case history. case #1 s 26 y/o p0010, previous sab in 2 years’ trying s bmi 18.2, healthy habits,...
TRANSCRIPT
![Page 1: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/1.jpg)
Case History
![Page 2: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/2.jpg)
Case #1 26 y/o P0010, previous SAB in 2 years’
trying BMI 18.2, healthy habits, no comorbid
conditions Usual cycles 40-45 days Husband good health No STDs or GYN surgeries Normal exam
![Page 3: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/3.jpg)
Case #1 Previous evaluations
– Normal FSH and LH– Low progesterone level on “day 21”– Normal semen analysis and HSG
Previous treatments– 6 cycles of clomid, hCG injections,
AIHS, luteal PG Resulted in one pregnancy with SAB
– IVF was recommended as next step
![Page 4: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/4.jpg)
Case #1 Recommended:
– CrM NaPro Tracking– optimal timing of intercourse– Vitamin B6 to enhance mucus
production– Timed hormonal evaluation, based on
charting– Fasting serum insulin and glucose– Follicular ultrasound series
![Page 5: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/5.jpg)
Case #1
Results – NaPro Tracking- limited mucus pattern– Good timing of intercourse– Severe PG and E2 deficiency in luteal
phase– Fasting serum insulin- normal– Follicular ultrasound series- slightly
small follicle prior to rupture, no PCO on US
![Page 6: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/6.jpg)
Case #1
Recommended – Support of luteal phase with postpeak
hCG injections, 2000 Units IM on peak +3, 5, 7, 9
– Continue vitamin B6– Continue fertility-focused intercourse– Reassess after 2 cycles of hCG
support
![Page 7: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/7.jpg)
Case #1
Results – On second cycle of postpeak hCG
injections, she conceived– At 5 weeks EGA, she felt like she was going
to miscarry. The progesterone level was very low. Human-identical progesterone was given IM twice a week and tapered as her levels returned to normal.
– She delivered a healthy baby girl at 39.5 wks EGA
![Page 8: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/8.jpg)
Comments
NPT cohort pregnancy rates (crude and lifetable) similar to IVF cohort studies.– Crude rates underestimate success;
lifetable rates overestimate NPT takes more time than IVF, but is
far less costly, and has much lower rates of prematurity and neonatal morbidity.
![Page 9: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/9.jpg)
Comments
With confirmatory studies, NPT should become a mainstream approach to infertility.– NPT does require additional training.
International multi-practice studies are in planning.
![Page 10: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/10.jpg)
![Page 11: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/11.jpg)
Case Presentations
Dr. Phil BoyleMICGP MRCGP CNFPMC
1. 40 year old Female – implantation?
2. Failed fertilisation with IVF – Egg Quality?
3. FSH Above 20 IU/L4. 100% Antisperm Antibodies5. Very Low Sperm Count
![Page 12: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/12.jpg)
1. 40 year old Female –implantation?
Dx: Unexplained infertility for 5 years Hx: Gravida 1 para 0 Misc 1 3 Failed IVF – 3 embryos replaced each
time
Problem with Implantation?
![Page 13: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/13.jpg)
40 year old Female – implantation? NPT Dx: Corpus Luteum insufficiency Conceived 3rd Cycle HCG Healthy Girl born, 9lb 5 oz. Mum aged 40yrs
Tried again age 42yrs. Conceived 12th Cycle HCG Healthy Boy, 8lb 6 oz. Mum aged 43yrs
![Page 14: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/14.jpg)
2. Failed fertilisation with IVF – Egg Quality?
Dx: Moderately severe Endometriosis Trying to conceive for 5 years
Female Age 40 Yrs. Hx: Gravida 1 para 0 Misc 1 1 Failed IVF – 3 eggs, None fertilised Had successful adoption
Egg Problem?
![Page 15: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/15.jpg)
Failed fertilisation with IVF – Egg Quality?
NPT Dx: Poor Follicular Fx / LTD Mucus Rx: Clomiphene, B6, Carbocisteine,
Amoxicillin Conceived 10th Cycle NPT Healthy baby girl 6lb 8 oz Full term.
Mum aged 41 at delivery.
![Page 16: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/16.jpg)
3. FSH Above 20 IU/L
Dx: Secondary infertility for 5 years, Hx: Gravida 2 para 1 Misc 1, Female
Age 40 Yrs.
1Failed IVF – No follicular development FSH – 23 IU/L
Problem – Perimenopause
![Page 17: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/17.jpg)
FSH Above 20 IU/L
Rx: Clomiphene 50mg x 5 days, B6.
Long Irregular cycles Conceived Day 50 of second Rx cycle Healthy Boy 5lb 13 oz at 38 weeks
Never Menstruated again!
![Page 18: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/18.jpg)
4. 100% Antisperm Antibodies
Dx: Infertility for 8 years, Female Age 37 100%Antisperm Antibodies Hx: Gravida 0 para 0 Misc 0,
2 Failed ICSI – 3 embryos each time
Problem – Male Factor
![Page 19: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/19.jpg)
100% Antisperm Antibodies NPT Additional Dx: Low Prog. And Low E2 Conceived 12th Cycle NPT, (5th Cycle Male
Prednisolone Rx) Healthy Girl born, 8lb 1 oz. Mum aged 39yrs
Spontaneously conceived again age 39yrs, but miscarried.
Spontaneously conceived 3rd time age 40yrs, again miscarried.
How significant were the antibodies?
![Page 20: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/20.jpg)
5. Very Low Sperm Count Dx: Infertility for 5 years, Female Age 34yrs
Count 50,000 per ml10,000 per ml
200,000 per ml 4,000,000 per ml 800,000 per ml
Hx: Gravida 1 para 0 Misc 1, (ICSI Pregnancy) 3 Failed ICSI, 2 – 3 embryos each time
Problem – Male Factor
![Page 21: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/21.jpg)
Very Low Sperm Count NPT Additional Female Dx: Low Prog. And Low E2 Conceived 8th Cycle NPT, 8th Cycle Male Tamoxifen, L carnitine, Pycnogenol
Volume 4 mls Count4 Million/ ml Motility 45% Morphology 4% Normal
Healthy Girl born, 8lb 8 oz. June 2004 Mum aged 35yrs Progesterone support during pregnancy until 28 wks Very important to treat the female…often combined
problem
![Page 22: Case History. Case #1 s 26 y/o P0010, previous SAB in 2 years’ trying s BMI 18.2, healthy habits, no comorbid conditions s Usual cycles 40-45 days s Husband](https://reader034.vdocuments.mx/reader034/viewer/2022051316/56649c885503460f949416ca/html5/thumbnails/22.jpg)
IVF - UK. Declining success with increased ageIVF - UK. Declining success with increased age