dr olivia stewart dr simon kelly - gp cme north/thurs_room3_1400_kelly... · 2016-06-11 · impact...
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Dr Olivia Stewart
14:00 - 16:00 WS #14: Fertility 101
16:30 - 18:30 WS #20: Fertility 101 (Repeated)
Dr Simon Kelly Obstetrician & Gynaecologist
Fertility Associates
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Fertility Skills Workshop
Dr Simon Kelly and Dr Olivia Stuart
Fertility Associates
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Fertility Skills Workshop• Practical Guide to Common Fertility Issues
– Dr Simon Kelly
• Office Gynaecology
– Dr Olivia Stuart
• What's New in ART?
– Dr Simon Kelly
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Fertility Skills Workshop
“A Practical Guide to Common Fertility Issues”
Dr Simon KellyMedical Director
Fertility Associates, Auckland
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Format of Session• Clinical scenarios
– Lifestyle and Fertility
– Fertility Work-Up
– Fertility Treatment
– Public Funding
– Egg Freezing
• Key Points
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Scenario Number 1
• 34 year old Charlotte, who has just seen you for the flu and then says “hey Doc, I’m thinking about having a baby next year, what should I be doing?”
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Key Things to Discuss
• Supplements
• Lifestyle Factors
• Checking Fertility
• When should I get help?
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Supplements
• Folic acid 0.8mg start 1 month prior to conceiving
• Iodine 150 micrograms begin at pos preg test
• 5mg folic acid : epilepsy, previous neural tube defect or family hx NTD, BMI>30, IDDM
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Lifestyle Factors
• Smoking
• Weight
• Caffeine
• Alcohol
What can I do?
9
Give yourself
the best chance
of conceiving
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Smoking is bad for fertility and
child
Women
• By-products detectable
in fluid around eggs
• Menopause occurs 1 to
4 years earlier
• Zona pellucida (‘egg
shell’) thicker
Men
• Sperm production,
motility, morphology
and increases DNA
damage
• Child born to a father
who smokes has 4 X
risk of childhood cancer
What can I do?
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Smoking is bad for treatment
• Female smoking significantly
reduces ICSI and IVF success rates
• Female smoking doubles risk of early
pregnancy loss
• …and there is no public funding for
female smokers
What can I do?
11
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Weight… What can I do?
12
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Homan, G.F. et al. Hum Reprod Update 2007 13:209-223; doi:10.1093/humupd/dml056
What can I do?
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
<16 16-18 18-20 20-22 22-24 24-26 26-28 28-30 30-32 >32
Relative risk
BMI
Public funding
cut off
Human Reproduction Update
Impact of BMI on female
fertility
13
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Impact of BMI on male fertility
• Obese men (BMI over 28) have sperm counts 22%
lower
What can I do?
14
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Caffeine…What can I do?
15
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Caffeine may impact on
treatment
• Trial looked at babies from IVF
• Group of women with
caffeine>50mg/day had less babies
• Some evidence that any caffeine is not
a good idea
• A Starbucks grande latte has 150mg
caffeine
What can I do?
16
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Alcohol… What can I do?
17
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Alcohol is not good for fertility or child
• Known teratogen (affects embryo / fetus
development)
• Unknown safe level during pregnancy
• Reduces female fertility
• Increases miscarriage risk
• Men >20 standard drinks per week
reduced numbers of pregnancies
What can I do?
18
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Checking Fertility- The Basics!
• AMH
– consider TSH
• Semen Analysis
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AMH
• Blood test
• Any time of cycle
• Can be done on COC, breastfeeding, pregnancy (slightly lower)
• Not funded $85-110 varies with courier
• Assay has been problematic (now more stable)
• Polycystic ovaries v high AMH
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AMH: Anti Mullerian Hormone
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Semen Analysis
• 2-3 days abstinence
• Sample to lab within 90mins
• WHO Criteria (2010)
– Concentration > 15Million/ml
– Motility > 40%
– Morphology > 4% normal
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When should I get help?
• Trying for 12 months
• Ask about contraception
• Consider early referral if:
• >35yrs
• Irregular or absent periods
• Medical or surgical conditions that may affect fertility
eg endometriosis/pelvic surgery/chemo or radiotherapy
• Family history early menopause
• Recurrent miscarriage
• Genetic conditions amenable to PGD
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Scenario 2
• Alice and Sam have been trying to conceive for 18 months: “Do we need IVF Doc?”
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History-Key Aspects
• Treat as couple
• History is critical
– Age
– Duration
– Ask about contraception
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History -Key Aspects Female
• Cycle regularity
• Prior conceptions-current and past
• Gynae problems: STDs/Endo
• Medications
• Prior medical or surgical problems
• Family history
• Smoking
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Fecundity and age
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Even IVF can’t overcome ageing
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History-Key Aspects Male
• Prior paternity
• Erectile problems
• Medical/Surgical history
• Medications
• Smoking
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Drugs and Sperm
• Teststerone/Anabolic steroids
• 5 alpha reductase inhibitors
• SSRIs
• Alpha-blockers
• Calcium Channel Blockers
• Ketaconozole
• Cimetidine
• Colchicine
• Marijuana
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Investigations-keep it simple
• Female:
– AMH (or early menstrual FSH/Estradiol)
– TSH/Serology/Prolactin
– Ultrasound
– ? Progesterone
• Male:
– Semen Analysis
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Treatment Options-The Fertility Ladder
IVF
Insemination
Ovulation Induction
Diagnosis
Age
Duration
Egg DonationSurrogacy
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Public Referral
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Public Funding Scoring
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Publicly Funded Treatment
• Criteria are the same across New Zealand
• People need > 65 points using the fertility CPAC scoring tool
– Score > 65 only means eligible
– All have same wait time till treatment
– Higher score doesn‘t mean more urgent treatment
• The CPAC score can only be calculated by a fertility specialist.
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Waitlist for Treatment
• The wait to treatment varies across the country
• Generally 12–18 months, you can check this when you make your referral to your local clinic.
• You can have a private consultation to access public treatment. This is useful when time is of the essence.
• Patients can access private fertility treatment whilst on the public waiting list.
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Scenario 3
• Caitlin is aged 39 and single: “Should I be freezing my eggs?”
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Egg Freezing
Fertility preservation: • Cancer
• Social
• Religious or ethical objections to embryo freezing
• No sperm at IVF
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Egg Freezing
• 3000 babies
• Vitrification
• Not funded**
• $10k Collection & Freezing
• $5k Insemination & Embryo Transfer • ** may be funded in women requiring cancer treatment
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Egg Freezing – first half of IVF cycle
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Aneuploidy - rate by age
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How many Eggs do I need?
Largest study to dates demonstrates how many eggs required per baby:
• 25-34 required 8 oocytes
• 35-37 required 10 oocytes
• 38-40 required 14 oocytes
• 41-42 required 50 oocytes
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Key Learning Points
• Discuss importance of lifestyle and fertility
• Age is best indicator of fertility
• AMH best test for female fertility
• Refer early!
• The Fertility Ladder
• Public consultation vs funding (CPAC score)
• Freezing Eggs is available but always better to do when younger
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Thank you