powerpoint slides here

NaProTECHNOLOGY AAFCP meeting, Wichita, Kansas 19 th July ‘07 A Family Physician Approach to managing INFERTILITY & RECURRENT MISCARRIAGE Dr. Phil Boyle
NaProTECHNOLOGY Oct 1995 – EP1 MC/Practitioner n Completed final exam in Nov 1996 n Started Educator Program Oct 1997 n Combined with Ultrasound training in Pope Paul VI Inst
n NaProTECHNOLOGY n Opened Private Practice NaProTECHNOLOGY and FertilityCare 2 nd Feb 1998
…So I was well prepared…!
…until I started to practice…!
NaProTECHNOLOGY n Spent time with Dr. Hilgers in Omaha n Corresponded frequently via fax n Over 18 to 24 months developed useful “Tools”
NaProTECHNOLOGY n Further refinements continue n Dr Amanda Lamont Dr. Joe Stanford Dr. Tracey Parnell Dr. Kevin Mc Carthy Dr. Caroline Guindon Dr. Anne Carus n FertilityCare Practitioners n Patient suggestions
n n n n n NaProTECHNOLOGY n The treatment approach matures and changes with time, allowing for new discoveries
NaProTECHNOLOGY n All couples must be married
NaProTECHNOLOGY n Marriage is n About personal commitment between loving spouses
NaProTECHNOLOGY n Marriage is About personal commitment between loving spouses n An important institution for safeguarding the welfare of children
n Probability of Separation United Kingdom 52% of unmarried couples separate within 5 years of the first child being born n 8% of married couples separate within 5 years of the first child being born n Dr C. Richards www.lovewise.org.uk
NaProTECHNOLOGY n Challenging cases Menopausal – FSH up to 28 – 6 months of amenorrhoea n Blocked fallopian tubes – surgical reconstruction n Male factor infertility – Urological referral
n Female approaching 40 n Reduced Success Rate n Increased risk of Miscarriage n Down’s Syndrome – Risk advice
n NaProTECHNOLOGY n Initial Consultation Fill Standardised “Medical Consultant” form n Obtain and clarify complete history n Baseline Ultrasound Scan n Arrange for Seminal fluid analysis n Refer for Laparoscopy/Hysteroscopy (if required)
n NaProTECHNOLOGY n Initial Consultation n Explain normal cycle
NaProTECHNOLOGY n Observe your signs of fertility
n Record your “Fertility Profile” n Make it personal
Stunning new concept! By documenting the biological markers of fertility we can assess a couple’s fertility potential even before they attempt conception.
The individual fertility profile…. Can identify Abnormal bleeding patterns Limited cervical mucus flow Timing of ovulation Length of luteal phase of the cycle
The FertilityCare Physician n Can predict which couples are at increased risk of … Infertility n Miscarriage n Abnormal pregnancy outcome
n Furthermore….. The FertilityCare chart can let us know if the treatment plan is effective ….or not!
Timed Blood Tests n Another stunning new concept!
Day 21 progesterone n This is an “all or none” concept n n If the blood result is low you are not ovulating If above 30nmol/l (9.5ng/ml) n Deemed “Normal”….you are ovulating.
Timed Blood Tests We assess “OPTIMUM FUNCTION” of the follicular or luteal phase of the menstrual cycle
Day 7 after ovulation (Peak +7) progesterone Progesterone of 30nmol/l is Deemed “sub­optimal” ovulation ….you are ovulating, but poorly! n n Increased difficulty conceiving Increased risk of miscarriage P+7
60nmol/l 30nmol/l Peak + 7 Progesterone 60 – 100 nmol/l (18.5 – 31.5 ng/ml) Oestradiol 17 beta 400 – 800 pmol/l (110 – 220 pg/ml) …..….aim for “just right”
NaProTECHNOLOGY n We outline the “Treatment Plan”
Finding the problems n n n n Introductory Session Video / DVD Read User Manual Booklet Immediately Contact Teacher­ Practitioner to arrange Follow up Blood Tests / Semen Analysis via Family Physician n REVIEW IN 10 to 12 weeks time
FU 1 FU 3 FU 2 FU 2 FU 4 FU 4 Med r/v Med r/v
Med rv NaProTECHNOLOGY n 3 Phases 1. 2. 3. Finding the problems average 3 months Fixing the problems average 3 months Counting “Good” cycles 1 to 12 (18) months
FU 1 FU 3 FU 2 FU 2 FU 4 FU 4 Med r/v Med r/v
Med rv NaProTECHNOLOGY n 3 Phases 1. 2. 3. Finding the problems average 3 months Fixing the problems average 3 months Counting “Good” cycles 1 to 12 (18) months
FU 1 FU 3 FU 2 FU 2 FU 4 FU 4 Med r/v Med r/v
Med rv NaProTECHNOLOGY n 3 Phases 1. 2. 3. Finding the problems average 3 months Fixing the problems average 3 months Counting “Good” cycles 1 to 12 (18) months
Couple are “Healthy & Happy” n Cigarettes Alcohol Caffeine n Stress reduction n Nutrition & Vitamins
n n Effective cycles ­ A Couple are “Healthy & Happy” n n n n Hormones in optimum range Satisfactory Cervical Mucus Bleeding Pattern is Normal PMS – controlled
Effective cycles ­ B n n Proven Follicular Rupture Normal Anatomy – Lap & Hysteroscopy
Effective cycles ­ C 1. 2. Frequent “Enjoyable” intercourse Minimum “Stress” n n n n Work, Illness, Bereavement, Holidays, Sick Child, Relatives visiting, Anniversaries of miscarriage Friend or relative conceives
For how long? n 12 effective cycles (18­24 months) n Optional extra 6 cycles
For how long? n NICE Guidelines UK n n n 84% couples pregnant in 12 months 50% of couples not pregnant after 12 months will conceive spontaneously in next 12 months! So it can be normal to take 2 years to conceive
For how long? n n Give control to the couple Ultimately it is up to them….but help them to make a fully informed decision that they are happy with
Recurrent pregnancy loss n Recurrent pregnancy loss affects up to 5% of couples trying to establish a family Clin Obstet Gynecol. 2007 Mar;50(1):132­45 n n n Clotting (15%) Chromosomal Studies (3­5 %) Structural abnormalities (2%) BMJ 2005;331:121­122 (16 July)
Recurrent pregnancy loss n A definite cause is established in no more than 50% of couples ACOG 2002 Int J Gynaecol Obstet. 2002 Aug;78(2):179­90
Recurrent pregnancy loss n 75% of women will go on to have a successful pregnancy if offered nothing more, and nothing less, than tender loving care and reassurance through ultrasound that nothing is abnormal BMJ 2005;331:121­122 (16 July)
Recurrent pregnancy loss n n Out of 325 idiopathic cases, 70% (n = 226) conceived, with a 75% success rate 170 out of 325 = 52% of all couples… BMJ 2005;331:121­122 (16 July)
Recurrent pregnancy loss n n Infertility and miscarriage are opposite sides of the same coin When the underlying problem becomes even more severe, couples with recurrent miscarriage cannot even conceive
NaProTECHNOLOGY n 3 Phases 1. 2. 3. n Finding the problems average 3 months Fixing the problems average 3 months Counting “Good” cycles 1 to 12 (18) months We apply the same principles for miscarriage evaluation and treatment
Finding the problems …The first medical review 1. 2. 3. 4. 5. Blood Results Chart Ultrasound Seminal fluid General health
Blood Results Full Hormonal Profile E2 on P­5 every other day until P+2 n P+E2 on P+3,P+5,P+7,P+9,P+11 Day 3 n FSH, LH, Prolactin, Rubella, n B12, haemoglobin, Thyroid Function n Testosterone profile if indicated
n Blood Results if P+7 only Check Progesterone and Oestradiol 17 beta on P+7 every cycle n Low Progesterone on Peak +7 n n What does it mean? How do you treat it?
Low Progesterone Clues for Corpus Luteum insufficiency n n n Very low levels PMS Shorter luteal phase
Low Progesterone Corpus Luteum insufficiency n n n Treat with HCG 2,500 iu sc on P+3,5,7,9 Higher HCG dose if female is heavy Add clomid after 2 cycles if hormones remain suboptimal
Low Progesterone Clues for Poor Follicular Function n n n n n n Slightly low progesterone Low Oestradiol levels Late ovulation Long mucus cycle PCO Normal length luteal phase
Low Progesterone Poor Follicular Function n Ovulation induction n n n n Clomiphene Letrozole …esp. for PCO Menopur (FSH/ LH) sc. Titrate dose of medications according to P+7 results
Low Progesterone In all cases n n Confirm ovulation ie. follicular rupture by ultrasound within 2 to 3 cycles Low P+7 could be from 3 follicles with corpus luteum insufficiency
First follow up ­ Goals n Aim to achieve n n n n Optimum hormones Proven follicular rupture Assess & Treat male factor Secondary concerns n n Mucus Bleeding pattern
Ovulation Induction ­ Nice UK Guidelines Feb 2004 Clomiphene – 12 months n Risk of multiple pregnancy approx. 10% n Unexplained fertility n Clomiphene citrate treatment increases the chance of pregnancy 2.37 fold (Cochrane)
n Ovulation Induction ­ NaPro Guidelines 2007 n n Clomiphene – 12 effective cycles Risk of multiple pregnancy approx. 3.5%
Male Fertility
Male factor n Seminal fluid collecting device n n n Intercourse conditions Non­latex, silastic Lab in 1 hour
Semen analysis Volume: 2.0 ml or more n Sperm concentration: 20 million spermatozoa per ml or more n Motility: 50% or more motile n Morphology: 15% or 30%***
n Semen analysis n Sub­optimal result FSH n LH n Testosterone n Thyroid Function n “Healthy lifestyle” advice n “Fertility Plus” for men
n Semen analysis n Consider Urology referral if.. History of Mumps or Testicular trauma n Symptoms of varicocele n Previous STI n Difficulty with intercourse
n FertilityPlus for men www.marilynglenville.com L Carnitine Vitamin E Zinc Selenium Vitamin C….. And other supplements ….Improve all semen parameters Largely based on published studies
Semen analysis Repeat analysis in 3 months
Male Factor infertility n If still sub­optimal Refer to a “good” Urologist n Try treatments with some evidence of benefit
n Male Factor infertility n Men with hypogonadotrophic hypogonadism should be offered gonadotrophin drugs because these are effective in improving fertility. Nice UK Guidelines Feb 2004
Surgical management n Where appropriate expertise is available, men with obstructive azoospermia should be offered surgical correction of epididymal blockage because it is likely to restore patency of the duct and improve fertility. Nice UK Guidelines Feb 2004
Surgical management n Men should not be offered surgery for varicoceles as a form of fertility treatment because it does not improve pregnancy rates. Nice UK Guidelines Feb 2004
Semen analysis n Low count – Tamoxifen 20mg od – HCG injections 5000 iu x3/w – Indomethacin (Prostatitis) – Antibiotics – Ciproxin 2­3wks – Menopur 75 iu x 3 per week
Semen analysis n Low Motility – Co­enzyme Q10 (200mg daily) – Diclofenac 100mg pr. nocte (Prostatitis) – Antibiotics Ciproxin 250mg bd. 3 weeks
Semen analysis n Low Morphology – Pycnogenol 200mg daily
Semen analysis n Screening for anti­sperm antibodies should not be offered because there is no evidence of effective treatment to improve fertility. Nice UK Guidelines Feb 2004
Semen analysis n Antisperm antibodies – Low Dose Naltrexone – Diet – Prednisolone
Semen analysis n Generally poor chance if Count is persistently below 1 million n Motility persistently below 10% n Morphology persistently 2% normal
n Second follow up ­ Goals n Mucus n n Add Mucus enhancers if required Abnormal bleeding n Address the multiple causes
Mucus n n Carbocisteine 375mg tid x 7 days from day 10 or 11 of cycle B6 100mg daily n n If no Improvement…add Amoxyxillin 500mg tid for 5 days from day 11 n Stop, If no improvement after 2 to 3 cycles
Tail end brown bleeding 1. 2. 3. 4. 5. 6. 7. Low hormones – 70% Low Endorphins Physical – Lap & Hysteroscopy Infection – 3 to 5% Diet Herbalist? others…to be discovered…
Wait for 12 effective cycles …hopefully by this time next year you will be pregnant ….sooner is a bonus Plan your holidays
Case Presentations 1. Typical Case 2. 6 recurrent miscarriages 3. Long Standing Infertility
Long Standing Infertility Case 1 n Typical Case Presentation
Typical Case Presentation n n n n n n Primary Infertility G 0, P 0 – Nov 2005 Female 35yrs, Male 36yrs TTC July 2000 Dx: Endometriosis, PCOD, Low Prog. Seminal fluid ­ normal Laparoscopy July 04 Moderate endometriosis ­ diathermy
Typical Case Presentation n 18 cycles ovulation induction n n Clomid followed by nolvadex (Tamoxifen) Advised next step…IVF
Typical Case Presentation Presented in Nov 05 for NaProTechnology n n n Cycles 35 to 49 days Severe dysmenorrhoea Severe PMT
Typical Case Presentation n n Previous Dx: Endometriosis, PCOD, Low Prog. BUT n n n n Severe uncontrolled PMT No Insulin sensitising treatment Follicular rupture unknown Mucus quality unknown
Typical Case Presentation n Step 1 (1 cycle) n n n Cyclogest 400mg pv nocte for 10 nights start day 3 after ovulation Metformin 850mg bd Step 2 ovulation induction n Letrozole 5mg daily for 3 days (day4)
Day 7 post ov. P 25 nmol/l E 325 pmol/l
Typical Case Presentation n Review (2 cycles) n Cycle support n n n Ovulation induction n n n Cyclogest 400mg pv nocte for 10 nights start day 3 after ovulation Avandia 4mg od Clomiphene 50mg daily for 8 days (day2) HCG 10,000 mid cycle Ultrasound Follicle Tracking
HCG P Proven follicular rupture P P 68 nmol/l P
E 418 pmol/l Laparoscopy P 7 Prog 66 Oes 430 Positive test +++ Typical Case Presentation n n n n n n n Review (3 cycles) Proven follicular rupture Optimum hormones Satisfactory cervical mucus Normal bleeding pattern Controlled PMT “Enjoyable” – stress reduced environment n Need Repeat Laparoscopy & Diathermy
HCG
Proven follicular rupture Laparoscopy P 7 Prog 66 Oes 430 Positive test +++ HCG
Proven follicular rupture Laparoscopy P 7 Prog 66 Oes 430 Positive test +++ CRL 15mm 7w 6D EDD 5 th June 07
Typical Case Presentation n n n n Pregnancy Review Vaginal Cyclogest nightly – 12 weeks Progesterone blood tests every 2 weeks Transfer to GP and Obstetrician
Case 2 n 6 Recurrent Miscarriages n Couple 1 n Couple 2
G.W. ­ 6 Miscarriages Dec 04 6.5 years Age 40y. n DOB Aug ‘64 G0 P0 SA 6 (6­13wks) n n Dx Unexplained Recurrent Miscarriages Regular cycles – 28­30 days n Surgery to remove Uterine Septum Sept 04
n G.W. ­ 6 Miscarriages NaPro Assessment n Low Progesterone – 35.5 nmol/l n Low B12 – 187 pmol/l n Under­active Thyroid – TSH 4.42 iu.
G.W. ­ 6 Miscarriages n Treatment Femara 1.25mg daily for 3 days from day 3 n HCG 5000 on P+3,5,7,9 n B12 4mcg tid n Thyroxine 50mg daily
n G.W. ­ 6 Miscarriages n Conceived with an optimum cycle
31st Aug 05
CRL 33mm
10w 5days
EDD 24.3.06
G.W. ­ 6 Miscarriages n During Pregnancy Vaginal Prog 400mg n Prednisolone 5mg daily n Eltroxin 50mcg daily n Folic Acid/ B12 n n EDD 24 th March 2006
G.W. ­ 6 Miscarriages Baby Girl @ 39 weeks gestation n 6lb 7oz n Cesarean Section n n Mum and Baby are well!
Case 2 n 6 Recurrent Miscarriages n Couple 1 n Couple 2
G.C. ­ 6 Miscarriages Presented Feb 2005 n Female 33yrs. Male 40yrs. n n G6 SA6 from Oct 02 – Jan 05 n Miscarriage at 5 to 9 weeks each time
G.C. ­ 6 Miscarriages n Dx: Balanced Translocation Ch 7 and 18 n 30% miscarriage risk every time n 5% risk abnormal baby n n Additional Dx: n Uterine Fibroid – 2 x 3cm anterior fibroid
G.C. ­ 6 Miscarriages Normal clotting n Normal day 21 progesterone n n Unexplained why 6 miscarriages?
G.C. ­ 6 Miscarriages n Additional Problems with NPT Moderate PMT symptoms for 7 days n Abnormal bleeding n Low Progesterone on P+7 n n Query “Some immune factor?”
G.C. ­ 6 Miscarriages n Rx: Pre­conception n Letrozole 2.5mg for 5 days from day 3 n Luteal HCG 2,500 P+3,5,7,9
G.C. ­ 6 Miscarriages n Rx: Post­conception Gestone 200mg im twice weekly n HCG 5000 sc twice weekly n n Prednisolone 5mg daily
G.C. ­ 6 Miscarriages n Rx: Post­conception Gestone 200mg im twice weekly n HCG 5000 sc twice weekly n Prednisolone 5mg daily n n Continued treatment until 35 weeks
G.W. ­ 6 Miscarriages Baby Boy @ 37 weeks gestation th n 6 March 2006 n 5lb 5oz n NVD – with Vacuum n n Mum and Baby are well!
NaProTECHNOLOGY Any Questions? Dr. Phil Boyle