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I? Good morning, everyone. Welcome back. Welcome to your first session. We've got Mister Rogers with us today. He previously gave us a lecture on early pregnancy problems on. We've got privilege of having him again today to talk to us about infertility. Just a quick reminder. As everyone knows, all of us started to do this. Anyway, please put your name, your university, your your group on where you communicated in the chapped. Uh, any questions, please? And put them in the chat. A mask at the end. If, for example, you got a question to ask, then then I lost. Mr. Energy is doing the presentation. Please raise your hand. Town will call upon you. Um, so without further ado, I'll have bring you to miss torture. Good morning, everybody. Nice to meet up again. So today we will recover. Mainly. The cause is on the main approaches to treatment. I I'm a little director. Consequently clinic. So that's sort of my country to interest. And today we like to cover the physiology. The investigations and the treatments are some fertility because it's some fertility, because it doesn't mean that they can't get pregnant. They have got a problem, and I try to resolve it. So something clearly the much gentler, milder technology that infant. So we'll try to see the normal physiology. That's a cycle you look at. The very end result. Juman function fibroids and the mitral is's male factor. Similarities is lifestyle and treatments. I'll talk about tripping bored than the lifestyle quick look of the causes of mail off in front of you or something that they are. You can see manufacturers a big fact that because the tumor factor annihilation, you got unexplained where we still haven't found a course for it. You got endometriosis, sexual dysfunction and make us hostilely on. A 1/4 of the patients will be having more than one factor. This life is very useful to explain to my patients and Alice to students about the anatomy so you can see here. This is the vagina cervix. I'm relieving the sperm's here in the uterus for intrauterine insemination, you're already showing different phases of follicle growth of ovulation. The eggs release the memory of a mix of the A, but less is in the ambulance, and 5 to 6 days later they come back in the uterus to implant, so it's a quick review status. So let's look at how ah follicle growth from the initial stages. You can see here a primordial follicle is only 0.2 millimeters, and then there's an initiation face. But they are recruited, and then they become into pre Androgel, and then they become recruitment into the cycle. Then it become an entrance follicle. So this has been a beard starts on with a reentrant stage because in the ankle stays a little bit of fluid around the over. And then there's a selection for the dominant follicle. I don't want you to. Just 20 millimeters is before all of this. So if you put them into two categories, you have the basal growth for 65 days. Then you have the recruitment for the cycle five days and then 10 days to get really for all these and again break them again. You can see that this part, the primordial of pre Androgel, is the stage where we, uh, it's a stage. Where the hormones don't act is in the antrum follicles that the hormones act FSH to recruit a follicle. So this is the three hormonal face, and this the whole face Quickly The women coming to see me off. I do a scan and I try to do it in the early follicular face Where the endometrium. This is a scan of the uterus. It's an anti budget uterus is surviving canal on endometrial here. Then the major mistake because you just had a beautiful and I see it three groups of patients. One group is here with the Lord's Conceive these follicles here, this one you love seven years, 6 to 10. And this is a moment of the polycystic ovaries. So three groups of women were coming at the same time in the cycle that can only face. And then I'll be scanned them a week later and then in the mediums now become take. It's got a typical triple therapy here. So what is happening, though? In the follicle a phase estrogen is going up. You said you make the end of me. Don't take on that is helping the implantation process In the whole ovary, there's a dominant follicle. This dominant follicle is now getting ready to overeat. So this I call it has a very only true face. They come back one week later and you can see the endometrium here has become echogenic. So the dollar home is from this room and the follicle has collapsed. This is a corpus luteum, and you can see the Doppler flu around the Corpus Luteum. This is producing pretty strong. So in the normal menstrual cycle, it is divided into two house the follicular face that falling history student by FSH from the anterior pituitary on the follicle releases Easter. The Syrian makes endometrium think and I been like a triple there in the lutein face after relation, The following becomes Copper City and the dominant pollen is pretty strong. Really strong makes the in the Mitchum echogenic. It's stick because of mucus, so it helps with the implanted. So let's look at the cause is in the female. So my presentation is quite different from the standard way of president. So I'm looking at causes and then looking how to resolve them and then go on to treatment severely in of ovulation. So you got these causes here. I'll touch with each one separately. So failure of ovulation is a place where for some reason, a woman is not ovulating. No. Normally, there are certain times in a woman's life. She will not be already. She's pregnant. She won't be ovulating. She's menopausal, that she won't be ovulating. It's been hurting, so she won't be all day. What is important is as the approach menopause Women start having less ovulations and the cycles become irregular and they get heavy appearance. So as the result of the follicle counters, the account is getting less. The ovulation battle gets affected, and therefore the patients don't get years. Let me tell you what, in simple words, if a woman having regular cycles select 28 30 days that when she's over it and in a national cycle of that said, there's a political of it's and there's a little face and in the middle is the ovulation. If you look at polycystic ovaries, the ovulation could be put into three categories Is a woman who always regularly like normal. She has a 28 day to day cycle, and another quarter of women will have no real issue. They get no beaters, and then there's a middle. So 25% over late and regular cycles 25% know, get no beer. It's on the 50% get irregular. Peter's let me define it. A big bowl when I say irregular period means they have delivered. So instead of having a little cycle of 28 days there, cycle man coming 35 days off 42 days or 50 days? No, we divided the site into two hearts for legal and don't you? And the ablation comes at some point where the cycle is becoming prolongs. Coming late, the follicle. A phase expanse, it takes longer for the polyp to grow. But once it's over this, the usual face is fixed. So in a 28 day cycle, a woman ovulates around a 14 in a 35 year cycle. A woman over is around day 20 months. That means 35 minus 40 in a 42 day cycle. A woman always around, they 28 so 42 minus 40. So that way you can see the follicular phase is expanding and the utilities to become a charter. Same. So as a moment. One approach is menopause. A cycles become a bit more frequent and shorter, so the follicular phase and becoming shorter and the little face is constant. Occasionally, you will get a little face? No, uh, not constant. But most of the time it is constant. Let's now talk about polycystic ovaries. So no difficult policy. Ovary has got these features. They haven't enlarged ovary. They're large number of follicles for medical students. I say 12 or more follicles are defined This polycystic on a scale. These follicles are pellets really arranged and the, uh, between two and eight millimeters in size. Economy dominant. Typically, the patient may complain off irregular cycles, which means dealing sites. It would be having messages, um, and acne and the B m. I increased. So let's go little bit further on polycystic ovarian syndrome. A syndrome is there. All the features are some of the features that we describe a breath. So what's going on? Okay, so the process of ovulation is affected, so that's failure to a late. Then there's the scan shows features off, increase in size and and follicles, which are modern, 12 in number. And then what is going wrong is the increase or wearing and million production. So let me briefly explain to you all assistant already is How does it happen? Why does it happen? The short answer is it's not really clear, but the proposal, says tears. And the theory is this. For some reason, the androgen levels in a woman's blood system is higher, and these engines, when they're higher, they still it the over to grow follicles and therefore you see more follies. But the problem is unusual is that when it is stimulating the ovaries, it doesn't allow the follicles to progress to us ovulation. So the degree of the region that is race will affect the degree off the symptoms. So this race and is causing follicles to grow, but not to continue growing and become dominant and hold it the same animal is also having the skin leading to act me and her stitches, so let's go little more deeper into it. So the theory is that when a woman consumes carbohydrates, she produces insulin to digest it cover. But in these women with polycystic ovary, their insulin is a little bit resistant. That means not working to its efficiency, the nature so two proven, then becoming diabetic. Their insulin levels are higher to deal with the carbo 100 thinking to you well into live in school. Higher because of the resistance. There's a side effect. It degrees is the sex hormone binding globulin in the patient. That's sex woman mining. Blow it and when it's decreased, then in the androgens are being released in the system. So the sex someone by a big woman, I explained to patients, is a mopping home. One. It removes the tests, runs off the engines and females, and removes Easter gyn or female hormones in the mail. So the SSBG goes down, then the and regions are more freely available in the blood and therefore creates all symptoms. So the treatment is simple. You degrees your Kabul 100 and they thought, your less insulin and the different SSBG goes up You can also add to that high intensity exercise is to mobilize the fact that the home on the line we also use is supplement called you know settle with improved the action off incident, and the fourth thing you use is using metformin, which is used for diabetes to potentially the action of incident. All these things are collecting the SSBG and therefore mopping the entrance, so hopefully this clarifies polycystic ovary for a bit, and then in these moment we will stimulate them, make them over late and therefore they should've few pregnancy. If this is the only reason why they're not conceding, let's move on to the tubes. The fallopian tubes and they said earlier, is a place for the egg and the sperm meet. The first lies in the Y and then they grow to a blastocyst and they come to you. Tris implant, if they do, is not booking optimally. I eat, they're blocked. Doesn't the patient longer? How do you test that? You There are three ways of testing that you, the hysterosalpingogram, which is called issues Tree is an X ray where you inject it die and then you take an X ray to check the juice. And then there's a history contrast some something go sonography which is called high cozy on. Then you go like Proscar say, obviously we will be doing the laparoscopy in all our patients. So we added with X ray HSG or hypo. So in both the first two you injected dye and then you are the scan on you. Check the X ray in laparoscopy. The diarrhea use is a metal in blue dye and in patients where we have to do a laparoscope for any reason. Then we will check the tubes. But for us, here's a picture off the high cozy Where I've been such a dye is going to you, Tris, and then into two's. So if you just quickly go back on the do the two aspects to the tube, the tube is blocked. When we put the dye and they put the dye not going through, they could be fluid in the juice because that hydro something jeeze that means it is blocking. The fluid is collecting there, and then you got to do, which is great and but not functioning. That means the junior is damage to a next ent, but the damage allows the diet too fast. You so. Although we have got, um, agency test these up agency test, it is not testing the function. The only test for function is pregnancy. So if a woman is pregnant, that means of June was functioning property quickly. What I does do gently get affected is mainly infection. It could be other factors, but infection is generally affecting the Celia off the endo, some peas and the communists infection that you need to be aware of infertility is. Let me, of course, don't worry. And other infections also that any infected that makes it dukes can affect it damaged the juice. And that may be due the damage of the end of something's and therefore leading to to failure of conception or a topic pregnancy. Let's move on to endometriosis. No endometriosis is, to put it in simple words. Is endometrium. That's the line outside people, The guarantee. So it could be in the muscle. And then if you call, I don't know what those it was in the bed of this or in the ovary that is the endometrium than that it's called End of Interests. This picture here shows endometriosis in the only. So let me explain to you a little bit further when the follicle office is sticking place. The follicle is by losing estrogen. Yeah, used to go is acting on the endometrium and makes it so. If you want endometrial in the order, that would become think, and then that has to shed and lead. But the endometrium in the already been a lot of people to pass the blood out. So to collect Cindy over on that it's called endometrial really system as students we remember. They also called chocolates is because the endo matures is cyst contains blood, which is altered and appears very brownish in color. So if you see a laparoscope, be and you see the cyst being removed, you'll see this chocolate brown fluid coming out from the ovary that this medicine no difficulty endometriosis, president's minute deep dyspareunia, some fertility and the and pain in the abdomen, which is psychological in nature. So typically, patients said, I can't pain before my periods, and when I get my periods, the pain is better. Still painful. But it is better. The pain is worse before the meal, because the endometrium in the ovary and the Benlysta average is is causing this condition. And a the other symptom of endometriosis could be if in the Mitchum is lying in any open and it's got a cavity, it sheds that the bleeding. So typically, if it's in the bladder, patients even ever have my peers. I passed blood from the urine. It is in the rectum. There's blood during beaters from those two. If it's there in this car, cesarean scar or leprosy be scarred that she bleeds from the scar when? When she gets, um, period. So it's a difficult cycle back, and the mattress is, if maybe coincidentally present for women and may not affect fertility or it may affect fertility. There it is. There, in the ovary on the way it affects the fertility is growing in the ovary is damaging the over the result and also affecting the quality of the eggs. The diagram of endometriosis for treating When you do surgery and you got the ovary and take the blood out, it is the lining off the cysts, which contains, and the little cells. And if you do not destroy the lining, the system in regard on the where you destroy them is diet. Tell me so when you do that same, be destroying the Aricept. So is that really it's a Catch 22 situation. Treating in the mitral asses will bring the results over the result down. So before you treat this moment, um, you to counsel, let me explain to them on they may spontaneously also concede, so it could be causal off cash. Let's we'll want to five rights. So 103 women have five rights, and according to the wh of classifications of fibroids zero and one is inside. The government, as in this case on do is more than 50% in the cavity. Sorry zero is completely in the cavity. One is more than 50% in the cavity and do is lesson from 2%. Guarantee 01 and do is likely to affect in politicians. Three is just below the endometrial in the muscle, and four. It's in the middle of the muscle, clear of the guarantee and clear of the cirrhosis. And why is getting close to the cirrhosis? Six. It has come out of the several, but mainly in the muscle, and seven is completely out. As you see in this one. This is seven, and then you want the good unrelated five, which is like a little bit uncle, and the fiber is hanging outside the uterus. So 01 and double affect fertility with implantation and many to miscarry. Three. Likely to affect for not sure five. Unlikely to affect six unless you defect or seven. And our elected of Paxil, the location of the fibroid, is very important to understand. It's very common. 103 women have it and then it's more common in certain communities. Now, Feinberg's You do not need to remove fibroids and fertility unless they're impacting on the plantation as a 01 and two large fibroids, which are there in the interview. Evolution may Need surgery. Sometimes there's debate about whether we should do routine surgery or do it in case of the implantation is not taking it. This we'll want to the next one, and that is not me. So let me quickly reminding you. The uterus is still up in two hops in the mother's womb, and they come together and then the joint, and then the middle of it is dissolved, and then you're trying to cavity, like trying to respond. So if you look at this picture on the side, the top one is by carnage. Uterus. That means that the uterus is remaining in two hearts. This is a cavity, and this is a survival so completely separate. A huge house in the picture lower is that you drive septum that mean they have joined together on the top, but in between, there's a little separation or partitions. So, like in a room, if you put a garden in the middle, the room and divided into two house So the lot of patients can conceive and have a normal pregnancy and on a delivery. Sometimes patients who can see on the present with a breach presentation because the baby can turn around and they end up having us is that it's actually so anybody beaks is there. It could reject you. Try malformations either a septum or a bike on it. Uterus woman with septum on their having premature labor or miscarriage. Then you must divide the septum and increase the space in the cavity on level. Give them the chance. And the last thing that I'm discussing this age when I say ahh, I mean reproductive age. The very assess over in reserve is by doing an FSH follicle stimulating hormone. If the level is high 7 30 or more, it's suggest menopause 10 to 15 is suggesting lowers the and 3 to 10 is low. Now is, uh, this effort City cycle dependent. So it should be done. Day 123 of the side image and Imuran home is now only being replacing the deficit. It is it's independent of the cycle. On broadly speaking the levels. These levels are you k way off measuring, So I don't know what the European levels are. But these units are you convinced of this? Three below three is very low to to 17 is lowers up, 17 to tell if I average is up and the liver is above 25 is good results or polycystic Congress, So image is a very good way of assessing. Now we do some other blood tests. So if you're always having irregular cycles, then we may do best Strong mentioned about sex hormone binding globulin and 310 days. That means how much free androgen is present in this is this is generally associated with polycystic ovary syndrome. You also do a tyrant function test, and this is linked with irregular cycles and miscarriage and then prolactin. As you know, relaxing is the one that helps in the breast, and the raise levels in. Women were trying to conceive. They may present minutes off the galaxy. Oh, really itches. Breast milk formation on is linked with me. Jittery legion says it's prolactin. Eugene them by giving the cavern go lean on that will suppress a prolactin and then they tend to conceive. So let's go back to the age or reproductive age. So the way I assess them will do a scan. I look at your follicles to see here this woman who is about your reserves, but three follicles discovered 8 to 10 follicles and he's got more than 12. So I simplified this worsen off. Assessing over in reserve understands camp, and that's called antral follicles Down in the jewelry. If they want to do follicles been student for a total, then the reserve is very somebody who's very minimal. 3 to 5 follicles Central Focus on me suggesting lowers of our memory and 6 to 11 is average yourself. 12 or more. Folic was good reserve or polycystic ovary so and you're following count and image and me to do an over in and you can see from this graph of the fecundity all the pregnancy. Chances are decreasing. A woman is born with the fixed full of eggs, and as she is, the reserves going down. So around about 36 37 this drop in the over in reserve ST. How does it matter really life. So if you look really life when she's in the mother's woman 20 weeks gestation. She had 6 to 7 million oh sites At birth, it goes on to 1 to $2 million sites at 30 is 300 to 500,000. At 37 years, it's 25 at 51 years, which is the average age of menopause is about 1000 so you can see how rapidly this is drug. Let's get about this into success rates in IVF. If a woman has built 35 the success around what 42% 35 to 37 dropped to 31% that do most a 38 to 40 drops the 22% The light buts. So there's a pregnancy miscarriage also in addition to and then it's only one toe do it close to 20% and wanted to to 40 45%. About 44 is one of us. So you can see in a quick glance how the egg reserve is going down because the woman long fixable of eggs and the success rates we talked about the woman. But let's come to the male factor. So men, they have this at one day because so far when we did all the tests, we haven't seen any garments. Where is the minute you can take a semen analysis and get it's A normal count is 15 million per ml total down to 39 million water 50%. But more importantly, progressive motility is 30%. This is the normal. I don't do person to be more normal forms to refocus and all. There should be no blood nation that been sticking to each other. No antibodies. We should be less than 10% and no signs of infection. So that's gives you w enjoy Nance's off semen. Well, so what could be present in there could be no spots. North months mean either. The justices on producing sputum of the Wasatch is blocked. Loss phone numbers could be 10 to 15 million. It's like you know, or below five million very on poor sperm motility could be less than 50%. Progressive would really has to be less and high number of abnormal forms, which means normally 4% normal is a normal. So if you get 3% of do person, the 1% that means a number of number falls are higher to keep it simple. And the question my patients ask me Abnormal forms will not fertilize it, not produce a bone babies, but they just won't fertilize. So it the percentage of abnormal from the high and the possibility of a normal sperm reaching the eggs low on there with a chance of getting pregnant come lower and last of all little. But there are men who had a vasectomy in previous relationship, and now I've got a new partner and then presents to us trying to conceive. So let's go further if you look it over a picture, there are many obligations on the thoughts that the sperm count is declined. As you go, you can see it's very high in 18 cents 18 or 5 1950 when the World war was there and then in 98 engine. So this is the normal sort of Congress accent and the several environmental factors that are affecting these. So if you look at broadly, you suggested the patient on a couple well, it's a lifestyle measures, and I'm not going to go into that today, So if a woman is not ovulating, then I will be doing cycle monitoring and I'll be giving them closing to make them over late until the mend you dry. There's a sperm count is low, the motility is low or a patient is single using donuts, bombs or a Sam's sex couple in those patients. We do enjoy trying in some age, but this form is inserted into the uterus when the moment it's pollinating idea is just in big drew for glasses. Asian, it's generally use for unexplained fertility, even have been trying for two years or more. Juvenile factor. A lower interest exceed, which is also called intracytoplasmic. Sperm injection is useful man factor or when they're I'm yet on the example for placed. So let's go live with further in the lifestyle. The thing that I would like to point out to patients is if a woman was smoking is going to up affect her chances of getting pregnant, keeping pregnancy and a good, uh, this increase risk of spontaneous miscarriages on a topic pregnant. In fact, if a woman is pregnant and if you're smoking fetus over results to sum it up so it's smoking will accelerate the accelerate the Lawson productive function, and if that happens, menopause can come between 1 to 4 years and women who are smoking and come for IV treatment. Their need for um doing repeating cycle is twice compared to non smokers, so they're chances of getting eggs for embryos and fertilization, and pregnancy is lower. Come back to patients a lot but lemon in smokers. So smoking is an important thing to be a twice a lifestyle change for those who are trying to get pregnant. Where the male passes got some semen. Perimeters and spun function are effectively smokers, but we don't have conclusive evidence. Very effects. The ultimate outcome depends really having a baby. Having said that, passive smoking see in the mail this morning and the woman is the 10. The passive smoking will have it back on the woman. It's a or on the child and therefore back reproductive consequence. So smoking in men should be also discussed. Some of the centers in the UK, but they provide free treatment for IVF. If you're a smoker, then you have to give up smoking for six months before you be offered free trip. Let's look at obesity or raised them on, saying there's several woman who are obese on Menorah B's and they get pregnant, and then obesity is associate it with a little less function, like polycystic. All right, reduce over in response to when you stimulate that some of them don't respond well. That's because the reason being mind worry more medication. The whose side quality may be affected. The intermittent function may be affected, and they could be low. But treats on do. When they do get pregnant, they could have increased risk for maternal fetal complications. Julian Pregnancy, if you compare that with men even in men of a city, affects their productive function. Say it is important to wife, women and men who were trying to conceive regarding the role of raised PMI and how they should work to us. Decreasing that be my increasing this successfully. In some cases, we do medical treatment to release me a month on. In some cases, we have to offer for bariatric surgery the problem in bariatric surgery that you do that you do the surgery. One should not conceive for a year because the absorption the nutritional of drop, it will be so. There are centers in the UK Mister Wild Free treatment for IVF, but If you realize 1 20 you will not be given treatment. Follow the above reasons. There are other treatments besides one we just mentioned, like egg donation for premature and failure off lures of preimplantation genetic screening. Preimplantation genetic diagnosis very scream the embryos and then implant them in. Patients will have a uterus being removed because of cancer. Are the reasons the goal for sorry GNC, where somebody else carries the baby for them? The fuck do preservation in patients with cancer are they are young, but they do not have a partner and they would like to preserve their fertility. And the way we do that is the egg freezing or everything, and women who are very young on. They're not some of the periods that only with preserving the country people cancer is over in a tissue, please. So these are the different methods and other treatments that can be there. Let's come to interview drive insemination so you can see here weekly. These semen is taken and it's fun and concentrate. Sample is and 70 uterus your nose come down. More to be single women and same sex couples use Jonas pants. I yes, so broadly speaking the way I do. I If I stimulate women with FSH for about 10 to 14 days, give them an Ellis Blah for which is a day six on the farm, animals in the refugee and 17 to 20 millimeters is. We give them the edge and collect the X 36 to 40 36 last afterwards. So when I stimulated him, the follicles are multiple. Uh, give them sedation and under are some guidance on the little needle is insert it and the fluid is aspiration. Once we asked her to get the A an IVF, the eggs kept you on this moments kept around the A. There's an X e. The human is's is stripped on. This from head is put inside the then the fertilizer is to tell you to do running. But like a 80 not little be exact. Dividing to two sons, four cells itself Merola. Blast is's expanded bust and then the glasses, insurgent, uterus and transfer these other rather you pictures. One thing about um, embryo is that you can get a nice looking Enbrel, which is called 30% success story, and of pregnancy and, um, enroll in three cells don't look good. And one said it would be good and still achieve pregnancy. This pregnancy could be a normal baby, and this could be abnormal. So we cannot say the genetic makeup of the chromosomes are a little off the Enbrel By just looking at and transferred you, you release the emperor in the uterus and then tomorrow has to implant in the pundits or into your posterial. So there really isn't a prevention space and that doctors theobromine so quickly A few things here you can see it. Is this the woman 28? Andrea was biopsy on these emerald were collected. And if you have a look at to say which embryos look normal to you, which looks at all So my next light shows you that these embryos were all no. They were five full, and it is known so these ones work with back to achieve pregnancy. So the Enbrel could be on a flight or you bite and and break members with you about so the next generation, like if you do biopsy called p gs. Your biopsy being done, you pick up the antibiotic, I'm rose and put them back degrees. The effect of maternal age increases implantation really increase pregnancy in life. But rates reduce miscarriage from abnormal emrouz on. We'll support deteriorate, putting single member back and release the time to like but cost. So these are interiors being proposed for me? Yes. If you look in plantation, you have you applied and rows an implant and even an implant. Embryos that don't implant because miscarries. But there are a group of emperors which I do, Clyde. But they don't. So women diagnosed with cancer due to other than chemotherapy or radiotherapy If they're single, you do like freezing. And they're couple. We do groceries. They're very young and they're not having cycles. And we do over into shoes. Freezing Single are not planning pregnancy at present. In those cases, we do preservation of a for social reasons. You have a premature and failure off the poor order result. Then we do regulation. Thank you. And I'm having to take questions. Thank you. Only started Very helpful lecture. Um so we've got one question I please everyone. If you got any questions, please put them in chat other ways. Raise your hand and we'll call upon you on the first questions from here. Uh, I know the allergist off with the first successful idea for free on maybe the second. In some cases, um, when does the energies off a second idea? Eso the energies offers once fresh cycle and one frozen site if they're frozen embryos left. But if you go to, um, a dean Sorry, Scotland, They give three cycles. So everywhere depends upon the local government deciding on how much money they can elevate to a sweaty. Some centers have no money. They don't know for any, But then that is very much debated. So one fresh cycle on a frozen embryo transfer isn't to be in the back. Think the criteria. And if you got your age is about 40 or 42 your images low. Be in my race, your smoking, then you like to learn even treatment or you dilate. Think of much. Uh, next question is for the IVF selection. Um, could you just go back to the sample slide on down? The optic seemed quite obvious, but what? See what the trisomy and want to sell me look like again, please. So here you see, you can look at it and you can see. One looks good on four. Looks good. This three and two also looks good. I looks fine. Sixes. Okay. Seven weeks of hard. This one looks or 10 weeks old, but otherwise you can't speak up. But when you do the biopsy, you can see one, 23. So you cannot make it by just looking at it. You have to do a biopsy to make out. But this one looks killed. This looks killed. Experiences is a problem here, but you can just look and say so. That's what they're saying. That if you got a lot of emperors proportion of the emperor's, they're going to be your ploy in proportion. Gonna be unemployed. And the way we can find out is the preimplantation genetic screening. And then you take a bus. So that will help you to reduce the time for a moment to get pregnant on the cost on the miscarriage rate and the abnormality Little. Thank you. Next question is, um, an endometriosis. Cysts like every this is called over to administration or me under mutant goes, goes up and goes there out of nowhere. Yes. So there are many tears, and then we have many theories. We don't know the actual answer. So one of the theories is retrograde menstruation. Blood is going back into the patrol cavity. And and the cells and Lamictal cells day implant wherever they fall. And then the other theory is called Epitol Mr Happens at. But some individual cells are present in different parts of the morning, and they get stimulated because hormones will act on receptors. So there are many theories about it. One of them is this. Then you got the implantation way. We do surgery and you got this. You sit there in a second. Some of the endometrium that desk do is implanted at the scar or a laparoscope. Be some cells in Blanding into bed. So there are several Deary's on these are hypothetical periods which are not really clear. But I think retrograde implantation and the presence of any new little cells, naturally or in people, is most like to terrorism. Correct. Eight. Thank you. Same was gonna come on to your question, but because you put your hand up. Uh, you know, you just want me to on then please ask your question. Good morning. A police. I would like to know the cause, the courses or fibroid because currently in my country, especially gone when you take that About five. About five fu men Elise a possibility off. One. Getting fibroid is very high, and it's causing a lot of the prostate in effect among a moment. So I would like to know the cause is off this fiber. Thank you, Yeah, so five words are home run based Juma's They are they every night very, very rarely there, malignant and that is called sarco. Very extremely rest. So you should even bought about malignancy in these patients. They're so the uterus is made of muscle man in the middle that is alive. So the muscle, sometimes for more like a little knot. And then the estrogen is accumulating that not it becomes fiber, says five room. Fine, right are well defined lesions, which are nice and clear on. They are based on inherent propensity off being so so the estrogen dependent and they are muscular lesions, and they're just a curling Maurine. Certain groups there's no other reason, for it is more common in certain ethnic backgrounds, as as you mentioned in your country. Women are seeing more fiber So that's that explains that 103 women will have fibers on back after 40. It's almost one engine incidence goes up. So some people used to stay in the bus. Driver really is like, you know, if a woman is not pregnant, they end up having fiber is like believing off the uterus That brings, He has good, but that's not true. It is occurring as a benign, muscular lesion based on the estrogen, and it's just there's no genetic reason, but it is probably all it cost. Oh, great, thank you. On it's question is, what could be the cause is a woman who experienced Mood Woman straight in within a month and during the course Communist rations, they need a lot longer lasting. Wouldn't six days be the first part? Uh, what may be the causes of women who experience multiple menstration within one month. So, as I said before the cycle, which is regular means you got a follicle of eight, which is equal to the luteal phase. If Woman is not ovulating, then she's got only follicle appears there's no little feets and therefore, when the endometrium is becoming thicker and thicker and thicker, the enemy in loses his blood supply and she pleads, and the bleeding is more random and more frequent now a different times in the life of the woman. The ovulation pattern is not correct, so when you Burti is coming, the ovulation is being established after but on lactation, the ovulation is getting established vanishes approaching menopause. At these times, the cycle, maybe a bit frequent ovulation off the shorter cycles is a sign off. Low reserve on delayed ovulation means delayed cycles. Is a sign off. Polycystic a Weeble? Oh, the ovulation is has not when there's dealing ovulation and the estrogen is high, then the end of May to mystical. When you finish going more frequently on or not occurring, the endometrium is taken as in menopause, so if you could take in the meter, the building will be longer, heavier and the moment you pass clots. Bleeding between dealers is linked with polyps or fibroids, and they can go under me all its present with no symptoms or spotting, whereas fibroids and president heavy bleeding, which is just like a beer. So you have to find out whether there's a physiological or a pathological cause off frequent bleeding. Thank you. On expression is in women who opt for anonymous sperm donation. What other factors to consider? So here the question is the egg donation and then enormous. So first of all, she must be having premature ovarian failure. Or she is older age group, and they're over. The result is this this law. So she's looking at getting pregnant, and she's using a dollar from a donor to provide the eggs and have a big So the anonymous one is generally based on the country's legal roots. So in the UK, we don't have anonymous. You have to declare, uh, the donor be known. But we do not provide the information to the patient, but the child, when his bone can get access to their genetic energy so they can find out up to basically 80. Because if you look at spin, they do anonymous in the sense they do not like the donor off the receiving to communicate. So the the Edex of anonymous and known donation is based on that. Should we hold back that information from the child? The child's know who's my genital father or mother and you can say is we should let them decide what they want to know or not know about that father a month. So their mother is the one who's given them. But but the genetic mother is the one who donated the eggs, and John would like to know the genetic heritage. So that's the Edex. Thank you, Um, is it possible for a woman to administrate without populating? Yes, As I said earlier, when they are not ovulating, they can still produce. Estrogen usually makes it in the rectum, take as energy becomes thicker and thicker, it loses, not supply on breaks down, and it tends to be erratic, irregular and heavy. So typically in women with polycystic ovary, they grow follicles. But the follicles do not draw on you, becomes dominant and hold it in Some group of patients for that estrogen that is there all the time can make the end of me to take. So I explained to patient. But I'm teaching polycystic ovary, the woman with policy. Overly. They have lots of follicles that there's loss of estrogen, and the end of it, um, is getting no progesterone, so they're more likely to get endometrial cancer in the long term. because it got under balls. Estrogen. So I give them a contraceptive pill and make them have Peter Street or four times a year. So unopposed estrogen can cause thickening of enemy. Too many irregular, but not be in shock. Thank you. Um, woman with his citizen experience. Irregular menses. What? Maybe the calls irregular menses her statism. You're looking at a most likely polycystic ovaries. But what is vestiges? Um, basically, androgens are present in the blood. These are free and urgency, like this strong, and they act on the poly. So there are two groups of women, one who got polycystic ovaries, and one where the hormone levels are normal. And they were hostages. Um, they may be having in your perfect sensitivity to androgens. So there's certain ethnic groups where the hair following those are more sensitive to indigenous, and therefore they get her citizen. They may not have polycystic ovaries, but they have a citizen. No. There's another group of women who may have adrenal tumors and adrenal glands. Also campus temperature. It's so there's three groups. A dramatic sensitivity to end organ have follicle to the normal strong levels. Polycystic ovary and adrenal be in prison. It could be also medication. So you may be taking some medicines. Was gonna be infested strong, and they can cause Also husband. Medically Great. Thank you. Because medications like dying a just helpin repressing the size off endometrium. Yes. So I said, and the uh huh. The main bottom endometriosis is and the media meaning stimulated by eastern. So you figure on these drugs that will suppress the end of each of the metal ages so you can give one receptible. You can produce the gents, or you can give us a strong Also you don't use. This is wrong because of the hostages. Um, like side effects. So we used for a chest surgeons, maybe Okie. The next question is, is it possible to use assisted me? Predicted technically intracytoplasmic sperm injection in the case of infertility caused by low sperm count. Yes, I've been ideally, as I said, lows from come could be put in to do categories very low. Oh, yes, likely low. Otherwise everything else is normal. So if it's very low, then doing intrauterine insemination treatment will not work. In those cases, X e is the for exceeding. Interested such a problem in sperm injection, even for patients who go IVF, sometimes the spun does not fertilize the IV. In those cases, we have to do big, see so failed for glasses, Asian and very nose gums and robotics. But it's simple sperm in England, they're president that you they have to bind and naturally, conceiving that this farmer has to enter the eight that entered entry or binding. If it's affected, it affect the physician. That is why, and unexplained infertility exceeds probably a better option in some cases. Thank you, Um, go a couple more questions left. But what is the connection between everything? A. M instructions on PC rest? And here's highly up risk. So I think the key point. You must understand this. If Woman has regular periods, she's ovulating. If she's having delayed units, she's ovulating late. But if she has got a very big gaps off like, say, if you ask the woman, how many pills do you get in a year? I get three burgers. That's pretty big, so she still may be ovulating, but the likelihood of ovulation is no. So all relation brings about just run and then the drop of the hormones so in a mental cycle. You get estrogen making the lining, think ovulation restaurant, making the lining ticker toe allow implantation. And then the cycle ends the session producing drops and they get a period envisions with irregular cycles. Likes polycystic ovary or any or peri menopausal woman. The estrogen is building the lining, but the position doesn't come. So the periods that are coming But when the lining and become take it has to share. It has to be, so they leave. So let's take a most women bottom woman. If you give decision to a postmenopausal woman, what will happen then? Um, it'll become take if you keep on giving it for a long time, they'll be hyperplasia and you get irregular bleeding. If you continue giving it for a year or do she'll get in the middle? Cancer. So Eastern baseline, anything. There's no precedent even shed and Rosie stronger down to that. And that's why I end of interest is you get processed. Oh, Jen, don't get processed, Ron. We get produced with General, which is the on regional delegated off. I hope that clarifies Yes. Thank you. Um, next question. Is it possible to have a regular bleed. Well pregnant. Yes, of course you can bleed, So meaning could be from the cervix. Because it is an extra organ. There could be a selective polyp on day. Could be some Michael Cancer is missed. Bleeding from the uterus could be linked with the placenta. So low 9% and it's separating. And it's causing spotting in pleadings. And then sometimes, when the president of separates the President Eisenhower big enough to continue the baby to grow but still is separating because living. So if 70% of the president is intact, the baby will continue. Great. So if a lot of press enter separated and the bleeding and tell me that they miscarry, so bleeding in pregnancy could be pregnancy related on normally, Miss Lady Nonpregnancy is linking that. So it's thank you. I just shared the feet, but form please have one. Make a note of it onto your last question. Which is, is it possible for a woman to still have a normal pregnancy even after ectopic pregnancy? So ah, high proportion of our patients, collectively pregnancy. They go on to have a knowledge. So we do tell our patients that when they haven't had a big toe to come for early pregnancy scans to exclude a toe. The incidents of ectopic pregnancy is one in 200 on if he's had an ectopic is five times higher, and that is coming to 5 to 1 200. So it's still ah high group of patients who have normal in treatment. Okay, Thank you much, Doctor. Thank you much for today's session. Very informative. I'm definitely into a lot. So thank you for giving you times. And, um, it's a little best of all. Thank you. Everyone. Please make a note of the people form, ensure you pull that. And again, it's difficult. And also very helpful to our doctors to get the feedback a swell. I keep the line open for 30 seconds. Make a note of it. And please. We joined the same Think our next session. Thank you. Thank you, Doctor. Thank you.