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Fertility Assessment
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Fertility AssessmentThe Reproductive Medicine UnitUCLHRehan Salim MD MRCOGConsultant Gynaecologist
Infertility definitionFailure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology
Prevalence15% of couplesrelated to age of female partnerrelated to history of sexually-transmitted disease
Probability of pregnancy84% in 1st year92% in 2nd year
Age, fertility & miscarriage
Risk of Downs syndrome birth by maternal age
Assisted conception HFEA 2007
Mean age of mother at birth, England and Wales, 1970-2006office of national statistics
Chart1
26.7193413009
26.6189674364
26.5207226104
26.4140286877
26.3624310617
26.4359317332
26.5214602062
26.6343954229
26.7222948819
26.8292784763
26.8859129075
27.007114933
27.1047450212
27.2074643284
27.2851258588
27.3272923962
27.3829714811
27.4536238124
27.4534403257
27.5639235448
27.6524961692
27.7150699121
27.8515978552
27.9469858293
28.1162862506
28.1771274717
28.1837314163
28.275166221
28.342139314
28.387587467
28.5036227713
28.5848327019
28.7013234098
28.8342773929
28.9375117144
29
29.1
p
Year
Figure 2
Figure 2:Standardised mean age of mother at birth, 1970-2006
YearMean age
197026.7
197126.6
197226.5
197326.4
197426.4
197526.4
197626.5
197726.6
197826.7
197926.8
198026.9
198127.0
198227.1
198327.2
198427.3
198527.3
198627.4
198727.5
198827.5
198927.6
199027.7
199127.7
199227.9
199327.9
199428.1
199528.2
199628.2
199728.3
199828.3
199928.4
200028.5
200128.6
200228.7
200328.8
200428.9
200529.0
200629.1
Figure 2
p
Year
Age at referralHFEA 2007
ObesityBMI < 30 (ideal 28) kg/m2Reduces fertilityIncreased risk ofAnovulatory cyclesMiscarriageGestational diabetesHypertensionThromboembolismObstetric delivery problems
Managementtreat couplerefer to specialist clinic systematic investigationappropriate treatmentrecognise emotional impactWelfare of the child
When to referone year unprotected intercourseearlier ifwoman over 35oligo- or amenorrhoeasignificant historyeg previous ectopic pregnancy, PID, endometriosis
InvestigationsGeneral healthBMIRubella immunityHepatitis B,C & HIV(cervical screening)Triple swabs
Fertility tests: semen analysisuse lab of referral unitoperator-dependentWHO criteria: count >20 million/mlmotility >50%morphology >50% normal
Investigations 1 14 21 28 Day of cycleOvarian functionOvulationProgesterone
Investigations 1 21 28 35 Day of cycleOvarian functionProgesterone
Investigations 1 11 18 25 Day of cycleOvarian functionProgesterone
Ovarian functionOvarian reserveThe capacity of the ovary to provide eggs that are capable of fertilization resulting in a healthy and successful pregnancyMeasure ofFertilityRisk of miscarriageChances of success with treatment
Ovarian functionFSH and oestradiol early in the cycleovarian ultrasound for antral follicle count
FSHOestradiol
Antral follicle count
AFC and age
Fertility tests: ultrasound
OvulationMid luteal phase progesterone28 day cycleDay 21
Tubal patency
Tubal patency
Laparoscopy
Summary of investigationsDay 1 5FSH, LH, OestradiolUltrasound Day 7-10HSGHyCoSyDay 21 (or 7 days after ovulation)Progesterone
Summary of investigationsRubella immunityHepatitis B,C & HIV(cervical screening)Triple swabs
Semen analysis
Treatment optionsReassure and waitOvulation inductionAnovulationSuperovulation & intrauterine inseminationMild male factorUnexplainedMild endometriosis
Treatment optionsIVFtubal damagesevere male factorsevere endometriosisunexplained infertility if prolonged or older womanfailure of simple treatment
The Reproductive Medicine UnitOut-Patient ClinicsSuperovulationIntrauterine Insemination (IUI)Ovulation Induction (OI)IVFUltrasonography (USS)Oncology StorageFertility and Psycho-sexual counselling
Success Rates 2007IUI
RMU - IVFFull range of IVF treatments(IVF, ICSI, Surgical sperm retrieval)Collaboration with The Assisted Conception UnitPCT contractsHaringeyKensington & Chelsea?Barnet
ACU IVF success rates
Fertility AssessmentThe Reproductive Medicine UnitUCLHRehan Salim MD MRCOGConsultant Gynaecologist