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Okay guys. Hi, everyone. So um I'm Doctor Karki just to remind everyone who's new. Um I work as a G P in London and I have got some uh postgraduate qualifications in Obstetrics, Gynaecology, family medicine, sexual health, that sort of stuff. So we thought it would be nice to talk about infertility today because it's quite an interesting topic. Um There is a lot of information, a lot of information um to talk about and again, you will know my style most of you who was on the previous call. I'm not going to be telling you all the answers. I want you guys to participate. Please put your hands up and we will go to each other and feel free to also comment in the chat if you want to. Um but would be really helpful to kind of get us all together and then um participating. So let's crack on infertility. Can anyone define what infertility is? Hippus? Ariga Christie Jeb Azad, Shereen Sue calling you all out. Anyone know what infertility is? This is slide one of like 24. So we can't sit in silence. And what I would say is guy caveat is that. I don't really mind if you get it completely wrong. That's the whole point of teaching. We're all learning. So, I, I put your hands up, answer stuff. Get it completely. Go wildly wrong. It's not a problem. We're here to learn. Okay. Go for it. Um, Christie. Um, I'm only just going to go in a layman stem and say that inability to, uh, reproduce biologically. Okay. Yes. I like that assad. Can you add anything to it? Uh I was about to say, unable to be having a child or uh it will be same as Christie's reproduce. You're right. Yeah. So you're, you're largely right. The only thing to add is basically that it's actually, it's also to the fact that there's a timeline involved. So the timeline is important. Um It's normally over, say a specific period of time, usually 1 to 2 years and again, the, the time depends a little bit on the circumstances of the women or if they've had surgery for treatment. Um, if there, if there aren't any, anything going on because why that's important is that when you're looking infertility and I'm gonna, I can really talk about it from, from the UK perspective. But, you know, I, I think it will be something to think about from different countries is if someone said, uh you know, we were kind of a baby and you say, okay, what's the situation as to what we've been trying for like three weeks, you say, well, what, you know, you may not depending on the period cycle and how long it is and all that. So we don't even know when the ovulation is. So it's not enough time really. So there are definitions which will come to later in terms of time and all those sorts of things, but we have to put a time limit on it. So we understand that. Ok, so let's talk about incidents, couples who are concerned about their facility, facility should be informed um that there's about 84% of couples in the, in the population that will conceive normally within one year, as long as they're not using contraception. And as long as they're having regular sexual intercourse, what is regular sexual intercourse? Anybody, how many times a week is regular sexual intercourse? Guys? Anybody Christie Samuel, please? Three times a week. Yeah, you're looking at three times a week really? Again, the guidelines sometimes very in different places depending on their, their rules. But I would say at least three times a week would make sense. Ok. So infertility, what are the causes of infertility? Go for it, guys. I just want you to throw out any causes. Yeah, so soon and, and sure enough, talked about what, what definition is, we've said 12 months, it's only 12 months to a year. Look, if you look at the previous life, which is quite helpful, I'm going to just bring it back to the previous slide, if you are having sex regularly within uh within one year, 84% of the population will conceive. And actually, if it's not one year, they would normally say by the second year cumulative rate is 92%. Okay. So, male fertility, male fertility, family infertility. What does family and fertility mean? Shereen, sorry. Uh diaper. It's female infertility and mail, in fact, activity. Yeah, I mean, Shereen, I like what you've done there because you've done that classic thing that we all do when we just say the two people involved and it's their fault but which I like but that's not I need more than that. What what is male fertility mean? What is family impotency? Okay. Polycystic Ovary syndrome. Yeah. Uh sorry, male fertility could be like a sperm defect or might be sometimes like erectile dysfunction and things that that. So I think for infertility, infertility couples, we tend to look for the mail or to diagnose the main fest and then we go to the female. So that's why I came up with the male infertility. Okay. So you said you said sperm. So what issues could there be with the sperm one? You said there's dysfunction. Anything else that could happen? It could be like sperm count and motility decree? Good things like that. Very good. So azoospermia or motility issues, that's very good. Okay. Anything else that could be a cause for female? So into you trying cause extra you trying cause ovarian failure, endometriosis. Very good. What would be um what would be an entry you try and cause Christy Samuel, I would say from a developmental causes like um you know, non patent fallopian tube. Yes. Fallopian tube disorders. Okay. Why don't we see some of the Olympian tube for a second since you've mentioned that, which I hope you appreciate fallopian tubes. Guys, fallopian tubes. What happens? You've, you've said non patent, what can happen to a fallopian tube? Give me some conditions that damage the fallopian tube. Yeah. Uh like uh pelvic inflammatory disease. Thank you by all. Okay. Here. Hi come. Um pelvic inflammatory disease can actually leads to fibrosis and that will actually inflammatory disease. What's, what's pelvic P I D? What, what causes P I D guys? Give me some different inflections. Biggest infection is I'm like chlamydia. Uh Yeah. Good. I like that. So P I D couldn't damage the fallopian tubes. Can anything else damage the fallopian tubes. Endometriosis, endometriosis. It's not really endometriosis is what guys? Um Shereen. Yeah, I was speaking more like adhesional, fell up into these obstructions and like sometimes um if there's a previous, you know, like a topic, pregnancy or whatever, I don't know. Very good. A topic. Pregnancy is a very good one. Um Very, very good point. Um Okay. So a topic, pregnancy would cause damage to the fallopian tubes could potentially lose the fallopian tubes. Adhesions. Yes. And that's a good point. If you're thinking about endometriosis, that's probably how it would impact on the fellow produced through adhesions. Also repeated. The P I D element is office there. Um What about Polycystic Ovaries syndrome? Is there anything? What is the problem? What we're thinking about with this? What's the, what's the path of physiology, guys? What we're thinking or give me something else that, what's it to do with, what happens with your periods when you have Polycystic Ovary? What, what could happen? Are they regular or irregular? It's a regular period. It's something to do with the ovulations, the PCR ovulation. So, ovulation is a problem, right? Because if you're, if we're thinking about ovulation and you're not regularly ovulating. Can you get pregnant easily? No, because we don't know when the eggs coming. Okay. So that's a good point. Again. What about, is there anything else that we can think of? Asherman syndrome? Jeb of a queen Jeb. Tell us all about Asherman syndrome. Uh Hi. Oh That's when uh scar tissue. So you can also call it as intrauterine addition to see like a so that like a scar tissue it spawned inside the uterus or the cervix. Yes, perfect. OK, guys have to say I'm really enjoying this group. You guys are fab and doing so well. So we're going to go through the cause of infertility, spell dysfunction, 24% ovulation disorder, 21% fallopian tube damage, 14%. And we mentioned chlamydia. You guys got the endometriosis, quote, a failure. So, that's the infrequency thing. That's the, one of my most common things with in my practice is I hope it's okay to tell you about like, you know, things I see because it helps to kind of contest one of the things I said, how much sex. Yeah, like once or twice a week or we have sex just around the ovulation, you know, according to the AP and I've, so to them, why don't you just have sex every day or at least three times a week? And we will see how things go three months later. Get a phone call. Doctor Karki. Could you refer us to X hospital because we are pregnant? So it's often to do with that quite a failure or infrequency. So, uh mucus defects, you know, that's something that, um, uh it's an interesting one. It would be more probably when you refer on to the clinic to find out. It's not something you'd probably find it the first element. Uh, as, oh, sperm ear, which we mentioned, unexplained is a big one. Look at it. It's 28%. It's the big one. We don't know. And that's really difficult, isn't it? I think the hardest thing in medicine that you guys will learn and see, and I'm sure you've seen in your practice is what, when you have a child or you have someone or you have anything and you, and they say, what's the problem? And you say, I just don't know. And the reason I'm mentioning that is that we have to be very sensitive with fertility. It's an important subject and the way we handle ourselves, I'm going through things and it's kind of a whistle stop tour is already like 1 20 where I am and we've got 40 minutes to go through like loads of slides and there's loads of things and there's a bit in a bit which I'm going to quiz you all forever like I always do and we're gonna have fun. But um this is a serious issue and you know, it could even be people in this room, people we know who've had or suffered with or struggling with infertility. So I really want us to, when we're counseling, when we're discussing patient's, I want us to take every piece of empathy we've got and really put it into this consultation because people really are affected by this and, and, and I want us to just remember that throughout this constitution. Okay. One more thing, miscellaneous, 11%. I don't even know what miscellaneous was, but it was on the research. Okay. Changes in prevalence. We feel that things are going to change. If you look at the research, infertility service is likely to increase because of a number of reasons. One of them of course, is the increase of sexual transmitted infections. Anything else? Give me, give me um give me. One big thing that's happening is a trend around the world that is making for infertility happen more. Come on guys because you can't fall asleep. I want to hear the answers. Come on. He said everyone's leaving, you know, career minded, not want to have child early, leaving it late. And exactly that Christie Samuel once again stepping in and batting out the park. It's exactly that it's to do with the fact that women are delaying childbearing. Um, and in 1977 this is portion birth women over 30 was 23%. Okay. 2007, 48 over double that. And that was 2007. So we're looking at 2023 even more, um, even more opportunities to have hybrid working to work to delay things, freeze eggs. There's all this stuff that's happening now, which is really cool and female autonomy. It's, there's a lot of things to discuss and, and, and re production is really interesting, but that's a big thing to think about. Okay, diagnosis. This is the fun part. Guys. I want some history that I want you to ask a male. No, no. Let's start with women. What are you gonna ask the females when they come into your clinic? What is the history you're gonna ask? What's the first question? We just talked about it just now, stds, stds. Yes, we talked about that. Yes. Uh, regular, irregular menstruation's regular, irregular menstruation. Tell me about menstrual. What'd you ask in a menstrual cycle? Question? What immense your question? Is it regular? How long do you bleed? And uh was it heavy or heavy bleeding? Um I don't know. Very good. Anything else, guys, any time between period? Sorry, guys, one at a time, I can't see hands. If you could just check your hands up, it will really help because I can then um just allocate people stuff who's got anyone got hand up. Uh Nobody has got to handle Christie's Christie go for it. I will only just say one point. I want to know how old is the female old? Is it? Age was my first question. That's what I was thinking about, but it was good that everyone went into other questions as well. I'm going to give you an acronym I use when I was at medical school. It's I'm not sure if you guys have, have, have acronyms. I like it. It's called Marks M U C S menstrual cycle, urinary symptoms, cervical stuff and sexual history. I found this really helpful for Gyne histories because this gives you something to not forget about. So your menstrual cycle is going to be your, how regular are your periods? Do you, how heavy is the bleeding? When did you start having periods? Um Is there anything else about bleeding? You need to know there is otherwise I wouldn't ask it guys. Anything else you ask, what did we, when did they start having their periods. Yeah, we mentioned that. Anything else? Okay. Sue Shareem Jeb Assad Syringa Himba. Duration, duration of what of the period itself? Situation of the period? Yeah, that's, that's something to ask. Of course. Yeah. Anything else? So we said how regular are your periods? Are they regular or irregular? Are your, how long do you be when you have your period? You might even ask them. You might not, they might not know. So you might say how many pads do you go through? How many tampons do you use? Thank God. The color, the color. Yeah, that's, that's simple. That can be important. Yes, it should be part of a guy in the history, of course. Yeah. Any irregular color. Is it normal? Is regular? Normally women, women as you guys know, will have different discharge, different bleeding stuff. What you need to know is find out what is normal for them, you know, do pass clots, is it heavy? And then like is that changed is always change is a really important part. There's something you guys are not answering and I want to know why come on guy in your history, I could be wrong. But are you going to ask about the postcoital if there's any postcoital bleeding or things like that or am I good? Shereen, post so, bleeding, menstrual cycle, bleeding, postcoital bleeding which comes under the sea of my marks M U C S, cervical stuff. You can ask about, but there's one thing that I want to know about your periods. Do you get any bleeding between your periods outside the cycle cycle? You know, very important. Why is that important? Uh Does that tell you about endometriosis or? Yeah, it could tell you about the uterus is it could be tell you about polyp, it could tell you about again. Could elude or start you on your next question's about cervical stuff. So, you know, have you had because if we're thinking about ectopia in, if we're thinking about uh cervical, any cervical issue, cancer, whatever it might be, dyskaryosis, whatever if we're thinking about something else going on, if we're having some discharge and think about sexual transmission infection, a bleeding would be one of those things to think about. Okay. So we'll come back on to that in a moment. But cervical stuff you talked about, you said uh postcoital bleeding. Yes, because that can mean what Sharon, what can postcoital bleeding mean? Anyone postcoital bleeding after sex? What can it mean? Are we happy with it? Cervical causes, you know, STD. Yeah. Most of the causes of bleeding after sex are related to the cervix because it damages the cervix, irritates the cervix. So you're thinking about ectropion, polyp uh something else going on around the cervix? Yeah. S T I S Yeah. So that's a really important one. Are there smear's up to date? Have you had your smears? Smears? Leads to s what's your sexual history like? Why is that important? Because how is sexual history relevant to infertility because of S T I s and fallopian tube function? Correct? So, have they had any sexual history, sexual infection as well? Urinary symptoms? Have they got any urinary problems? Is there anything that can cause issues with your urinary symptoms that could be related to this? Nothing I can really think of. But I think the thing to think about is if you're having, um, prolapses or anything like that, obviously, you know, it may affect sex, it may affect other things that it can lead to important questions. They may have had some surgery in the past for prolapses or something that's important because that can affect the architecture of the womb and, um, and all the female genitalia. Okay. So we've said age, we've said uh, menstrual cycle, we've done all that really well, guys. So smears surgery. We talked about S T I S have we talked about anything else? What else do you want to know? Guys? Come on more. There's so much more. Um, has she ever been pregnant? Has she ever been pregnant? Why is that important? Mhm. Yeah. To know if uh perhaps uh or something like that. Yeah, you're right. Exactly. You're, you're exactly right. You guys guys, you know all the answers. I'm not doing any work here. You're doing all the work and you're answering everything perfectly. I trust you guys. I know, you know, the answers, but you're just going to bubble up with it even if it sounds crazy in your head. I'm pretty sure you know what you're saying and if it is crazy, don't worry, I won't demonstrate it straight away. I will internally keep it. If someone has had conception before, it means they're most likely to be able to conceive again. In fact, one of the things I remember researching, I need to read the paper, we'll find it. Maybe you guys can find it is that once someone's over 30 as long as they've had a baby, their fertility isn't, isn't like a 34 year old anymore. It's because they've already had one. So they're kind of back to pre, but the point is, you know, the, the egg quality changes. If we're looking at it from uh previous pregnancy. Yes. But what else do we need to know about that previous pregnancy? Come on guys. Well, they have working or hands up, please. You can just so I can get everyone to answer. Um, yes, Sharon. Go for it. Yeah. You need to know if it was like full term pregnancy or there was an abortion or, you know, miscarriage or something like that or if there's an ectopic pregnancy. So many things that you can find out from that pregnant and if the baby was alive, if it was full term. Very good. Very good. Anything else you might ask about? Okay. So let's talk about we've gone into upset your history a little bit and I like that because that's really helpful. What, what else would you ask? Cause we're talking about infertility here. What else might you ask about this pregnancy? Missed abortion? Yeah, I'm gonna bring sue in if that's OK. Soup Suit. Can you hear me? Was it a natural pregnancy or was it aided uh in terms of conception? Yeah, exactly. Was it a spontaneous, was it a pregnancy that happened naturally? Was it aided? Was it, what kind of aid was it? How many, if it was IVF, how many cycles of IVF? Did you have? These are all really important questions if we're, you're on Metformin or any medications, where do they give you clomiPHENE or any medication? These are really, really important questions because they help us to guide where we're gonna go. It helps us to guide so much of what we're about to do because if you're counseling someone and they've been through it all and you're telling them, well, this is how it starts, you know, you've got to tailor your conversation to them if they've been through clomiPHENE, if they've been through Metformin and they understand that's really great. And, and again, we can kind of Taylor that discussion for them. Okay. So the type of conceptions, previous pregnancies, um, anything else that's relevant to a person who wants to, who's infertile and always trying to have a baby and they can't have a baby. Anything else you want to ask them? But she was used contraception as she was used a contraception. Yes. Has she, she used the contraception? Is she using a contraception or she has used it in past, in the past? Okay. Why do you, what, what in the past? Why are you thinking about that? Just to take an Eastery? Yeah. Okay. Yeah. Just take a history. I mean, we can also like that. That's good. I want, I want more of a focus history that I want, I want questions that will help us to work things out or that will contribute to our management plan. It's, it's important. You're right. It's important to have a full history but give me more. So there is something there, for example, if someone was on the injection or the implant, that's important because those people, if I said, yeah, I just took my implant out last week or my injection, I had it like two months ago. You guys know contraception. I think I was going to talk about it and I was told that it's been discussed. So I'm going to talk about it as if you know it, if you don't know, feel free to let me know. I will try and talk about it a little bit. But the injection, one of the, one of the problems with the injection is what guys, is it the timing of the or relation where the sperm and the ovum. Yes. Well, exactly. It's, it's to do with the fact that the period sometimes takes a bit longer to come back. So, if I, if you had an injection three months ago and you're suddenly like, I want to have a baby. Well, you gotta wait. So thats is what you said is a good question. What contraception are you using in the past? Very good question. I like that. Um, Okay. So I'm thinking about other things that are relevant to the history now, not necessarily on the focus that so much, but what would you ask about past medical history? Was there any incidents of any other like polyps or cancer? Whatever? Was there any treatment regarding that? Good? Yeah. Is there a condition? Very good? So, cancer, any treatment you had down below any surgery? Anything you'd ask from a perspective of thinking about medication, you might give a pregnant lady? I'm thinking of two conditions. Uh Kristy go for. Would it be tire I'd problems? Very good. Yes, hypothyroidism. Anything else? And maybe diabetes you might ask about or gestational diabetes, family history. What about, what about hypothyroidism? Why we, why do we care about hypothyroidism? Oh, we don't care. Does anyone care if the ladies hyperthyroid yet? Suit, go for it, please. Yes, I'm sorry. Yes, I am. Uh Well, if the person, if the lady is hypothyroid tick, then that means that ovulation is probably not happening. Um, it would affect ovulation. It could affect ovulation. What else could it be? Why is it relevant to the pregnancy? So, you're right. Yeah, the hormones, the pre counseling, we're going to treat the thyroid and make sure she's optimized. Hey, that might bring her periods back, regular etcetera. It might bring the desired result. Let's say which is under that condition. Her thyroxine is on, she's on 100 microgram thyroxine. Her TFTs a normal, but she has a history of hypothyroidism. Why do I care about that? For a pregnant lady? Come on guys. Yeah, for a pregnant lady. Yeah, I think for the if she's pregnant, right. Well, she's so she's not pregnant but she's trying to get pregnant, right? Okay. She becomes what I'm thinking about. It's going to affect the child cns. Yeah. What condition do we get? If, if child doesn't have enough thyroxine? Um criticism, criticism. Okay. So really good. So, so remember sometimes you're asking questions that are not necessarily directly related, but if you tell her infertility consultant, he might start everything but he might have forgotten to give them thyroxine or check that because he may not be thinking about the endocrine results in, in, in practice. We tend to think about giving, you know, uh in fact, sometimes in real life, just parenthetically tell you guys, you know, sometimes we run ladies, hi, we run them on a hyperthyroid a bit in pregnancy just to make sure the child has got enough thyroxine to develop. But that's something an endocrine she will, will discuss when the time is right. Is there anything else from a, there's two really big, couple of big, really big things I want to get into about this guy's. I make no mistakes for laboring this because there are some magical stories. I'm going to tell you in a moment that you about this, but anything about your country? Uh, I'm sorry. is it, are you, are you looking for the tumor in between or if there's a thyroid problem or is that with the way you're looking? I think that's, that's, that's an important one. But again, you probably picked up in, in examination, you, you probably truly that a fair point. But I think pituitary adenoma or something like that would probably present with other symptoms, wouldn't it like some sort of visual dysfunction? Maybe some headaches generally. Um But yes, I think it's a fair point. You can add it in examination. Uh We'd probably be doing some bloods on that, wouldn't we? If we were to a blood test, what test would we do for that? Anything that would be secreted extra or no extra, that's forward, please put it. I didn't get a question. If we, if we were thinking about a adenoma of the pituitary, what would, what hormone would we test for? Um We should text for collating prolactin. Yeah. So we, we probably think about prolactinoma, that kind of thing. Okay. That, that's a good point. I'm thinking about this social history of this lady. What we're thinking guys, is there anything you want to know about what she does in her life socially that's relevant? Uh uh multiple partners or single partner? Is that what you're talking about? Uh Multiple partners is um is a good question and of course, that suggests sexual transmitted infection. It's something that we would have asked about. So when we said marks menstrual urinary, cervical sexual history, we're gonna ask about sexual partners, sexual infections, previous treatment P I D topics, all that stuff that's going to be covered in sexual history, which um which I think sue you had your hand up. Yes, I was going to say um smoking or alcohol, smoking and alcohol. Why are they important? Well, they do affect um the, the uh optimal body um uh systems. So yeah, they would bring maybe hypertension, maybe um other diseases that and influence inflammatory conditions that would affect fertility. Exactly. So, uh that's one thing I think the other thing is you're thinking about the longevity if you're going to refer her on some where they need to know that she's drinking or smoking because it affects the developing baby. And of course, smoking is really important because smoking is linked infertility. So, smoke is important. Is there anything else that alcohol, smoking? Is there one other thing we ask about illicit drug abuse, illicit drug use? Which illicit drugs would do, do people take a lot of nowadays? And would that be either marijuana or marijuana? So, marijuana, cocaine yet? So, I mean, if someone's trying to have a baby generally, most likely they're not going to be taking cocaine generally. I mean, most people will realize that would be very dangerous, but most people don't really think about the risks of marijuana. And I have an interesting story about this, which is why I kind of mention it is one of my patient's once said to me that and it's important for this, this particular they came in, they wanted to have a baby and they have been trying for a year. And I said, okay, we can refer you to the team, of course, and we did all the work up etcetera. And, and then I said to the, the chap, you know, you smoked and he said, yeah, I smoked marijuana like twice or three times a day for like four years. And I said to him, okay. The problem is in the UK we, the, if someone takes illicit drugs, you can't refer them for I for to the fertility clinic because it's such a well known prohibitor. It's a bit like uh I don't know of an example. Now it's a bit like calling a plumber and then opening all your taps and destroying a house and then calling the like, it doesn't make sense. So anyway, I explain this to them and I said, look, why don't you stop the we, you know, if you do that then and you're, you're, you're off it. I can refer you. But without that I need to. And they said, okay, we'll try and, you know, we've been doing it for years and I said, fine, three months later, I get a call from them saying, guess what? We're pregnant and it was stopped marijuana after a few weeks and within a month and a half they're pregnant. Why do I mention it is because it's such a powerful thing that we always forget. We said, oh, yeah, smoking drugs. Yeah. You know, just mention it. But actually a lot of evidence that shows that marijuana and smoking can affect a lot of particular marijuana can affect fertility. So something that we should also ask about, is there anything else that can cause people nowadays to have delayed periods or period issues? Um, that might be relevant to their lifestyle? Would it be diet changes? Again, the lifestyle we discussed about it earlier, isn't it? People going on veganism and yes, diet is good yet diet is important. Anything that goes with diet? What happens with, what else do we do with diet? Well, we don't cook anymore. We, you don't cook. Yeah. Sure. No, I'm thinking about what, when you say to someone make some lifestyle changes, what do you tell them to do? Sue? So go for it. Yeah, I was thinking I was thinking exercise. Yes. Good. Why, why is that relevant to fertility and periods? Well, it goes hand in hand with diet. Um, and um, yes, if your body is not prepared also, if you overdo exercise, um, like it does bring on a menorrhea of some sort. Exactly amenorrhea from over exercising. We see that in which kind of condition generally, um, people were athletes. Um, yes, athletes, anyone else? Yes. Any condition that we see in being an athlete I don't think is a condition. Any other conditions that we think about, I'm drawing a blank right now. Sorry. You know that it's related to exercise. Yes, I mean, you're really religious exercise. Yeah. A yes, anorexia is a really good point. So when you meet a lady who says we're trying to have a baby and they want to be, I think you want to ask about one more thing which I'm not, it's not mentioned in the slide, but it's important motivation like sometimes, yeah, a couple present together, we want to have a kid but it might be driven by one of them and sometimes they're doing things that are deliberately trying to actually sabotage that situation or their lifestyle is such that they can't. So for example, someone who's anorexic as low, be a mind, you think what's going on and you exercise it three times a day, I'm running and I'm doing and you realize they're not having periods. This is an important element to ask about. Okay. Um uh This is crazy. We've got like 17 minutes and there's so much magical stuff to go through. I'm gonna, I wanna, but this is, this is arguably the most important part. So I don't mind if we, if we spend more time on this and we pick up the rest later, but let's go. Let's keep going. History from the man. What are you going to ask the man what? I'm just gonna pop into it. So I'm going to show you the slide for the ladies. So it's for females. It's going to be aged. We talked about previous pregnancy, contraception, mental cycle, details timing of intercourse and frequency duration of infertility, history of abnormal spheres. Uh smears public surgery, S T I cancer treatment, hypothyroidism, drug history, recreation, whatever and lifestyle work, alcohol, smoking, exercise, history of from men, Azad. Are you around with us? Hipper? I've not heard from your hip. A are you around Sirica? Okay. Anybody who wants to tell me about men, what would you ask a man? Exercise, obesity, erectile dysfunction, erectile dysfunction. Good. Yes. Anything else? Childhood illnesses which could cause very good. What childhood illnesses could you think of? Which is wider business is a German measles, one of them which can cause mom, mom's is the main one that everyone thinks about that can affect fertility. Anything else? Some similarities to this screen you can see on you right now. Big testicular trauma, testicular trauma. Very good. Yes. Have they had a torsion? Have they had a testicle removed anything else that you can see? Or? I don't want you guys to just thing. But you, you know, have a look on it because we go on anything else you can think of. Gone sue drugs. Drugs. Yes. Good. Drugs. Their job, their job. Yes. What, why do you think about job? Well, uh, exposure to radiation? Yes. Yeah. Eat. Not very good product. Yes. Exposure to radiation. They are important. Definitely. Um I'm thinking about this line here. S T I S. So again, sexual activity infection is really important. Can they cause infertility? They can. What about any previous Children? Because that would obviously suggest that the, that the mail is able to reproduce. Um Okay. So let's go for that. Um positive history. So, illnesses, mum's puberty, ST eyes, orchiopexy or serve your trauma, testing a trauma. We talked about previous Children, drug history, prescribed and recreational. What would you do on examination? Mostly you would do the normal things. Weight is really important. We talked about B M I, we talked about all that stuff. Pelvic examination, polycystic ovaries. What features of polycystic ovaries? Could you pick up anything guys? Uh Yes, Azad. Yes. So it's the abnormal timing of the menstrual cycle. Yes, that would be on history. But yes, anything you'd pick up on examination. Jeb has mentioned hirsutism. So hairiness weights, cane. Yes. Anything else uh check for this pregnancy. Uh That time guys, I've got to say we're going in, coming in, go for it. I, I said for uh Polycystic Ovary Syndrome. My review as its name, a lot of cysts. Um even ultrasound. Yes. Is that something you can examination to who here has out some fingers? Nobody. So, investigation. Yes. Policy over. What? Examination findings, I think assad you had your hand up. Yes, it was regarding, are we examining a woman here? Because uh sorry, do men get Polycystic Ovary Syndrome? Anybody has that? No, no, no, no, no, no, they can't know that. Would, that would be something though. I think if a man presented with policy, Ovary Syndrome guys write that one up as a, as a paper and publish it and we will have something magical. Okay. I'm think I'm thinking about his acne. So Acne Hirsuta is um basically um signs of uh androgen excess. Um Okay. Uh Men, we've got the same sort of thing. Wait, we have the scrotal examination, varicoceles, penis and any secondary sexual characteristics which could suggest things. Okay. Really good guys. This is really good. We, we are sort of like quite close to. Yeah. Yeah, please. I have a question for Polycystic Ovarian Syndrome. Like detecting something like hypertension. Does it give us a clue? No, I don't think it would know. It's not a feature of policies. Uh Guys, what is Polycystic Ovary Syndrome? Anybody? Yeah, I guess it has two forms. The dominant and recessive one. So the dominance has to do it. I think it affects the kidney minus size potential. I'm just saying, doesn't give us a clue when it's, when it's, uh, I think you're thinking about polycystic kidney disease. Yeah. Yeah. Yeah. Yeah. Yeah. I guess I'm mixing up. It's okay. Um, okay. So that policies, kidney disease. Yes, that would cause hypertension. Yes. You have the, uh, different, there's no autosomal dominant recessive with policies over syndrome. Um There is genetic predisposition. Um policies. Andrew syndrome is a condition characteristic characterized by multiple cysts on the ovaries accompanied by a couple of different things, either signs of hyperandrogenism. Um So that would be hirsutism, acne, uh menstrual abnormalities, um blood biochemical markers, that sort of suggested. So, for example, you may have some of those symptoms and not have Polycystic ovaries on the scan and it wouldn't be Polycystic Ovary Syndrome. So it's actually a centrum diagnosed through an ultrasound scan as one of the key things to demonstrate uh Polycystic ovaries. I'm not going to go into it too much because we've got about nine ish minutes left. But that is one for you to have feedback on. I also appreciate that you guys have, uh unfortunately, unfortunately, the person who is presenting couldn't make it. And so I was asked to step in. Um, and I really appreciate that you guys, despite me stepping in with half an hour's notice have put me under the quality to ask everything. So I like that. I'm gonna go for investigations. Now, guys, what investigations are we going to do? This is, this is almost the last bit because we've got nine minutes and the rest of it is quite quick to run through. So tell me, so, investigations, guys, women, what are investigating? We mentioned prolactin anything else, uh, deficit in allege, um, Sharon, I'm going to come to you in a second, just going to have a side with hand up and then come back to you. That's good. Uh Go on. Uh First thing always the first thing you always check is the woman pregnant or not? Uh is she pregnant or not decent changes? Yeah. Good. Okay. Like that pregnant or not? Yeah. Okay. Anything else? Shereen? Oh, as odd. Finish up with you. So I was talking about the FSH and the alleged hormone or even the estrogen to find out effect. Anything else? So when do we get, you know, when is the, when in the, in the menstrual cycle? What happens at day? 14? Population? Two ovulation? What hormone changes go? Yester. What happens? Is there a surge of something? Yes. Uh What's the surge called? Couple slough TEM, corpus luteum. Yeah, something about corpus luteum. Um Ella, you get an LH surge, don't you? Yeah, surges and initiates like the estrogen uh egg release, correct? So that's the time we want to also do the blood if we can because it'll help us to work out if there's an eastern an LH surge. You've mentioned FSH LH, you mentioned pregnancy test. Anything else that we need to check? We said prolactin, we said tear. We're going to check thyroid function, aren't we anything else? Progestin progesterone? Yeah. So, the anatomy of the uterus, like if there's any blockage or anything like that. Yes. And the ultrasound. Yeah. Good. Can also do uh what speculum. Yeah, we, we've done that in examination. We're going to do a speculum because we're gonna look at the cervix. We're gonna look at everything good. Anything else to more things they hysteroscopy, history of itself, endoscopies or what? Why we didn't use your self conscious copy uh to check out the uterus and the patency of the uh fallopian tube. Again, to see is there is any, so would you do, would you just jump in straight with? No, no, no, no. We, we would really do that if we, if we got an examination that an ulcer and that suggests there's an issue of uh uh Zadia go for it. Uh This is not something a male doctor would do a physical examination of like a secondary sexual character development. We see whether the on the tanner scale as we see whether everything is perfectly developed by the according to the age. Yeah, that there is a delay. Very good. Yeah, delayed, delayed, uh secondary sex characteristics are important um And I think that's an, an important one to check the other two things I think we're thinking about really are FBC full blood count and rubella, rubella is really important. Um And I'm gonna time it will doesn't give us time to go into. But rubella, I want you guys to think about why rubella is important and I want you to do some research on that. What would you do for the men? Anything for the men? Uh huh. You probably do a sperm count when you just a sperm. Some, you know, you might check to see if there's signs in of, of, of uh delay in puberty or something. You may think about some bloods for hormones, wouldn't you like LSA LH FSH T uh testosterone G N H you know gonna the stimulating hormone. So you may think about all these things. But realistically if it's someone who's old and then you're probably gonna do some sperm, some sperm, some pearling. Okay. So I'm trying to fly things things because time is crazy against us. Um semen analysis making sure they're wearing loose underwear, smoking alcohol, drugs. There's underwear is important because we mentioned earlier and it was well said by, I think Shereen or somebody about their job, maybe Christie about the job and making sure they're not having too much heat down below that can damage the testicles in the, in the spring. Okay. Good. Anything else that you can do as a doctor to look after your patient's. Well, I'm gonna run through this because counseling, like, let them know the issuance of counseling. Good counseling. Very good. Uh, we put, like, as Shane said, the second psychological statement that they are, they're feeling incompetent, the psychological state is important. Yeah. So a lot of this now is really about being involved with the sort of stuff we talked about before, which is looking at smoking and drinking drugs, making sure they're not doing any of that. Um You know, in the UK, you're got, you actually can't refer someone if they're doing that, looking at their weight and trying to optimize these things. So as a doctor while we're waiting for these investigations with these optimizing folic acid because look, ultimately, they're still trying, aren't they? And if you're trying and you suddenly remember 28% unknown pregnancy. So if, if there is no um reason they've got all these things right? You know, keep taking photo casted because suddenly they might actually get pregnant pregnant and photo cast is very important to that. No. Does smoking the marijuana cause infertility in only females know it cause infertility in males and females. I think in fact, it leads the males is the one I'm more aware of cause I think it affects sperm quality, sperm count. Um uh In this, in the story, I gave the guy gave a sample after three months, his sperm count was better. His sperm motility was better. Um And so those things improved. Okay. And then of course, the main thing is really to refer. Um Now there's different reasons we're going to refer and I'm going to just run through them with a quick look. But essentially these are your sort of top line things on, on things we've discussed. And then again, it kind of goes into now like the, the actual guidelines of how we would do things in the UK and a little bit about what happens next. They're gonna see an infertility clinic and normally they would have some investigations, maybe a history of uh pictogram, lap and I uh diagnostic hysteroscopy. There's a various number of things that will happen um or they might be put on some clomiPHENE or some Metformin. Um They may be offered IVF, there's a few different things. So you got IBF, if it's sperm abnormality, they might have injection. If there's an interview, try and issue unexpended from maternity, there's a few different elements they can do. Um and I'm going to kind of draw a little last bit on the psychological part and, and really draw a conclusion here which is, this will cause a lot of stress. This is not an easy thing. So I want you to offer as much support, you can, you know, give fertility support groups, um offer counseling as you mentioned. And of course, um it maybe before and after and before during and after the treatment, I think that's gonna take us to mostly important stuff. I'm going to stop the share ing there and just ask, does anyone have any questions or queries at this point? No. Thank you. It was very clear. Thank you. Does that all make sense? I mean it's hard because we're talking about big issue and I'm trying to get everything and I want you guys, it's easy for me to talk to you, but it's boring and nothing you will get learned. But if you give me all the answers which you all new, it's perfect. I have a request. Okay, Taiwo go for it. Um Can we do obstetrics next time instead of time? Ecology? Uh Yes, I'm sure we can. I think Hannah, would you take that forward? We'll see if we have any, any open slots on the timetable, we can discuss that offline? Fine. Perfect. Um So guys feel free to feed back to Hannah. Any, any sort of topics you do like covering? I'm sure I think there's a curriculum already in place which is worth just speaking to her about. But uh feel free to sort of look into that. I think the other thing we would really appreciate is the feedback. Thank you. As odd for um for following my Facebook page. I'm a little erosion social media, but I will get back onto it. Um The feedback form is really helpful for us um uh to help realizing what went well, how we can improve. Um, if it was the right level, if there's any kind of feedback you guys want to give us verbally. Now, that's helpful. If there's anything that was good about the session or you, you like, that's really helpful or otherwise we can draw it too close. Uh, more like a studies would be better, more case studies, more case studies. Yeah, sure. Is that the same to you guys find that we will just keep the same pitch, uh, with, you know, I would try to complete one topic, you know, in, in a session without Russian would be, yeah. Sure, because we're kind of, in the end it was a little bit rushed. I, I think, I don't know, can just, uh, yeah, I mean, essentially the last bits are, are sort of, I kind of rushed through them because they're a little bit relevant to us at this stage in the sense that, um, once you referred onto infertility, there's a lot of stuff they're gonna do, they're gonna do is they're going to do examinations, they're going to do more and then depending on what they find, they're going to kind of go down that route. That's why I've sort of not gone too much into it. You know, it could be, I, I s, I could be IVF it could be clomiPHENE Metformin and, and even with me in my practice, I don't really know why they decided to do, which they decide to do often, you know, if there's no cause they will do uh clomiPHENE Metformin, try that medication route. Uh But you know, if there's someone who's got, for example, one of my patient's, she had a bilateral uh topics unfortunately. And so they had to do uh like IVF. But, you know, thank God it works. So it's always very difficult. And again, if it's a male problem, then the, the retrieval of the sperm or finding or then there's lots of stuff. So it's almost impossible to kind of go into that fully. Um Yeah, if you can keep the same pitch, it's good. Sure. The most important thing I want you guys to think about is the history of examination because those are really what is going to be our benchmark main thing. Thank you. Thanks guys. Thank you.