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Depends one to. Ok, so we're live. So, hi, everyone. Thank you for joining us on a Monday afternoon for our lecture. So you have Mr Nicolau with us today to give us a lecture on fertility. So I'll pass it over to him. Um If you have any questions, pop them into the chat. Good evening. Hi. Can't see you, but I'm pleased to be with you. Um As you can see, I'm still in my scrouch and I'm in the fertility unit here at the hospital after a long day. So I'm just going to share my few slides and we can go through and hopefully have a nice discussion. All right. So can you guys see that? Yes, I can see, you can see, you can see that's very good. So we're going to talk about fertility and the management of infertility. All right. And which is going to be approach for you to take a small clinical. Um So what is infertility and why bother about definitions anyway, II say to you when we meet face to face. But that uh philosophically, first of all, if you take it, um um you know, the basis of wisdom is the definition of terms. And in life, the in terms of managing something, it's, it's not as easy as it sounds to actually know what it is that you really want. And when you are clear about what it is that you really want, you're halfway there achieving it. But just to bring it more to clinical matters, I think um it is very important to know the definition of various conditions in medicine because um for various reasons, first of all, um uh whether you actually have the condition or not, um uh affect the prognosis, the chance of treatment. Um For example, if somebody has been trying to conceive for like uh trying to conceive for like two months, has different prognosis than somebody who has been trying to conceive for five years already, right? Um So the other reason is that um the definition, whether you actually have the condition or not affects and then basically um determines the diagnostic accuracy if you like or and o of of the various test results. So, uh a couple have been trying to conceive for three months and they do a histogram and they think one fallopian tube may be blocked um that has different weight than if the history of people has been done on somebody who has been trying to conceive for two years and has known other comorbidities like endometriosis and so on. And lastly, when you want to compare the effectiveness of treatment A versus treatment B. Um It's very important to know that you are um describing comparing people who actually had or didn't have the condition. So, infertility is a situation where a couple, a man and a woman have been having unprotected sexual relationships. That means without contraception for one year, that is according to the World Health Organization. So this is the definition of infertility and having infertility doesn't mean that you are infertile. So it doesn't mean that dynamically, you cannot have Children. It just means what it says that you didn't conceive after one year of unprotected sexual intercourse. And um um that some patients say, but we were not really trying the first few months, we were just having sex or they say we weren't trying that carefully and so on. None of these really matters when it comes to definition. Yes, there will be some months when they didn't have sex and so on. But then generally, if they've been wanting to get pregnant and basically sleeping together and then they haven't been using contraception for a year, then that comes as infertility, infertility in inverted commas, right? Um And infertility can be primary or secondary, primary is easy to understand if somebody hasn't conceived ever. That's called primary infertility. Secondary infertility is a little bit more controversial because it used to mean that there hasn't been any previous conception with secondary infertility. And I think in pockets of DNA, it says here in the UK, they still accept the same definition and the definition is important there for another reason because basically allocation of funding for her treatment is influenced by that. So you have some bizarre situations where somebody, for example, has conceived previously and had a miscarriage and they continue to try for a baby and, and, and, and, and, and, and there are some, some parts of the NHS that advise these patients that are now you've conceived the, the clock has to stop again, start again and you have to try for another year or two before you are eligible for NHS money, which, which is ridiculous. So the World Health Organization, hi mister, it's still stuck on the first slide. I'm talking about what is amazing. Lovely. Just wanted to double check. So yes, I'm talking about what is secondary subtility. So the World Health Organization has basically amended the definition to make it more clear and they say secondary subfertility, infertility and II use the term infertility and subfertility interchangeably here. I mean the same thing but secondary if you have had a successful pregnancy before and delivered the baby, right? That that is secondary infertility. Whereas if you had a miscarriage before or something like that, uh and it's still primary subfertility. Ok. And in terms of prevalence, how common it is, um we believe it affects about one in six couples. So, and why does infertility matter? What's the impact of infertility? Well, I'll just tell you here, it is infertility. As we will see, it is a situation that matters a lot. It has a huge impact on individuals and, and families and societies, right? And it is the impact is at all levels. First of all, medically, if you think about it, infertility means one has to have like go to see doctors have blood tests, have invasive other tests like laparoscopies, histograms and so on and has to have treatments that quite often are unpleasant and painful and invasive and risky such as to have like transvaginal collections or laparoscopies or other procedures. And um some of these statements have complications like ovarian hyper stimulation syndrome or internal bleeding or infections, um or chronic pain and so on. Um but also infertility um is sometimes the symptom or one of my manifestations of a wider problem, which can be, you know, things like um anti inflammatory disease or endometriosis or a more general health problem, like for example, um thyroid disease, other, other metabolic disorders and so on. Um And that's just a purely sort of like physical or medical sort of impact. But um infertility is associated with a lot of psychological morbidity such as um anxiety, uh depression, um anger, um or other problems such as um for example, um the feelings, feeling of uh reduced self esteem uh for the individual um and affects not only one person but basically the partner. So it can be associated with um um relationship issues, sexual difficulties, not causing infertility only, but uh as a result of infertility, we can have sexual difficulties. Um and um also um affect um um uh relationship in the work environment. So, for example, women often basically um find it difficult to tell their employers um that they need to take time off to go and have fertility treatment for an IVF cycle. They need several scans and several attendances and procedures and so on over a period of many weeks. Um And then uh worldwidely in, in some societies, at least infertility is associated with the degree of social stigma and social exclusion and so on. And don't forget the financial burden associated with fertility investigations and treatments. And only a very small portion of that is found on the NHS even in the UK where we've caught the National Health Service. But in other places like uh in the United States, people have to self fund that or of course, on insurance, we, we're talking about a huge amount of money, all right, and fertilities associated with more general societal issues. Um because uh it gets questions about not just funding for fertility services.