Managing unwanted childlessness Dr Jodie Semmler fertility SA Dr Louise Hull Senior lecturer in reproductive medicine WCH, University of Adelaide and fertility SA ‘For unflagging interest and enjoyment, all other forms of success lose their importance in comparison to a household of children’ Theodore Roosevelt Age makes a difference Lifestyle Advice • • • • • • • • • Intercourse every 2-3 days optimises conception Fertile times of the cycle Moderate alcohol intake (no binges) Stop smoking Optimal BMI between 19 and 25 Avoid Drugs Avoid occupational exposures to solvents etc Folic acid, Vit B 6 and 12 supplements, Omega 3 Vitamin supplementation (Vit E and Selenium) Causes of difficulty conceiving Eggs Sperm Need to meet EGGS! Assessing Ovulation • Are your cycles regular? • Mid luteal prog – day 21 if day 28 cycle, day 28 if 35 day cycle (timing critical) • Basal body temperature • LH kits • Cycle tracking Ovarian Reserve Ovarian reserve may be reduced even if ovulatory Assess with egg timer test day 3-5 FSH AMH ovarian volume and antral follicle count If low ovarian reserve –prompt referral for fertility advice. Associated with poor response to gonadotrophins, possibly poor oocyte and embryo quality if markedly reduced, ?increased miscarriage Anovulation • Hypothalamic dysfunction (normal FSH/LH) • Hypogonadotrophic hypogonadism (low FSH/LH) • Premature menopause (high FSH/LH) • Hyperprolactinaemia (high PRL) • Abnormal thyroid function (high TSH) • Polycystic ovarian syndrome • Tests- day 3 FSH, LH, PRL, TSH, androgens if suspect PCOS • USS pelvis –ovarian reserve, PCOS Hypothalamic Dysfunction • • • • Simple Environmental Causes Exam/ other stress Travel Perimenarchal • Weight related Causes • Anorexia/malnutritian • Exercise induced amenorrhoea • Psychiatric • Depression • Organic Causes (pan hypopit) • Brain tumors –need MRI • Endocrine disorders Ovarian Failure high FSH and LH and low E2, normal prolactin and thyroid Further Investigations may include: chromosomes autoantibody screen bone mass lipids Treatment – donor oocyte programme estrogen replacement therapy counselling Prolactin • Elevated prolactin on 2 occasions • Galactorrhoea, breast discomfort, visual field abnormalities • MRI/CT pituitary • Treat with Carbergoline (0.5mg weekly) Thyroid disorders TSH to screen • Symptoms • Goitre/thyroid enlargement • Referral to endocrinologist/surgeon for treatment and ongoing care. Polycystic ovarian syndrome 2 out of 3 of: • Oligo/ammenorrhoea • Clinical and/or biochemical signs of hyperandrogenism • Ultrasound • And exclude other causes of anovulation PCOS consensus agreement ESHRE/ASRM (Rotterdam) 2003 Hum. Reprod, (2004) 19,1:41-47 PCOS Investigations Investigations: Insulin resistance (blood glucose) Lipids Endometrial thickness PCOS fertility treatment • • • • • • Weight loss Clomiphene Metformin Ovulation Induction with FSH Ovarian drilling IVF –risk of OHSS Ovulation Induction Sperm Male Factor Disorder • History – – – – – – Previous surgery/trauma Congenital problems Infections (mumps orchitis/STDs) Other illnesses (cancer/chemotherapy) Smoking, drinking, drugs Occupational exposures Semen Analysis More than 1 semen Analysis usually required (3 months apart) • Normal SA • >20 million per ml • >50% forward motility • >3% normal morphology (WHO strict criteria) Other sperm defects • Kruger et al 1986 (strict morphological criteria) • <15% normal morphology (old criteria) associated with reduced IVF fertilisation even with normal counts. No data yet with new reference ranges, 4% normal shapes is 5th centile, may be fertilisation issue if less than eg 8% • ICSI restored fertilisation rates Investigation of an abnormal semen Analysis • If semen Analysis abnormal - repeat S.A. • If mild/ moderate oligozoospermic (majority) - IUI/IVF/ICSI • If azoospermic/severe oligozoospermia -further investigations Investigations of Severe Semen Defects FSH/LH/testosterone/PRL/TSH If abnormal then MRI pituitary USS testes (tumour) Chromosomes/CF mutations/Y chromosome deletions Management Hypogonadotrophic hypogonadism -FSH treatment Mild sperm defects -IUI Testicular failure -ICSI/TESA/donor sperm Obstructive azoospermia -PESA/TESA Intrauterine Insemination 15-40% chance of pregnancy over 3 cycles (very dependent on patient selection) FSH Injections to ensure 1 or 2 eggs present at insemination Need patent fallopian tubes Risk of multiple pregnancy Low sperm morphology , unexplained and endometriosis patients do poorly PESA/TESA ICSI IVF+/- ICSI approx 50% chance of pregnancy in 1 cycle if < 38yrs Meeting up Assessing Sexual dysfunction (5%) • Male history important – – – – – How often do you make love? Do you get erections? Can you penetrate your partner deeply? Do you reach orgasm? Do you ejaculate? Assessing Tubal Damage • Have you had tubal surgery, endometriosis, painful periods, appendicitis or infections like chlamydia? • If no- HSG (reliable indicator of tubal patency not obstruction) • If yes- consider laparoscopy and dye • History of Tubal ligation/reversal – high chance tubal issues • Congenital anomalies - best assessed by MRI, 3D ultrasound, Hy Cosi or saline sonogram. HSG not as accurate for this Endometriosis Tubal damage, Oxidative damage to oocytes/embryos Eutopic endometrial changes (implantation problems) Painful intercourse Management: Surgery, GnRH agonists before IVF Other causes Unexplained Failed Fertilisation (5-10% IVF cycles) Implantation Failure Recurrent Miscarriage IVF Who needs referral? Referral to Fertility Services • All couples concerned about fertility should be offered a consultation • Further investigation should be offered after 1 year of failing to conceive • Earlier investigation should be offered to: – Women >35 years – History suggestive of anovulation, tubal disease, pelvic surgery, endometriosis or male factor problems – Family history of early menopause The goal of treatment A single healthy baby born at term