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

Infertility general adviceSexual intercourse every 2-3 daysStop smoking & reduce caffeine intakeAlcohol

ObesityBMI < 30 (ideal 28) kg/m2Reduces fertilityIncreased risk ofAnovulatory cyclesMiscarriageGestational diabetesHypertensionThromboembolismObstetric delivery problems

UnderweightBMI

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