Non IVF Fertility Treatments Dr Mary Birdsall Overview • Advice • Surgery • Empirical clomiphene • Intra Uterine Insemination (IUI) • Letrozole • Ovulation Induction using gonadotrophins • Donor Insemination • Egg Donation • Embryo Donation • Surrogacy Advice • Folic acid and iodine • Bloods • Lifestyle: BMI, cigarettes, alcohol, drugs, exercise, sleep, vitamin D, diet • Environmental influences: Bisphenol A, pesticides, phthalates, parabens • Timing of sex • When to start treatment, public eligibility Clomiphene • Used since 1961 • Used for ovulation induction or multifollicular development • 50mg tablet (max dose 150mg) • Use for 5 days start during period (days 3 to 7) • Symptoms: headaches, hot flushes, blurred vision, mood disturbance • Twin rate 9% triplets occ • Monitoring Clomiphene 15% pregnancy rate Indications : short duration unexplained Intra-Uterine Insemination Timing of IUI Indications for simple IUI • Two patent tubes • Sexual difficulties • Cervical infertility (usually post cervical surgery) • Wish to avoid multiples • Donor sperm IUI with stimulation • Clomiphene alone under 40 • Clomiphene and FSH age 40 or above • Should have 2 patent tubes • Indications: unexplained, mild to mod endo, mild male factor (not 2 factors) • 20% take home baby rate under 37 • 12% twins, 1% triplets Success Rates IUI s Polycystic Ovaries Polycystic ovary syndrome • PCO on USS • Oligomenorrhea • Signs of androgenisation eg acne hirsutism • Bloods: AMH high, LH may be high, Test may be elevated , HBA1C • Exclude other causes hyperandrogenaemia Polycystic Ovary Syndrome Management of ovulation induction PCOS • Lifestyle and metformin • Clomiphene • Letrozole • Ovulation Induction using FSH • Laparoscopic ovarian diathermy • IVF Letrozole vs CC for PCOS n=750 Letrozole How to use letrozole • Neg pregnancy test • Start day 3 5mg for 5 days • USS day 10 and advise timing of sex • Midluteal phase progesterone • Side effects: headaches • Twin rate 4 % • Unregistered drug for this indication Ovulation Induction Using FSH Ovulation Induction using FSH • Drugs expensive • Intensive monitoring • 20% chance of a pregnancy per month • Multiples • OHSS • Conversion to IVF or follicle aspiration FSH vs Laparoscopic Ovarian Diathermy Hypothalamic Amenorrhea • Common cause of ovulatory dysfunction • Low BMI • Too much muscle – and too little fat • Stress • Kallmans Functional Hypothalamic Amenorrhea Treatment hypo hypo • Lifestyle gain weight, reduce exercise, CBT • Protect bones • Nurture uterus • Ovulation induction and need both FSH and LH injections • Clomiphene and letrozole are ineffective • Increased risk LBW and miscarriage and multiples Donor Insemination • Heterosexual, single women and same sex female couples • Known donor or altruistic donor • Donors have to be identifiable • Counselling • Never use fresh sperm • Use IUI or ICSI Egg Donation Egg Donation • Indications: maternal age, genetic, same sex couples • Egg donor: medical screening, counselling • Egg donor does IVF cycle and donates eggs • HART Act : donors cannot receive any valuable consideration • Births Deaths and Marriages • Reproductive Tourism Pregnancies Following egg donation • Lowered risk of chromosomal abnormalities • Increased risk of hypertension • Increased risk IUGR • Increased risk of LSCS • How old is too old? • Physician review at age 45 Surrogacy Indications for Surrogacy • Absent uterus eg hysterectomy, Mayer-Rokitansky-Kuster- Hauser Syndrome • Other uterine abnormalities eg unicornuate, previous rupture, fibroids • Medical issues making pregnancy too dangerous eg cardiac, Turner syndrome, renal, cancer • Men in same sex relationship • Previous failed IVF treatments Surrogacy • Ethics Committee Assisted Reproductive Technology Committee • Medical, Legal, Counselling Reports • Approval for Adoption from Oranga Tamariki • IVF and Embryo into Surrogate • Surrogate is legal mother at birth • Intending parents adopt baby Embryo Donation • Not common • Counselling • ECART application and police check • Difficult for the donating couple.