIFT
• Changing profiles

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EUTCD

• HFEA
• Bring under licence from April 2007 (now June
  2007)
• Sperm prep
• IUI-H
• GIFT

• EU directive
• Stringent tissue handling conditions

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Tertiary Referral

• 2y care facilities
• Unlicensed treatments
• Licensed treatments
• Non- ART
• ART

• GP support for tertiary treatment
• Welfare of the child
• Pregnancy support

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GP support for 2y/3y treatment

• Prompt appropriate referral
• Welfare of the child
• Ongoing medical/psychiatric management
• Weight management
• Counselling
• Pregnancy support
• Shared prescribing

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PCT Support

• Facilitate access to pathway of care
• Provide appropriate funding to comply with the
  NICE Guidelines and the associated DoH targets
  allowing treatment to be provided in a timely
  fashion
• Determine local criteria for application of
  limited funding
• To apply funding criteria equitably
• Remain open to new developments

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NFCL - What do we do?

• Clinics
• Trans-vaginal ultrasound scanning
• Andrology
• Embryology
• Treatment
• Counselling
• Education
• Multidisciplinary links
• Research

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Clinics

• Fertility
• Accept 1y, 2y and 3y referrals
• Investigation, results review, treatment options
  discussed
• Gynae-endo
• Investigation endocrine related fertility
  problems
• Management ovulatory dysfunction

• Young peoples clinic
• Advice on fertility for future
• Oncology/endocrinology/urology etc.
• IVF clinics
• Investigated patients arranging treatment
• Follow-up following unsuccessful treatment
• PP clinic

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Trans-vaginal Ultrasound

• Diagnostic
• Natural cycle follicle tracking for DI/IUI
• Ovulation induction
• Ovarian stimulation for IVF
• Early pregnancy
• Up to 30 scans/morning 5 days/week and Sat am
  limited facility

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Andrology

• Diagnostic service
• Semen analysis Newcastle
• Pre-treatment assessment semen
• Epididymal/testicular sperm processing
• Sperm storage
• Pre-treatment/post retrieval
• Oncology
• Sperm donor bank

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Embryology

• IVF
• ICSI
• Embryo freezing
• Embryo culture
• PGD
• Research

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Treatments

• Ovulation induction
• Clomiphene/gonadotrophins/GnRH
• IVF
• ICSI, sperm retrieval, embryo freezing
• Donor gametes/ embryos
• Surrogacy
• Fertility preservation
• Sperm storage
• Embryo storage

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Counselling

• Treatment implications counselling
• Fertility therapeutic counselling
• Psychosexual counselling
• Fertility awareness

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Other activities

• Well established clinical links with other
  specialties
• Education
• Research

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Future Fertility Issues

• Fertility preservation
• PGD
• Donor recruitment strategies
• New technologies

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www.nfc-life.org.uk