THE LEEDS CENTRE FOR REPRODUCTIVE MEDICINESEACROFT HOSPITAL

Version 1.1: January 2010

Explain the treatment process Clinical Laboratory Nursing

Highlight risks in treatment OHSS Multiple pregnancy

Factors affecting outcome Increase awareness of protocols Information regarding research projects

Normal menstrual cycle controlNormal menstrual cycle controlGrowth of the egg andGrowth of the egg andwomb liningwomb lining

Ovulation and wombOvulation and wombsupportsupport

FSHFSHLHLH

OestrogenOestrogen ProgesteroneProgesterone

Why do we need to make changes? We need more than one egg in the cycle Not all eggs fertilise or grow Not all embryos have a good potential

for development We want to transfer 1-3 embryos for a

good success rate We do not want the gland in the brain to

become confused in treatment

Long Protocol

Flare Protocol

Short Protocol

1. Suppression of the natural cycleTo switch off the gland in the brain so that it does not interfere in treatment

2. StimulationHormone injections to produce multiple eggs

3. Ovulation trigger or HCG injection

4. Egg collection

5. Embryo transfer

6. Hormonal support after the embryo transfer

Oral Contraceptive Pill

Prostap once a month injection OR

Buserelin daily injectionOR

Nafarelin three times a day nasal spray

Side effectsheadaches, hot flushes, night sweats, mood-

swings, prolonged period or second bleeding

Ovary Uterus

Dose of stimulation is adjusted for:Reserve of eggs in the Ovary (hormone levels and scan findings)

Age Weight or Body Mass IndexPast history (infections, cyst removal)

Presence or absence of PCOS

Types: Menopur, Merional, Puregon, Gonal-F, Fostimon

All are subcutaneous injections

x xx

x

HCG injection Pregnyl (commonest)

OvitrelleRecombinant LH

Timed 36 hours prior to egg collection

Performed under ultrasound guidance Fast acting sedation & analgesia Duration 20 - 45 minutes Out-patient based Return home after 2-3 hours Need care after returning home

DO NOT DRIVE OR OPERATE MACHINERY

Common Symptoms

mild discomfort for 1 - 3 days (Paracetamol suppository)

slight discharge

“hang-over” effect

Sperm production

Insemination of Eggs or Sperm injection into the eggs

Fertilisation check

Observation of growth

Selection of embryos for transfer

Requires a full bladderPerformed under ultrasound guidance

After Embryo Transfer: Hormone support:

Mainly Progesterone Some HCG (with low risk)

Pregnancy test 14-16 days later

Worried Please contact US

Risk: Multiple embryos = in multiple pregnancy rate

Our Objectives:1. To maximise the pregnancy rate 2. To reduce the risk of a multiple pregnancy

Before you think “great, a twin pregnancy! We have our family completed in one go!”

Let us look at the facts of the next slide...

Risk Twins Triplets

Average Duration of Pregnancy (Term = 40 weeks) 37 weeks 34 weeks

Proportion of premature low birth weight infants 50% 90%

Neonatal death (1st week of life) 5 x higher 9 x higher

Postnatal cerebral palsy 4 x higher 18 x higher

Maternal pre-eclampsia 3 x higher 9 x higher

Maternal diabetes 2-3 x higher 2-3 x higher

Maternal coronary heart disease 2 x higher 2 x higher

Maternal death from cardiovascular causes 7-11 x higher 7-11 x higher

Maternal death (overall) 2 x higher 2 x higher

We consider SET in: Women < 35 years First treatment cycle When fertilisation and growth of embryos is satisfactory

When there are spare embryos for freezing

Day 2, 3 or 5

Objective: Select the best embryo at the earliest

opportunityChoice is dependent upon: Total number of embryos available Quality of embryos

Please trust us to do the BEST in your cycle

Cyst formation during the suppression phase

Risk of cycle being abandoned (Poor or Excessive response) (5-10%)

On the day of egg collection No eggs (<1%) Not being able to give a sperm sample (anxiety,

stress, very low counts, poor testicular function) Back up freezing or Emergency PESA

After egg collection Complete fertilisation failure (3-5%) Failure of growth of embryos (<5%) Failed embryo transfer (very rare ; one a year)

Infection Pre-treatment swabs Dalacin cream Cleaning the vagina Sterile environment “No touch

technique” Antibiotic in flush Prophylactic

antibiotic in “at risk cases”

RARE

Injury to bowel leading to internal infection RARE

Injury to blood vessel leading to internal bleedingRARE

Version 2: March 2008: VS / EB

The risk is highest after the ovulation trigger and if you become pregnant

Who is at a higher risk? Women with polycystic ovaries Young women < 30 years

Severe OHSS is RARE (1-2%). However this is

because we monitor everybody ‘at risk’ANY CONCERNS:

Contact the Emergency On-Call phone

Miscarriage (15-20%)

Ectopic pregnancy (3-4%)

Multiple pregnancy (25%)

Version 2: March 2008: VS / EB

Age (years)

PESA MESA

Anonymity Laws

Scarcity

Recruiting known donor

Version 2: March 2008: VS / EB

Egg CollectionPreparation of sperm sampleInsemination (IVF) or sperm injection (ICSI)Fertilization check Embryo TransferFreezing

Looking for the eggs

A human egg in its surrounding cells

A tenth of a millimeter

Produced in unit by

masturbation

Sterile specimen pot

Witnessing procedures

In vitro fertilisation: IVF

Intra cytoplasmic sperm injection:ICSI

• Only mature eggs can be injected (usually ~70%)

• Around 10% will be damaged by the injection

• Pregnancy rates are the same as for IVF

Fertilisation

overnight next day

Version 2: March 2008: VS / EB

Normally fertilised egg

• Usually around 60% of eggs will fertilise normally

• A proportion may be unfertilised, abnormally fertilised or non-viable, these eggs cannot be selected for treatment

• Patients will be telephoned the day after egg collection

Embryonic Development

2 cells 4 cells

8 cells

Morula Blastocyst

Early day 2

Late day 2

Day 3

Day 4 Day 5

fragmentation unevenness of cells cell numbers

Good Poor

Embryos for transfer selected (consents checked)

Spare embryos may be- frozen- or placed into extended culture with

a view to freezing(depending on quality)

Stresses of infertility and infertility treatment

HFEA Code of Practice requires all units to offer counselling as a normal part of treatment

Types of counselling Arranging an appointment Confidentiality

Both Partners: Healthy life style No Smoking Female: Avoid alcohol altogether Male: maximum of 12 units per week

Female Partner: Good diet and normal body weight Up to date cervical smear Folic acid 400 mcgs daily Rubella

Tight schedulePlease arrive promptly for appointmentsAllow plenty of time for parkingPlease ring unit if late or unable to attend to give us time to reschedule appointments

Be sure you know what to do next before leaving the Unit

Both partners must attend the nurse consultation session

Bring a passport sized photo of both partners and think of a password

Photo ID (passport or driving licence)

HFEA Registration

Welfare of the childCommunication consentGP lettersInformation check listTrust consents to treatment

number of embryos to be transferred observation and freezing of spare

embryos

IVF /and ICSI consentUse of donor sperm / eggsEmbryo researchHFEA forms – use of eggs, sperm

and embryos embryo freezing fate of sperm and embryos in the

event of death or mental incapacity – disposal, research or posthumous use

1.NHS2.Self-Funding or Private

PaymentIf you are paying for your own treatment, payment must be made at the consultation appointment

cash cheque credit card

Homecare dispensary service for all patients

Pharmacy (prescription charge is payable)

InjectionsNeed to consider

self/partner injection GP/Practice nurse Daily attendance to ACU/Gynae ward

9-10 visits over 6 weeks

2-3 months

LCRM working hours - 8.30am - 5.00pm (0113 2063100)

In an emergency...Out of hours weekdays (5pm until 8am) and weekends - A team member can be reached on a mobile phone via St James’s switchboard (0113 2433144)

Please try to contact staff during working hours as at other times they are not in the hospital and do not have access to your notes or the appointment diaries.

Support Line – www.lacu-patient2patient.org.uk