Case History Case 1 s s s

Case History

Case #1 s s s 26 y/o P 0010, 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

Case #1 s s Previous evaluations – Normal FSH and LH – Low progesterone level on “day 21” – Normal semen analysis and HSG Previous treatments – 6 cycles of clomid, h. CG injections, AIHS, luteal PG u. Resulted in one pregnancy with SAB – IVF was recommended as next step

Case #1 s Recommended: – Cr. M Na. Pro Tracking – optimal timing of intercourse – Vitamin B 6 to enhance mucus production – Timed hormonal evaluation, based on charting – Fasting serum insulin and glucose – Follicular ultrasound series

Case #1 s Results – Na. Pro Tracking- limited mucus pattern – Good timing of intercourse – Severe PG and E 2 deficiency in luteal phase – Fasting serum insulin- normal – Follicular ultrasound series- slightly small follicle prior to rupture, no PCO on US

Case #1 s Recommended – Support of luteal phase with postpeak h. CG injections, 2000 Units IM on peak +3, 5, 7, 9 – Continue vitamin B 6 – Continue fertility-focused intercourse – Reassess after 2 cycles of h. CG support

Case #1 s Results – On second cycle of postpeak h. CG 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

Comments s NPT cohort pregnancy rates (crude and lifetable) similar to IVF cohort studies. – Crude rates underestimate success; lifetable rates overestimate s NPT takes more time than IVF, but is far less costly, and has much lower rates of prematurity and neonatal morbidity.

Comments s With confirmatory studies, NPT should become a mainstream approach to infertility. – NPT does require additional training. s International multi-practice studies are in planning.

Case Presentations 1. 40 year old Female – implantation? 2. Failed fertilisation with IVF – Egg Quality? 3. FSH Above 20 IU/L 4. 100% Antisperm Antibodies 5. Very Low Sperm Count Dr. Phil Boyle MICGP MRCGP CNFPMC

1. 40 year old Female –implantation? s s Dx: Unexplained infertility for 5 years Hx: Gravida 1 para 0 Misc 1 3 Failed IVF – 3 embryos replaced each time Problem with Implantation?

40 year old Female – implantation? s s s NPT Dx: Corpus Luteum insufficiency Conceived 3 rd Cycle HCG Healthy Girl born, 9 lb 5 oz. Mum aged 40 yrs Tried again age 42 yrs. Conceived 12 th Cycle HCG Healthy Boy, 8 lb 6 oz. Mum aged 43 yrs

2. Failed fertilisation with IVF – Egg Quality? s 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 s Egg Problem? s s

Failed fertilisation with IVF – Egg Quality? s s NPT Dx: Poor Follicular Fx / LTD Mucus Rx: Clomiphene, B 6, Carbocisteine, Amoxicillin Conceived 10 th Cycle NPT Healthy baby girl 6 lb 8 oz Full term. Mum aged 41 at delivery.

3. FSH Above 20 IU/L s s Dx: Secondary infertility for 5 years, Hx: Gravida 2 para 1 Misc 1, Female Age 40 Yrs. s 1 Failed IVF – No follicular development FSH – 23 IU/L s Problem – Perimenopause s

FSH Above 20 IU/L s Rx: Clomiphene 50 mg x 5 days, B 6. s s Long Irregular cycles Conceived Day 50 of second Rx cycle Healthy Boy 5 lb 13 oz at 38 weeks s Never Menstruated again! s

4. 100% Antisperm Antibodies s Dx: Infertility for 8 years, Female Age 37 100%Antisperm Antibodies Hx: Gravida 0 para 0 Misc 0, s s 2 Failed ICSI – 3 embryos each time s Problem – Male Factor

100% Antisperm Antibodies s s s NPT Additional Dx: Low Prog. And Low E 2 Conceived 12 th Cycle NPT, (5 th Cycle Male Prednisolone Rx) Healthy Girl born, 8 lb 1 oz. Mum aged 39 yrs Spontaneously conceived again age 39 yrs, but miscarried. Spontaneously conceived 3 rd time age 40 yrs, again miscarried. How significant were the antibodies?

5. Very Low Sperm Count s Dx: Infertility for 5 years, Female Age 34 yrs Count 50, 000 per ml 10, 000 per ml 200, 000 per ml 4, 000 per ml 800, 000 per ml s Hx: Gravida 1 para 0 Misc 1, (ICSI Pregnancy) 3 Failed ICSI, 2 – 3 embryos each time s Problem – Male Factor s

Very Low Sperm Count s s s NPT Additional Female Dx: Low Prog. And Low E 2 Conceived 8 th Cycle NPT, 8 th Cycle Male Tamoxifen, L carnitine, Pycnogenol Volume Count Motility Morphology 4 mls 4 Million/ ml 45% 4% Normal Healthy Girl born, 8 lb 8 oz. June 2004 Mum aged 35 yrs Progesterone support during pregnancy until 28 wks Very important to treat the female…often combined problem

IVF - UK. Declining success with increased age