Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um I hope everyone is doing all right. I hope I don't take longer than the hour that it should take me to run through this presentation um As I was explaining to Sir Maya, I hope I pronounce the name right um I'm gonna base mainly my presentation uh following uh nice guidelines since that is mainly what you will be asked um During exams um can I just ask around what years you guys are at in medical school if anyone minds putting it in the chat. Otherwise, I'm happy to move on, I'm happy for you guys to ask questions along. Um I have a mental meter that will do in a bit, and I also have a cahoot if you guys can just join now and throughout the presentation, I will move onto cahoot to ask you guys. Some questions is that OK um so just to yeah sorry. Um I was also I'm not sure if you can see the chat, but we've got four people saying that they're in fourth year. Yeah I'm just I'm looking at the chat right now okay. Thank you alright that, so just before we start, I think it's important to understand um what we um what the presentation about this today and so I just wanted to know if anyone could define me what infertility means without looking it up based on the nice guidelines, if someone could just pop it in the chat aurand, mute themselves okay um So um I'm happy for people to type as I go along. I have no objections, um so infertility as defined by nice is the inability to oh sorry is the inability to conceive after one year of frequent intercourse. This means um 2 to 3 times per week and this has to be um unprotected sexual intercourse. Uh Nice guidelines does emphasize um that even if you don't conceive after one year, there's still quite chances to conceive after two years, but for definition's sake is one year, there's two types of um infertility that we can have we can have primary infertility where you have never achieved a pregnancy and we can have also secondary infertility where at least one prior pregnancy has been achieved. Um This can happen due to multiple factors. This could be someone's health um could have changed meaning that now they have been infertile, due to some cost that we will discuss um in a bit um or it can also be um you have you now have a new partner and in the case the new, you might not be able to conceive with a new partner, so you might have also developed secondary infertility um Just I think it's one of the more important aspects um to emphasize when you're having a discussion um with people regarding um fertility is that actually there's quite good chances of conceiving um a child without any need for medical intervention. Um trying to conceive to have a child and not getting a positive pregnancy test can be quite stressful um for couples, so some couples might come a little bit earlier and present to you seeking for help to conceive but one of the most important aspects is reassurance, reassurance can go a long way, and as you can see from discharge, it's based on age, you can see that as we age, the fertility rates do go down, but overall after two years, we do have a 90% conception rate without the need of any assistance. Um This is just a small breakdown. I've got this from the WHO website and it's the Communist cause um of some fertility. So as you can see um it's actually most of the cases are a mixed cause of infertility, so it's not just the females infertile, the males infertile. There's quite um a large amount of cases where both um the partners might have something that community Vly is making the page the couple but we would define a sub fertility, which is um when the patient's might be fertile, just having trouble conceiving one second um So now I just wanted to go to the mentee meter. I don't know if people um can see it, can people see the men queue meter um So Maya um I've sent the code in the chat, so if everyone just checks the chat, it should come up yeah there's a menta meter for a question on what things we would ask for infertility history on how you might approach the conversation, I know sometimes a bit hard to um say it, so it's easier if we just make it anonymous and people and can just type are people able to type, is anyone able to um no uh we've got thumbs up and we've got people saying they can see it. What I can't why can't I not see what people are bloating is that uh can't eat cheese you, what people are writing this a bit oh there we go Sdi Previous sexual history, last menstrual cycle. Menstrual history, I need my knee surgery, s. T. I. E, cause that's the eye, any surgery. I'll have one for like another minute, if any other people can think of any questions, specific that you would like to ask of any specific symptoms. The patient might be experiencing interception very good and actually family history, medication history, family history that's not a good history how they've been coping, yeah how they've been coping, so stress is um something that patient's will present. It's quite a stressful um situation and uh stress in itself can also lead to um couples being infertile, okay. If there's any other things, people can think of just put them on the chat, I'm just gonna go on to um the next slide, so uh this is um some of the things that we might think about asking when we're taking. Um I've split between female and male history taking and also examination so in a in a female in a woman, we will want to ask about the age because um age is quite an important when we're thinking about the referral criteria uh for secondary or tertiary investigate um center investigations um does anyone know what people stands for. If not, I will um let you know so it means so many patient how many um pregnancy at the woman has taken two term, how many times um though um um how many preterm babies the woman has had how many abortion that includes uh miska um miscarriages and how many living um children the woman has and you will see most commonly people right g. P, um a plus B and I will discuss this um in a second, so it's quite an important to know um how many children the woman has have so sexual history um This includes how frequently they're um having sexual intercourse um any contraception. The woman has had um how long they've been attempting and also a sexual history to screen for any possibilities um of s. T. I. S. As that is um a big cause of infertility ability um contraception. It's important because one specific I will have a question later on one specific type of contraception does can delay um can delay ability to conceive all other contraceptions over all um It said that you have return um instant return um op ability to conceive so some of the ability of the symptoms that you might ask for is a mental history, So you want to know how frequently they're having periods are they regular are they heavy are they painful. Um This is because it can 0.2 different diagnosis such as um it could fibroids, endometriosis, um If they're not having many periods that could have something like peco's or they could have early um early menopause or valiant failure. Galactorrhea is quite important to ask because in some women they might have high prolactin and high prolactin, has many many causes. One of them is also um stress her tourism is another one because it's one of the hallmarks for pecos, which is one of the communist cost of um um of infertility. Then we have oligomenorrhea, which I've mentioned thyroid disease and although thyroid the rate of thyroid problems in pregnant women's and on the general population uh during pregnancy, it doesn't increase the rate of thyroid problems. Um thyroid problems can increase the risk of infertility, especially hyperthyroidism, hyperthyroidism, especially in hyperthyroidism, is due to weight loss, weight loss can cause um infertility as your pituitary stops producing FSH and ellis and LH. Um Some people disorders that you might ask for is the spaniard diarrhea so painful um painful sex um that could be a sign of endometriosis. Um We had a patient that I was were discussing uh in the doctor's mess where she was having difficulty having pain and that's because she was diagnosed with endometriosis on the posterior aspect of her uterus, so she um one of the consultants actually gave some sexual advice about sexual positions that reduced um impact to the posterior aspect and it helped reduce the amount of pain that woman had while having sexual intercourse. Um Yeah another thing is previous surgeries is very important um as any surgery can cause um adhesions to form in the abdominal cavity and these can cause uh the tube the tubes um to be scarred and stress CA is also a cause of reduce the bill oh drug history especially um it's becoming more frequent um Anabolic steroids in the gym um can cause a common cause of infertility. You want to know if they're smoking if alcohol you wanna take b. M. I forgot to mention all of this is very important as they're basically reversible causes of infertility and just generally improve people's health overall. Um So I have some questions for you on the cahoot, I hope it works. Um I started infertility uh okay. I think there's a question that's about to come up that there's one question coming up. I hope I haven't started too early, okay, did something did something happen. I'm just I'm gonna restart it because I didn't see any response is coming up cancer the questions, but there was no question. I've created a new game pin. It's just loading 6776651 If people are able to join, so one person is joined so far three people, and while people join, I'm just gonna talk about gravity and parity, so gravity is the total number of times the woman has been pregnant, regardless of the outcome of the pregnancy and parity. Is a number of deliveries. Specifically after 20 weeks of gestation, A usually we've annotated as uh g, p one, p two, and a is a b, a, b, a plus b a, meaning the number of birth you on 24 weeks and be being the number of miscarriages or determinations of pregnancy before 24 weeks gestation. I'm going to start see if it works with the question, can everyone see it, oh, sorry, I I will not be able to do, I guess I have it on a different than me quickly. Yeah I won't be able to do that on this occasion with this computer, sorry, I'm really sorry, um okay, so I I've written the question out here, so uh unfortunately, the answer is there, uh but so for a woman who's had three previous babies and one set of twins and one ectopic she would have been um and who's currently pregnant, so she would have had um her current pregnancy counts as one gravida. Her set of twins, twins counts as once when you're talking about gravity, so she will have gravity, too, her other baby cause, she has three babies, will make her grab it to three and her topic will make her grab it to four. She's had to um to um what do you call it to birth twins, counters one when you're talking about p. A, so she's have to even though she's had three children and she's had one um ectopic so she will be g four, p two plus one and this is quite important and when you document, especially in g p practice, um the more complicated and that's usually what um gynecologists and obstetricians will document is at people and as I said before, that's the number of term birth, preterm birth, abortions, and living number. The thing to note in this with the same question is that um it will be the same just that the number of living children will be three, so b g 42013. That's usually how you would see it annotated um in the books. Um Next, um on the examination of females, there's a few things that a nice ask you to do unfortunately, just examination um heart examination and not part of it, but you can also do them as just regular investigations, So what nice requires us to do is to do b. M. I. As low and high b. M. I. Both reduced fertility. They want us to assess for her tourist um which I have a slight next on how to assess a tourism in different ethnicities, acne because it can be a sign of peco's galactorrhea, as this is a sign of hyper prolactinemia, and then they want us to do an abdominal and by manual examination, um The thing is important to find on the examination, especially the by manual is if it's painful and resisted, which could be a sign of vaginismus, which is um when the body automatically has like a fear and the vagina will contract and will um prevent um intercourse. On the by manual examination, there's three things mainly that you want to look at one is a uterine motility, which is the most likely thing to come abnormal on the examination and this could be a sign of um adhesions as that's what cause reduced mobility. The next thing you want to look at is for any masses and any other next or masses are ovarian canceled to proven otherwise, and this would require um ultrasound investigation, Then you want to try to assess for the uterus. Um don't the uh disheartened. If you can't assess for the size of the uterus, as people with small fingers are generally unable to assess for the size of the uterus, As this requires you to have your fingers below the cervix so that you're able to push the uterus up. The other thing that you can assess is retrograde and integrate um uh integrate um uterus. So quite important to just note at the actual masses, ovarian cancer castle to proven otherwise, but there is other differentials, so this is a fairing ham galloway score and it's a sign of high androgen which is one of the three hallmarks for um peco's. Um I remember in medical school. They told me that anything above aids is being high, but it actually depends on your ethnicity, and these are some of the scores I could find um for different ethnicities as we can see um asians and South americans have a lower threshold to be considered high androgen so high um the soft room um In the medical history taking, it's quite similar um to the female history taking. Uh We also want to specifically ask about any childhood infection specifically mumps, rubella, and measles, as all of these infections can actually cause um testicular inflammation during childhood and there's specifically more dangerous you catch them during adulthood as this can is one of the causes of sterility. I had some questions on cahoot, but unfortunately we will not be able um to have them done. Uh. Quite important to ask is about trauma, lots of kids, especially in school um receive, depending which kid you are, will receive quite a lot of testicular trauma and torsion is quite an important thing to ask as it will require um stitching of the test is to the scrotal sac and sometimes it can lead to loss of the testing within six hours. If it's not treated, um undescended testes are quite important to ask, especially given that the data that if you have to undescended test is your chance of fertility is 35. If you have one undescended testes, your chance of fertility is 80 and if you have to undescended testicle, it's around 90 for um percent and again because um males are usually further for longer periods of time, we can develop um stomach disease such as deputies, liver cirrhosis, CKD, which are things that we develop at older ages and these are all causes of infertility. Another important thing is um stress. Again, um it can cause erectile dysfunction, which makes difficult intercourse, um which can be a cause of infertility. Again, usually, your drug histories for alcohol smoke booking um illicit drugs, etcetera. Mail examinations we want to assess the appearance again uh for decreased sexual characteristics, um gynecomastia, which can all be a sign of hypogona gonadism. Do you want to assess for the penis opening specifically where the urethra um comes out of and at this particular examinations for any cancers, varicoceles as varicoceles reduced for um semen, sperm quality, um any hernias and soft testes are signed of hypogonadism and again undescended testes, so some of the investigations um that we have to do. I did have some questions on cahoot, but unfortunately we won't be able to do them is um for the mail, we it's quite simple you send for a semen analysis, and you have to ask the mail to not have had sex for the pre, to abstain for any um ejaculation for the previous three days and you have had ejaculation within the last seven days, once you send for um the semen analysis. If it comes back abnormal, you need to repeat it um uh within um three months and you want to do chlamydia testing to make sure that they don't have um tubules scarring due to an s. T. I. In female. There's a couple more investigations you want to do the two investigations that you have to do for female are mid luteal progesterone, and this is usually done seven days prior to the expected period. Some females who suffer from oligo urea, um uh oligomenorrhea or amenorrhea. What you usually do you try to estimate when the patient is likely to have to ovulate and then you will do um progesterone seven days from the expected period and weekly until you find out that the progesterone level is above 30 millimoles. If it's below, your you can't say that the patient has ovulated um some of the tests that you can do is gonadotroph in such as FSH and LH, but this is only done when you're expecting ovulation disorders. Otherwise, there's no indication according to nice to do FSH or LH in terms of TFTS I, I mentioned previously, uh there's no indication according to nice unless you have some thyroid pathology that you're acquiring prolactin is also not recommended unless you're again thinking of regulatory disorders, galactorrhea, or pituitary tumor, and again all of this would be um taken from the history and your examination, does anyone know any of the causes of um high prolactin, they have prolactinoma, it to its normal, yes, so stock effect, any other ones yeah antipsychotics or medications can cause um so important in your drug history to make sure that they're not on any of the anti psychotics anything else uh antidepressants uh huh not quite sure about them to depressant. I've not heard of it. If you've heard of it, it's then I would say so someone's typing, we stop typing okay uh. The other things are pregnancy stress and idiopathic, take it or some of the more common um ones let's see what rebecca is trying to type issues okay um well. I'll let rebecca try to finish typing so um and the other thing that you want to do is a chlamydia test as well for the female, just to make sure that there's no chlamydia in the system. Um So we've covered a bit of what you would do um in primary, in, primary care, can, does kind of anyone think of some of the referral criteria that we would think for um sending some for secondary care investigations the specific criteria that the nice wants us um to follow oh yeah I forgot to mention sorry, um I did lose some of my slides and I had to make them quickly. You would also test for gonorrhea, cause they can both um cause scarring. Usually, you might just want to do a full s. T. I. Screen. Yeah you're right um sadaf, so um does anyone know the any referral criteria um according to nice um for infertility treatment, If not that is fine, so nice does have um some criteria that we follow uh and this is the criteria as taken um from nice, So you want to refer anyone who's um under 36 year old with normal history and examination in both partners and have not conceived after one year. You want to refer for secondary care, and you can refer earlier um in patient's who are over the age of 36 you can also refer earlier for any of the patient's that have a menorrhea or albuminuria as there can be other pathology, um Previous abdo, um public surgeries, any previous um public inflammatory disease, s. T. I. S, abnormal, public exams or unknown reason for infertility such as cancer, so cancer patient's, as I will discuss later um depending on the cancer and the treatment that you get can become infertile, so sometimes what they do is you can cryo preserved um your semen or over for future pregnancies, So if a patient has any of the following, you can refer earlier. Otherwise. If you have a normal history and normal investigation, you need to wait one year without conceiving before being referred um to secondary care investigations um So these are some of the things they can ask you and in the exams of when you would refer um early for further investigations, further investigations could be um like a trans vaginal ultrasound um for looking for, like polycystic kidneys, it could be um you ultrasound could also look for endometriosis, but the gold standard for endometriosis as uh laproscopic um uh exploration to look for scarring on the end, um it um on the uterus all right and now we reach to some of the diagnosis that we can have um causing infertility in females, so we have um our relation disorders, and this is the um broken down into three types. We've got type one, type two, and type three, the most important type to be aware of is type two and that's because it forms the greatest amount um of causes of infertility, mainly comprised with peco's and can anyone um tell me the criteria the three criteria to diagnose um someone with p, cause anyone what what did they say infertility. No of relation yep, hyperandrogenism is one of them. Yeah cyst on ultrasound, so policies takeover is an ultrasound and the last one yeah that's correct you need two out of three, so um fsh, lh I don't think comprises um I did lose uh this slide if I remember probably at um oligomenorrhea, so, period less than nine periods um a year, If I am wrong, someone, please do update me okay. Um The other important one is type one and this is usually caused by a low body weight, so usually the treatment strategy for this is encourage weight gain um for the individual, and type three is quite a rare one and it would be an ovarian failure uh Picture Other important things that can cause um ovulatory disorders as I mentioned before is thyroid abnormalities, adrenal abnormality, so anything like pushing um congenital adrenal hyperplasia can also cause um ovulation disorders um and this is a diagram of the results and how they could be interpreted to know which type of um hum military disorder you're encountering so this taken for geeky medics on the left, we've got the female on, on the right, we have the mail, so you can think of them as essential, as stated here um as an ovarian picture, um So central are usually you're gonna get a low s. F. Fsh because there's an issue releasing it, which is going to cause low um estrogen. Oh sorry, um on, on a very in picture, you're gonna have low estrogen and because your body wants to um compensate for, it is gonna produce more fsh to try to create that more estrogen, but because your um sorry I'm sorry I got myself, so I got confused um yeah because your body has low your body is unable to produce um the estrogen. Your pituitary is gonna start working harder to produce higher FSH and that's why the FSH is increased and type three and some of the tubal disorders r. S. T. I. S. Such as chlamydia and gonorrhea, public inflammatory disease which um yeah uh previous tubal ligation, so pre, researchers are quite an important thing to cover and some of the uterine and peritoneal disorders are things such as fibroids uh Depending on the fibroids, they might not need management, but if they're very big, sometimes what we can do is to uh make a myomectomy, which is where you remove you cut off part of the fibroid to help restore um the uterus um normal anatomy to help the implantation of the uh of the fetus um. Endometriosis so nice states, um I'm sorry, I'm talking about, I've got ahead of myself so endometriosis can cause tubal distortion by um scarring of the fallopian tubes and it also reduces the fin brawl motility, which is our little hairs inside um the fallopian tubes that help move the album um down into the uterus. Other costs, a mucus facility, some people might have more acidic mucus, which can actually kill uh the sperm before they're able to travel inside. So some of the other things, I had some questions on this, but unfortunately we won't be able to go through them are contraceptives, so as I said on. The general rule of thumb is after stopping contraception, you have the potential to conceive a baby. The only exceptions are the combined patch and the vaginal ring, which can delay um fertility for a couple of months, and the other one is the progesterone only injectable, which can take up to a year to return to fertility, so it's important when you're discussing most of contraceptions with female with woman trying seeking advice to ask them if fertility is an important thing for them now and like this, you can decide if to give something that's short term or something that's a longer term mode of um contraception. The depo, in, yeah other things to consider is the patient is on Nsaid and say it's actually do reduce um fertility. Other common medications are things such as spur, spironolactone um and steroids, chemotherapy, neuroleptic drugs also very important to mention for any epilepsy woman who has suffers from epilepsy as some of them are contraindicated um during um some of the epileptic drugs are contraindicated in pregnancy and again recreational drugs in males. We have a few causes of infertility. The first one is primary spermatic genic failure, where the body is unable to produce um sperm. This can be congenital or acquired and again the whole trauma and proportion again come up here. So it's a very thing very important question to ask during your history and again in um post inflammatory um infections such as moms, rubella, and measles, so what the genetic disorders the most common being um clan filters, which is the x x. Y. Chromosomal disorder disorder, small testes, and androgen insensitivity syndrome, which uh previously used to be um called um uh particular feminization and what um yeah, sorry uh We can also have obstructions somewhere along um the tubes um leading to ejaculation. Um Some of this can be um congenital such as a malevolence, this which is a remnants uh from our embryonic state and this can occur near the prostate, which can cause an obstruction um to the ejaculation of um semen. Some of them can be acquired such as after any patient who goes for a bladder um surgery or any surgery close um to the public floor can disturb. Um I can traumatize the tubes um yeah um hypogonadism. we've got again um different types we've got primary, which is usually to do the stickler failure. It's quite rare and I don't actually know much about it um and uh hypogonadism scribe right and you want to encounter during your examination um and again just some of the common causes that you really have to get the grips done when you bring an examination, history examination, and primary care is obesity and very low PMI as both of these are causes of infertility, smoking, smoking is also very important because of the fetus, smoking leads to uh negative effects with the fetus. Alcohol um excessive system is also caused, reduces fSH and LH production um and woman, so here we go to the management. These are some of those places where they can start asking you questions on your finals um So for ability re, disorders, you we have different management depending on the type, so, in group one as we said, um the primary cost is low weight, so weight gain is the mainstay treatment for uh group one of military disorders. Um We, depending on this scenario, if we can, doesn't help, we can try pulsatile administration of uh gonadotropin releasing hormone, and this works by promoting um the ovarian follicles to develop in type two. Because the main cause of type two of military disorders is P, cause. The mainstay treatment is weight loss um Otherwise, what we the research is shifting and metformin is becoming increasingly important. Does anyone know how metformin might increase um ovulation um in someone with peco's, so death is typing, produces yeah, so what happens when you reduce since elin um sensitivity. Do you know the feedback loot trying to refer to. I did have a picture of it, but I lost it um when my presentation got deleted, yeah I'll give you 10 more seconds always, I'll give you the answer no yeah, so you're correct and it reduces insulin sensitivity, which is um and because people tend to have increased um insulin around their body, so insulin usually positively um stimulates the zika cells to produce um testosterone and it also stimulates um and testosterone is again one of the hallmarks of peco's, but it also stimulates as a result like an estrogen and precursor and production, which has a negative feedback loop with FSH and LH, and because we are negatively feed backing into the production of fsh and Lh, we can have the promotion of the follicular development, so that is the feedback loop for y metformin um is an effective treatment even in those who don't have um active diabetes um and the other option that we have if everything fails, we can try induction agents and usually before it used to be um clomifene was first line and now it has been switched to lateral sol, if I've pronounced that correctly anyone know why we have shifted away from clomifene and switch onto letrozole as the first line, anyone know the answer, if not I will give it around 10 seconds, okay so let's just uh sorry, uh so letrozole um has reduced incidence rates of um developing something called ovarian hyper stimulation syndrome, which is a life threatening um complication of ovulation induction, and it presents as hypothalamic shock and this is due to the increased capillary formation um on the ovaries and the multiple development of follicular um of ovarian follicles forming which have an increased permeability of the capillaries, so a woman can actually lose a lot of blood um intraabdominally causing a hyperkalemic shock. Um It can also discuss an acute renal failure and it makes you um pro, thrombotic, so um patient's can present with um dvt s and p. E. S. So the management for ovarian hyper stimulation syndrome is uh fluids for the renal failure, electrolyte derangements because the potassium might have gone up due to renal failure and aqSA parent to prevent embolic uh thrombo embolic events and determination of any pregnancies or any fetuses that might have developed, developed in the time to reduce the hormonal stimulation cost leading to uh to keeping the cyst um developing um and does anyone know how what's the mechanism of action of letter saw yep, it's an aromatase inhibitor, and again as I mentioned before it has um it produces the amount of estrogen production, which um would usually negative uh In this scenario, negatively feedback Fsh in the pituitary leading to uh uh the promoting of the follicular development um In the third line with ovarian failure uh the only thing we can really do is um is give induction agents, so again we can try metformin plus latter sol, or gonadotropin um In some cases, we can also try laproscopic ovarian drilling where we make small holes into the ovaries to try to release some of the stores over for um implantation um. It's very um specialized so you would really need um someone much more senior to say the exact indications um anyone know how I I will go into the next slide. Anyone know how we would manage some a patient with hyperprolactinemia, a menorrhea. It's another feedback loop that we're trying to target so a patient presenting with amenorrhea due to hyperprolactinemia. What might we give them is anyone aware all right, so I'll just go to the next slide to show you the feedback loop, so this is a feedback loop of the yeah dopamine agonist, yeah, and the other thing is to consider if they're fit for pituitary um um surgery, but that would be um endocrinologist specialist, which would have to um get input on that, so the hypothalamus releases dopamine, which has negative um inhibition to the intuitive uh opportunity to the production of um prolactin and as we can see from this diagram, bril, acting um decreases libido, decrease, is gonna the trophy in release fsh, lh um and increases lactation um which can cause the galactorrhea, uh which can cause um I forgot the word. Um If the word comes back, I will let you know. Um the other options is for patient suffering from tubal and uterine surgeries, we can do small micro uh surgeries and laproscopic tubal surgeries. Usually, you assess them in tertiary centers. You can inject some dye dye and do some um sequence x rays to see how to die, um spreads into the fallopian tubes to see where um there might be a haitians or obstructions, and depending on the um scenario, we can do different different procedures such as catheterization and cannulation to keep the keep them patent or try to remove some of the adhesions. Other things is at Hellos Elias is where I'm not exactly sure how it works, but we send some some waves and it helps melt away some of the adhesions that are have been formed and say previously alluded to um fibroids if they become very big and they are prevent um causing problems with fertility due to distortion of the uterus, we can do something called a myomectomy um pharmacological treatments for fibroids are available, but if you want to try to conceive the only real treatment that you can have have as myectomy, some woman choose to um go on the hormonal treatments to try to reduce the size and then go for the myomectomy, but my activity only um definitely um thing that we can do to try to improve the chances to conceive. Um. So nice uh on the management attended through endometriosis um offers two options, one is excision and the other is ablation from when I was on my placement and discussion with the gynecologist, she said that the preferred method for them is ablation as excision requires um surgery, and that again can cause even further um adhesions around um around the bowels and around the uterus and again we can use the add hellos lattices which as from what I understand um ultra, ultra sonic um soundwaves um uh unexplained infertility uh nice suggest that if we do not know the cost of infertility that we do not try to stimulate as there has been shown no increase in chance to conceive uh and we can offer IVF treatment if the couple has been unable to conceive after two years, um So the next I wanna, I'm sure you're all aware of the different types of uh um aided insemination. Um Nice has some guidelines that they would like us to follow again for who to offer intrauterine insemination um and unfortunately, they haven't updated them yet, but they have formed the draft for same sex couples and for same sex couples. They say six attempts of intrauterine insemination is equivalent to a couple trying to conceive for a year, so uh to offer them you um it can be offered to people who are having issues with intercourse, so someone who's having erectile dysfunction or someone who has a parent anatomy and is unable to have intercourse but wants to conceive can be offered intrauterine insemination. Um. One of the things to note is um males with hiv um the gold standard is to offer intrauterine insemination even though we um do say that if the viral load is undetectable, um it's unlikely that you will transmit hiv, but we something still offer um intrauterine insemination and hiV positive men as we can do something called sperm washing to reduce the chance of transmission um to the woman and again as I mentioned same sex relationships, which hopefully will be updated in the near um in the near future, um. There is again uh so the next stage would be um IBF and again nice, offers us a criteria that we have to follow and this is something again that you can be asked about on your exams so um in patient's under the age of 40 um If you've not been able to conceive after two years, um you would be offered um IBf, unfortunately, IBF and all the other treatments for infertility is a postcode lottery and I have to link at the end of what advice you can what you can offer in different areas of the uk, um in case you wanted to have it for your g. P. Placements um. So for people who aren't able to have sex or who um sorry ignore that, last part, so after someone struggle tried to conceive naturally, they've not been able to and they've gone for intra uterine insemination. If they failed after 12 cycles, you would offer them um Ivf um If there's a specialist, so specialist, gynecologist, beliefs that there's very little chance for you to conceive uh through sexual intercourse. They would offer you IBF um before um the, before the 12 cycles um and one very important thing to note is that you only get offered three cycles in the nhs, if you're if your area of the UK, uh get uh funds IBF um through your area through your catchment area, but if you've had a self funded um IVF cycle that does taken too account one of your three cycles, and that's because every um progressive cycle of IBf that the patient tries to go through will reduce the chance of IVF being successful, so if you go for a 3rd 1/4 chance, the chance of you becoming pregnant go down drastically. And if you turn 40 while receiving your course of IBf that they will not offer you any further um courses of IBF for a woman 42 42 is as above, um and again you would only be offered um 11 round of um IVF through the NHS if your catchment area, KIP allows, um One of the other things important to note is intracytoplasmic sperm injection and this is the main treatment that we can offer um males who have issues specifically severe deficit and semen quality, um obstructive as a sperm ear, which we mentioned before and non obstructive as well, um we can something's collect um semen um straight from the testicles or sometimes the mail might provide a semen sample depending on what the issue is and we can get the sperm and get the nucleus of the sperm and inject it into the over to um cause um a fetus to start developing the one thing that nice wants you to note that while the rate of fertilizations are much higher um than iBf, using intracytoplasmic sperm injection, the rates of pregnancy don't actually um increase they are the same as an IBf. Another thing that you can do is a donor, insemination, and outside donation. Um These are some of the indications um I really don't know all that much um around this topic um and as I mentioned before, um some patient's who might be going through chemotherapy or right the therapy um It's important to have a discussion before they start their cycles um regarding if they would like for you to uh to try to conceive in the future as we can try to cryopreservation it um some of their sperm and over um and finally one of another thing that some something's overlooked is adoption um yeah and this is the link. I will send out the slides and you can access this link by clicking them um So it's the local Integrated Care Board that decides what is available for you in your postcode um area and that is me done, does anyone have any questions. I am very sorry, I was a bit um stressed and a bit anxious um I tried to cover as much as I could accord through nice um guidelines. I'm very sorry that I had a couple of questions I wanted to do through you who, but unfortunately we weren't able um um to go over the uh yeah I can I can go through um I can go through how metformin helps um helps uh improve fertility, um so I I actually have it um the picture on my phone that wasn't able to upload um so metformin um reduces and um improve um one second what do we say, so it reduces, um and it improves um so high insulin causes increased, um positively stimulates the THECA cells um in the ovaries um to produce testosterone, which is the hallmark, one of the hallmarks for peco's and the other thing it does it increases um the production of easter oestradiol I'm just gonna spell it out for you. Is trying to dial and estradiol negatively um stimulates the thicker cells and to um oh sorry issued out, then affects the granulosa cells, uh sorry issued out then affects the pituitary and negatively stimulate the pituitary as we um as it was on this where's the uh over here so and metformin produces insulin, which causes reduction um in the production of um estrogen, which would normally negatively stimulate the pituitary and the hypothalamus, which would reduce the production of FSH and LH, which would reduce the development of follicles and the ovaries, does that make sense. I don't know if that clear that um let me go on, my I've lost my flights again did, that did that make sense enough hi, sorry, um I just didn't understand so if um high insulin causes the production of testosterone and then also Easter dial and then you were saying how that negatively stimulates the pituitary, so you have a reduction in FSH and LH is that correct. So far, yeah give me once second, I, I have written it down on the slides that I will uh send you on the additional notes uh one second okay, so metformin reduces insulin sensitivity and usually insulin will positively stimulate the thicker cells to produce testosterone and to produce um estrogen. Estrogen usually has a negative feedback loop in the pituitary with FSH and LH so having high levels of estrogen will reduce the FSH and Lh, lH production and Fsh and LH are both important in the development and promoting follicular uh are important in promoting follicular development, so if you have high estrogen, you're unable to produce high enough levels of fsh to start the development of follicles in the ovaries, um which would later um be produce suicides to fertilize does that make sense yeah It makes sense, I just I thought metformin increases the insulin sensitivity, so wouldn't it like make the effects of insulin it more prominent. Um I I see what you mean um So I I did have I did some teaching with some bread uh the other day about this, and this is how they described it to me, so, I'm trying to describe it as much as I can from how they explained it to me. Um I can try uploading the slide that they sent that they sent me about that explains it when I send the slides to you would that be beneficial, yeah that would be really helpful, thank you sorry, that's all right does anyone else have some questions anyone else. Um If not um I just want to say thank you so much for hosting the session oriole and for delivering it, it was very useful and very comprehensive as well um and I think it definitely covered exactly what you said in terms of how we need to learn it according to the nice guidelines. Um So thank you so much for um doing the session. Um I will stop the recording now and if if you send me the slides and I can email it out to everyone who signed up um and also feedback from and we'll get everything back to you as well. I will add that one um picture that I promised okay that's fine thank you so much bye. Bye.