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					          Fertility Issues

Dr Jane Stewart
Newcastle Fertility Centre at LIFE
               Fertility

 Who to refer
 When to refer
 How to refer
 Secondary care provision and changes
 Tertiary care
 Licensed treatments
 Primary care support
1 in 7 couples will experience a problem
with conception in their reproductive
lifetime.
   Who/when to refer – primary
             care

 Reassurance as appropriate
 Referral as appropriate
 Other options
                                               Normal Cumulative
                                                Pregnancy Rate
                                     100
% of couples that have




                                      90
                                      80
                                      70
                         conceived




                                      60
                                      50
                                      40
                                      30
                                      20
                                      10
                                       0
                                           0             1         2

                                                       Years
      Factors important to
            fertility
 Eggs
 Sperm
 Tubes
 Sex
       Primary Care Assessment

 Fertility               General
      Risk factors           General health and
      Ovulation               wellbeing
      Sperm                  Sexual health
      [Tubes]                Weight, smoking, alcohol
      Sexual function        Folic acid
                              Smear
                              [FBC, TSH], rubella

   NICE 2004
             Who/when to refer

 Immediately                     Issues
     Significant risk factors        Female age
     Identified cause                Relationship
 Early                               Welfare of the child
     Significantly anxious           Medical/psychiatric
                                       problems
     Female age >35 years
 Otherwise
                                      Desire to proceed
     At 1-2 years trying
         Old Technologies

 Acceptance of childlessness
 Adoption
 Fostering
 Extended families
                                               Unexplained subfertility

                                     100
                                                                           2 years failure to
                                                                            conceive with
% of couples that have




                                      80

                                                                            regular intercourse
                         conceived




                                      60

                                      40                                    and normal
                                      20
                                                                            investigations
                                       0
                                           0           1              2

                                                     Years

                                                  <35yrs     >40yrs
               Ideal Referral

 Details of both         Confirmation of
  partners                 ovulation
 Relationship            FBC, rubella (TSH)
 Duration of trying      Semen analysis (x2 if
 Salient risk factors     relevant)
 Significant             [Tubal patency if
  medical/psychiatric      access]
  history
 Previous                With results in the
  pregnancies/children     letter.
 WoC issues
            Referral Pathways

 PCT directed
     2y/3y services
     Patient choice
     Choose and book
     Treatment availability

     There are no eligibility requirements for
      fertility assessment.
      Secondary Care Provision

 Investigation        Unlicensed
     More detailed     treatments
      investigation
      Tubal patency
                       Licensed
  

      testing
                        treatments

                      Overlap with tertiary
                       centres
            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
         Unlicensed treatment

 Ovulation induction    Sperm prep
     Clomifene           facilities
     Gonadotrophins     IUI-H
     GnRH               [GIFT]
 Scanning facilities


                         Changing profiles
                       EUTCD

 HFEA                       EU directive
     Bring under licence        Stringent tissue
      from April 2007             handling conditions
      (now June 2007)

         Sperm prep
         IUI-H
         GIFT
            Tertiary Referral

 “2y care” facilities    GP support for
 Unlicensed               tertiary treatment
  treatments                  Welfare of the child
 Licensed                    Pregnancy support
  treatments
     Non- ART
     ART
           GP support for 2y/3y
                treatment

   Prompt appropriate referral
   Welfare of the child
   Ongoing medical/psychiatric management
   Weight management
   Counselling
   Pregnancy support
   Shared prescribing
              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
        NFCL - What do we do?

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

 Fertility                     Young peoples clinic
    Accept 1y, 2y and 3y          Advice on fertility for
     referrals                      future
    Investigation, results
                                   Oncology/endocrinology/
     review, treatment
     options discussed              urology etc.
 Gynae-endo                    IVF clinics
    Investigation endocrine       Investigated patients

     related fertility              arranging treatment
     problems                      Follow-up following
    Management ovulatory           unsuccessful treatment
     dysfunction
                                PP clinic
      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
                        Andrology

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


 IVF
 ICSI
 Embryo freezing
 Embryo culture
 [PGD]
 Research
                  Treatments

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

 Treatment implications counselling
 Fertility therapeutic counselling
 Psychosexual counselling
 Fertility awareness
           Other activities

 Well established clinical links with
  other specialties
 Education
 Research
     Future Fertility Issues

 Fertility preservation
 PGD
 Donor recruitment strategies
 New technologies
www.nfc-life.org.uk