Infertility New Issues. Yunus Tayob Clinical Lead in Reproductive Medicine and Reproductive...

InfertilityInfertilityNew IssuesNew Issues

Yunus TayobYunus Tayob

Clinical Lead in Reproductive Clinical Lead in Reproductive

Medicine and Reproductive Medicine and Reproductive

Endoscopic SurgeryEndoscopic Surgery

Referral CriteriaReferral Criteria

BMI BMI

Eligibility for NHS treatmentEligibility for NHS treatment

Investigations – primary careInvestigations – primary care

BMIBMI

> 18> 18

< 32-34< 32-34

Ovulation RatesOvulation Rates

Reduced in both groups Reduced in both groups spontaneous and stimulated cyclesspontaneous and stimulated cycles

BMI < 18BMI < 18

Most likely to have hypothalamic Most likely to have hypothalamic hypogonadotrophic hypogonadismhypogonadotrophic hypogonadism

BMI > 35BMI > 35

Most likely to have PCOSMost likely to have PCOS

DiagnosisDiagnosis

Rotterdam criteria Rotterdam criteria

Acne, hirsutism, obesityAcne, hirsutism, obesity

Hormonal imbalanceHormonal imbalance

Ultrasound appearance of Ultrasound appearance of ovaries ovaries

Requirement 2 of 3 Requirement 2 of 3

Ovarian stimulationOvarian stimulation

Study of 270 women receiving Clomid or Study of 270 women receiving Clomid or GonadotrophinsGonadotrophins

Ovulation rates at 6 monthsOvulation rates at 6 months

79% BMI 18 – 2479% BMI 18 – 24

15.3% BMI 30 – 3415.3% BMI 30 – 34

12% BMI > 3512% BMI > 35

IVF / PCOS / ObeseIVF / PCOS / Obese

Lower implantation ratesLower implantation rates

Lower pregnancy ratesLower pregnancy rates

Higher dose of drugs requiredHigher dose of drugs required

Higher rate of miscarriageHigher rate of miscarriage

This extends to donor egg This extends to donor egg programmesprogrammes

Primary CarePrimary Care

Adopt the role of addressing the issues of Adopt the role of addressing the issues of BMI prior to referral to Secondary careBMI prior to referral to Secondary care

What lifestyle changes to support What lifestyle changes to support your patientyour patient

Discuss BMI and move to low GI dietDiscuss BMI and move to low GI diet

Caffeine reductionCaffeine reduction

Advice both parties to stop smoking and Advice both parties to stop smoking and reduce alcohol reduce alcohol

Start folic acidStart folic acid

AND check they both want the referral!AND check they both want the referral!

Weight lossWeight loss

Obesity itself increases insulin levels Obesity itself increases insulin levels

Weight loss Weight loss ↓↓ insulin concentrations insulin concentrations

Weight loss can restore ovulatory functionWeight loss can restore ovulatory function

Long-term effects Long-term effects DiabetesDiabetes

HypertensionHypertension

Heart disease Heart disease

Endometrial cancerEndometrial cancer

ELIGIBILITY FOR TREATMENTELIGIBILITY FOR TREATMENT

Concerns about IVF tourists to the NHSConcerns about IVF tourists to the NHS

Non EEC countriesNon EEC countries

Patients outside the East of England Patients outside the East of England boundariesboundaries

EligibilityEligibility

Living within East of England boundaries Living within East of England boundaries for a minimum of 12 monthsfor a minimum of 12 months

East of EnglandEast of England

Very generous in offering 6 cycles of IVFVery generous in offering 6 cycles of IVF

This has encouraged movement from This has encouraged movement from other parts of the countryother parts of the country

EligibilityEligibility

Who should adopt the policing roleWho should adopt the policing role

PCT’s opinion is that this should occur in PCT’s opinion is that this should occur in Primary Care settingPrimary Care setting

InvestigationsInvestigations

Significant proportion of Ix sent with Significant proportion of Ix sent with referral letters are;referral letters are;

Inappropriate e.g. LFT, U&E, Lipids Inappropriate e.g. LFT, U&E, Lipids

Performed at wrong time of cycle e.g. Performed at wrong time of cycle e.g. FSH/LH at mid luteal phaseFSH/LH at mid luteal phase

Progesterone at Day 21 rather than mid-Progesterone at Day 21 rather than mid-luteal phaseluteal phase

Rubella not testedRubella not tested

Sickle / haemaglobinopathies not Sickle / haemaglobinopathies not screened forscreened for

IVF where are we ? IVF where are we ?

West Herts fertility ServiceWest Herts fertility Service

Fund 3 IVF/ICSI cycles , 3 embryo transfer Fund 3 IVF/ICSI cycles , 3 embryo transfer cyclescyclesTotal of 6 possible cycles including private Total of 6 possible cycles including private cyclescycles6 month wait from decision to treat for IVF6 month wait from decision to treat for IVF

Age 23-39 at time of treatmentAge 23-39 at time of treatmentBMI 18 – 30BMI 18 – 30Neither partner has been sterilisedNeither partner has been sterilisedNo living children in the relationshipNo living children in the relationshipLess than 3 NHS IVF cycles Less than 3 NHS IVF cycles Registered with a west Hertfordshire GPRegistered with a west Hertfordshire GP

IVF CentresIVF Centres

Hammersmith - within 18 weeks of referralHammersmith - within 18 weeks of referral

Barts & London – within 10 weeksBarts & London – within 10 weeks

Bourne – within 18 weeks (3 satellite clinicBourne – within 18 weeks (3 satellite clinic

Oxford – within for 4 weeks (2 satellite clinOxford – within for 4 weeks (2 satellite clin

Leicester – in the next cycleLeicester – in the next cycle

Egg DonationEgg Donation

If 9 months amenorrhoea, elevated FSH If 9 months amenorrhoea, elevated FSH and satisfy all other criteriaand satisfy all other criteria

Sperm DonationSperm Donation

No waiting timeNo waiting time

Must satisfy all other criteriaMust satisfy all other criteria

Single Sex CouplesSingle Sex Couples

??

Do we have enough money to Do we have enough money to continue funding IVFcontinue funding IVF

UnlikelyUnlikely

NHS Manchester and Wirral have NHS Manchester and Wirral have withdrawn funding for treatmentwithdrawn funding for treatment

South of England have withdrawn funding South of England have withdrawn funding for the current financial yearfor the current financial year

Expediency measuresExpediency measures

Miscarriage within waiting time renders Miscarriage within waiting time renders you ineligible for IVF treatmentyou ineligible for IVF treatment

Have to wait a further 3 years of trying to Have to wait a further 3 years of trying to conceiveconceive

Thank youThank you