Ivan Zamorano

Acupunture Treatment

Optimising patient fertility

Optimising patient fertility

Hi my name is Louise Johnson. I’m the
CEO of the Victorian Reproductive Treatment Authority and also spokesperson
for the Your Fertility program. I’d like to welcome you to this webinar on optimizing
patient fertility. Before I introduce the speakers let me briefly tell you about
the workings of the webinar. The lines will be muted throughout the webinar so
if you have any questions or comments, and we hope you will have plenty, we encourage
you to post them on the chat box in the bottom left-hand side of your screen. This webinar is only 30 minutes long so discussion will be brief. The most common
questions will be addressed briefly at the end. If there are more unanswered
questions we will produce a question and answer information and also think about
running some further webinars to answer your questions and explore the issues
more closely. We’re using phones so that this webinar can be recorded and our voices will be clear. We also ask you to complete the survey at the end of
the session so we can catch your feedback. If you have trouble hearing the
webinar using your speakers you can dial in to listen by teleconference. The number
and password you’ll need to dial is listed in the bottom left-hand corner
the page. Please use the chat box to raise any other technical issues you
have and we’ll help you. Research shows that most men and women want to become parents and
about 85% of young women indicate they decide to one child.
However there’s a gap between what people want and what they attained in
relation to their fertility. And there are predictions that in Australia up to a quarter of women
will end their fertile years childless. For some people, they’re affected
by social infertility, they may not have found a partner or be in a same-sex
relationships and need the use of assisted reproductive treatment in order
to have children. Fertility awareness is important
because it can help people who want to have children sometime in the future
optimize their chances. GP’s can assist patients in raising awareness for fertility
issues and developing a reproductive life plan includes whether they want to
have children and if they do, the number, spacing and timing. It’s important for
patients to know the factors that affect fertility, because these also effect
pregnancy health and the health of a baby at birth and through to adulthood. GP’s are in an ideal position to have opportunistic discussions with
women and men about fertility and what they can do to safeguard it for the future. Whether
we’re working at a population level through case based or national health
promotion activity to individual care, all of us have a unique role to play. Your
Fertility is a national public education program funded by both the Australian
and the Victorian departments of Health. And it aims to increase knowledge about
the modifiable factors that influence fertility. This evening we’ve pulled together two
great speakers to explore the crucial role GP’s and anybody in the primary
health care teams play in educating patients about fertility. Examine the role of primary care providers play, we have this evening Dr.
Magdalena Simonis. Magdalena is a GP and active fellow with the RACGP, the GP
examiner and also teaches medical students at the University of Melbourne.
In 2014 she was appointed the RACGP representative to Your Fertility. We also
have Associate Professor Kate Stern. Kate is a fertility specialist, gynecologist
and reproductive endocrinologist. Kate is also an associate professor of obstetrics and gynaecology at the University of Melbourne and the Royal Women’s Hospital. Kate is the head of the endocrine and metabolic service at the Royal Women’s Hospital in
Melbourne and head of clinical research at Melbourne IVF. Thank you both for joining. I’ll now hand over to you Magda. Magda, how does a clinician fit fertility and
reproductive life plan issues into a consultation? Thanks Louise that’s a really important question. Well, there are multiple
opportunities that the primary care provider has and outside of the “We
want to have a baby” scenario, When patients come in saying, you know, “We want to have a baby well, I’m ready to have a child.” Outside of those scenarios there
are opportunities that we can find to raise a fertility discussion and plant
the seed for further discussion. And assisting the patient to develop a
reproductive life plan. Opportunities such as you know, we’re getting married
or moving in together, we’re going on a holiday, they’re often
opportunities that you can just sneak, you sneak in and ask the question.
If they’re you know, interested in having children, when they’re planning on having
children, how many they might want to have and whether or not they’ve actually discussed this themselves with their partner. And arrange a follow-up
appointment because you know raising the question regarding fertility and
reproductive life plans raises lots of questions which you might not have time
to address at that point in time. So to provide appropriate counseling
investigations prior to specialist referral it’s important to keep this
very simple and accurate, this initial discussion and then follow through with
an appointment that meets their need and their timeline. And a really simple
opening question I use is you know, at the time of a pap smear or when a patient comes in for a gynecological checkup, you know, “By the
way are you interested in having children at any time in the future?” The response could be as simple no, at which point I then would probably consider
asking again in one to two years time, depending on their circumstances, if
they’ve changed. And I treat the ‘yes’ to that
question and ‘maybe’, as pretty much the same, because it’s a good
opportunity to discuss the window of opportunity based upon age and how age
impacts fertility, the timing of sex, asking them what they understand about
the fertility window during the menstrual cycle, informing them about the
importance of weight, smoking, alcohol, drugs, whether they be enlisted or other
and natural therapies. And then of course there are the medical aspects, you know
their gynecological and obstetric past history, the importance of taking
supplementation prenatally, not just during pregnancy, such as folic acid and
iodine and vitamin D. Immunizing them adequately for things like Rubella or Pertussis, looking at mental health history, current and previous family
history of mental health and genetic history such as diabetes and
Thalassemia. STI screening and of course the fertility tests such as the
anti-Mullerian hormone and in the case of the male partner, semen analysis. If the woman has irregular cycles you know, I’d offer
investigation at any point. If they’ve been trying for about six months and if
they’re more than 35 I would investigate and if they’re trying for four months
and they are over 38 or nearing 40 and over I’d recommend investigating and doing particular tests such as AMH but not
over interpreting them of course. Now we’re going to look at a few scenarios
here to just explore the opportunities that GP’s have and the first one is you
know the younger woman in her twenties who comes in for the pill, that’s pretty
straightforward, you know. I would probably say, you know, “Interested in
having children at any point in your life?” and you know if they say yes,
I’d say, “Well look do you know, when do you think?” They might say three or four years
from now so I’d offer them the chance to come in in about 18 months to have the
fertility preconception chat, and also engage them in the lifestyle
modification discussion. It’s important to sort of use very positive
opening comments such as you know; age can impact fertility, most women think
that you know, late 30’s and early 40’s, are safe to start having a baby
but in fact age has an impact on fertility and it’s better starting
earlier rather than later. So if the patient in the discussion or in the
consultation is 38 years old and says to me, “Oh, I’d love to but I haven’t written
met the right partner yet.” Then I would ask specifically you know, how they felt
about not having children ever and if that was an issue for them
I’d then mentioned the egg freezing option. And although single parenting is
not the ideal it is worth knowing that eggs are better younger and not older
and I’d offer her the opportunity to think about this and come back to
discuss it and and contemplate whether or not she was interested in having a
baby on her own. Another scenario would be the 35 year old woman who has the 45 year old male partner who’s response to the question was, “Oh I want to but my partner isn’t too fussed.” That’s not an uncommon response I get. And I then
again take the opportunity to inform her that you know having a discussion with a
partner based upon the facts that I’m giving her regarding women over the
age of 35 and even men over the age of 45 have declining ease of conception so I’d encourage her to bring him in for a chat if he, you
know, needs or wants more information, and also take the opportunity to talk about
lifestyle factors and getting herself ‘baby fit’ before that consultation that
she might bring, where she might bring her partner. And you know, it’s
important probably to use positive opening statements like you know ‘minimal
changes’ and ‘won’t have a positive impact on conception’ or even “Minimal amounts of
exercise can help.” Keeping it positive is important rather than stating the
obvious health issues that they might face if they are already overweight. In the scenario where she comes in with her partner, who was 45 years old and she
says, “Oh look you know we’ve been trying for six months, I need advice.” Or well she
might come in on her own or she might have brought him in with her and her
concern is that he thinks that you know, they should just keep trying
naturally. I explain to her and if he’s present also, that infertility
is not just a woman’s issue and that a third of the time the diagnosis is due
to female infertility, a third of the time it’s linked to male infertility and
in the remaining of cases infertility is due to a combination of factors from
both partners and in around 20% of couples the cause can’t be determined. So
it is important for him to understand that the spectrum of infertility does
involve men and I offer them the opportunity to provide a plan for
further chat through their investigation. And when I do have the chance to talk to
the male partner and he comes in to talk about their fertility issue, I make an
effort there to gain his trust because I might not be the GP that he has the
primary relationship with. She, the female partner is
often the person who has the primary relationship with myself so I offer him
the opportunity to talk about himself and his work and his career aspirations
and the amount of travel that he might engage and what interests he has whether
he goes to the gym and whether or not he takes any supplements at the gym. I take the opportunity
to talk about smoking, alcohol and drugs and exercise, previous infections or injuries that
might have impacted him or his sperm production. Generally concerns regarding sperm production and quality in men’s eyes
have implications regarding their masculinity. So I try to normalize the
discussion. I normalize the general examination part of it too, the
physical examination which really does need to be performed, and I include a
genital health examination as part of that too. It’s important to examine
the the genital area regardless of age to exclude such things as Klinefelter’s
syndrome, Varicocele, testicular lesions. And I take the opportunity there to talk
casually about screening also for testicular cancer and that in fact often
brings them on board rather than just the discussion about pure semen analysis
and quality. And it’s you know in their mind often, the thought is that they
might be shooting blanks. So that’s the statement that you just, I would never utter. I make comments like I expect that that’s probably what they’re thinking
and therefore I may comment such as you know, “Did you know that
lifestyle has a really big impact on the quality of sperm and a healthier
lifestyle can improve the quality for most men.” I’d like to
engage Kate here and invite you Kate to talk further about the
investigations and how we can better prepare patients for specialists
such as yourself. Thank you Magda, and thank you Louise and Madga for asking me to be included in this webinar, I’m very pleased to be here. And, it is such an important area for
patients and practitioners alike to have an awareness of their fertility and
particularly the impact of age because we think nowadays that everybody knows
that, as you get older the fertility diminishes significantly. But it’s remarkable
the number of patients who actually still don’t really realize that, and we
think that if they have treatment it will improve their chances of success so,
I’d like if I may, first of all talk about anti-Mullerian hormones, because
anti-Mullerian hormone is a test that’s done on lots of young women and
women in their 30’s and early 40’s who come to their doctors to ask about
having a test for how many eggs they’ve got left. So anti-Mullerian hormone, as you all know, is a marker of ovarian fertility, produced by these small follicles not
the tiny primordial follicles but the next size up follicles. So that’s as far as
it lasts, how many primordial follicles and I’m
just going to see if I can get the laser pointer to work here. But if you have a
look at this graph on the screen you see this is a graph of anti-Mullerian
hormone levels in women as they get older and you can see the blue; this is a study looking at over 3,200 women. And so the red line
gives you the average anti-Mullerian hormone level. This actually uses
differently units in this graph to the one in Australia but the point is the same,
that we can see that the number of follicles diminishes in the early 30s
and then much more precipitously in the 40’s. Now there are a couple of really
important things about anti-Mullerian hormones. It is a surrogate marker of how
many eggs there are, but it in no way gives you information about
the quality of eggs. So we know that if we go on age alone, when we talk to our
patients, if a woman comes in at 37 we know that her fertility is a bit less
good than it was when she was 25 to 30, that she will have less eggs and she
will have a higher percentage of eggs that are chromosomally abnormal. So it really just shows us this is a visual documentation of the fertility in
terms of eggs. Now the second point about it though is if you look at these blue dots,
you’ll see there’s a very wide range and I think maybe you probably have lots
of experience with patients coming in having an AMH done that is reported as
low. So a woman of 38 will come in and say, “Look the GP I went to before you
did this test and it says my ovarian reserves (are low) and what does that mean?”
And you know you would be saying, “Well, this is a completely normal situation
for your age. It does mean they’re less egg than they were before but in no way
impacts on the chance of you having a baby, it’s just a marker what’s going on
for the future.” And there is such an enormous normal range that we need to be very careful
not to over interpret or misinterpret results. What’s really
important in a young woman is an AMH of less than 1. A very very low AMH.
That is a significant finding in a woman under 35 because that means that she has
got, you know, maybe only a year or two worth of eggs left. If that young woman
with an AMH of less than 1 was trying to get pregnant, she would be fine. She has
no reduced chance of success at that time, but it means that she really
doesn’t have a long time ahead of her. In patients with Polycystic Ovarian
Syndrome we do often see an elevated AMH and it’s important not to be overly
enthusiastic about this because of course if a woman of 40 has a high AMH
that means she has lots of eggs but it doesn’t change the
fact that 95% of them, or 90%-95% of them are going to be abnormal. So I think
anti-Mullerian hormone is sometimes difficult to interpret, we have to make
sure we don’t frighten our patient by them misreading the situation. We all
know that there is an exponential decline in egg numbers with age and we
know that we have most of the eggs that we’re ever going to have halfway through
fetal life and then it goes down after that. And it’s very important when we’re
looking at age to think about egg number and egg quality, I think that’s a really
important factor. And this graph here looks a bit complicated but on the left
you’re talking about the chance, we can see that chance of getting pregnant each
month. Because there’s a term called ‘fecundity’, which means the chance of
getting pregnant each month. And when women are young it’s 25%, it’s actually
sometimes even higher than that. There is a 25 to 30 percent chance of getting
pregnant for the first six months of trying when you are young but you can
see that as you get older the chance of getting pregnant goes down and as it
goes down the chance of having a miscarriage goes up and that is largely
related to the age of the eggs and the chromosome normality and abnormality.
Over 85% of miscarriages are related to random chromosomal errors. So the
miscarriage rate goes up as the fertility rate goes down. Overwhelmingly
related to this chromosome, not other factors. So I think it is really
important to be getting the message out there about female age and fertility.
And another important message is for patients to understand that IVF does not improve
on the genetics of your eggs. So we here often in consultation a
lot later, patients thinking as they are 40 or 42, it’s okay, because IVF will help
them to have a baby. And that’s true to a degree but IVF will not improve on egg quality. So I think it’s really important to explain that to our patients as well, particularly in the setting of fertility awareness, the ones who may not even be thinking about conceiving. Now there’s just one other
thing I wanted to talk a little bit about and that’s semen analysis because
semen analysis is also very difficult to interpret in a practical sense. And we’ve
all had male patients come in absolutely crushed when they have a minor
abnormality on a sperm test, that they’ve been provoked into getting by their
girlfriend. So the important parameter in this semen analysis are the sperm
concentration and motility. And it’s normal to have more than 15 million
sperms per mil. Motility is also very very very sensitive to transport and sitting
around, so we do see quite a lot more variability in motility than we see in
concentration. The other parameter that is documented in semen analysis is the
percent, is the morphology or the percentage that look normal or abnormal
and that is much less relevant in terms of general fertility. So if a man has a
good count and good motility and 97% abnormal form, that’s fine. That’s
absolutely fine, that would not be having a significant impact on their ability to
get pregnant at all. It’s very important because a lot of men will have
a high percentage of abnormal form in the context of normal volume
concentration motility and they’ll be really really devastated and worried and
in fact can often get quite depressed about that, you know men are very
sensitive for that with semen analysis. So it’s important to explain to men that
in the context of spontaneous fertility, how the sperm look is very,
very, very minor. You know it’s really not a significant factor. The
other thing I just wanted to say is that when you do find an abnormal semen
analysis it’s important to repeat the test but not for a few weeks because
sperm take over seventy days to develop. So really you want to repeat the
sperm test in a couple of months. It’s always fine to just ring up at a
fertility specialist and have a chat with them about how, if you having
difficulty working at what to say to these patients.
I just wanted to highlight really two important parameters in the
primary care setting, mainly age-related fertility and AMH interpretation and
also semen analysis. So they’re really the main things that I wanted to
focus on tonight. All right, thanks Kate. (Louise) –
Kate talked about investigation. Do you want to just briefly tell us about treatment options available? Yeah so when a patient is referred for fertility assistance from the primary
care practitioner, and the primary care practitioner has already talked to
patients about lifestyle optimization and you know, making sure you’re as
healthy as possible, there are lots of different options to
look at in terms of optimizing fertility. Naturopathy and acupuncture are
complementary therapies that have been shown to optimize general health and
well-being and they may have a role in the in general fertility.
There are no large randomized studies confirming benefit in specific fertility
parameters but I think that they also help patients with their overall
well-being and resilience. If a patient is not ovulating very well we can use
ovulatory stimulants, tablets or injections, and sometimes surgery is
required if there is a mechanical blockage that can be fixed. In young couples
who have infertility of relatively minor you know, brief duratio,n we can
contemplate artificial insemination. Which really just gives a gentle little
boost, we use low-dose hormone injections to optimize ovulation and then artificial
insemination. And then there’s fertility treatments such as IVF where we’re
actually taking the eggs out after stimulation and making it ready. And
nowadays IVF is extremely successful treatment, extremely successful. But of
course as a woman gets older the chances diminish. So these are the
options available for patients and it’s important to know that there are a range
of options and patients, when they’re referred, are not necessarily going to be
rushed into IVF. So over to you Louise. Thanks very much Magda
and Kate for this discussion. We have invited you to ask questions and
there’s been some questions that have come up but there haven’t been some unseen answers that have come through with your questions, But please, as we’re completing the seminar in the next couple of minutes,
if there are questions please post them online and we’ll
develop a question-and-answer information sheet that we can distribute
to participants. Again thank you to our speakers Magda and Kate for your
participation this evening. We’ve run out of time, but you might find lots of
interest on the Your Fertility website, www.yourfertility.org.au
under the section called ‘For Professionals’. For instance there’s a link to the ThinkGP
model and you can earn CPD’s points while learning whilst on the topic.
There’s an optimizing patient fertility video, which is presented by
Dr. Caroline West, which expands on tonight’s discussion. There’s also a
range of resources that you can use as a patient, including evidence-based fact
sheets on the factors that affect fertility, developed in association with the
Fertility Society of Australia, and much much more.
So please don’t forget to complete your survey, your feedback is really important
to us. Thanks again and good night. Thank you very much.

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