“The National Maternity Hospital is delighted to announce the launch of its new Ireland East Fertility Hub supported by funding from the National Women and Infants
Health Programme (NWIHP)”
Written by Dr David Crosby, Consultant Obstetrician & Gynaecologist, Subspecialist in Reproductive Medicine, Surgery & Genetics, Clinical Lead Fertility Hub, Head of Department of Reproductive Medicine, The National Maternity Hospital, Dublin, Assistant Clinical Professor, University College Dublin
Dr Andrew Downey, Clinical Research Fellow and Specialist Registrar, The National Maternity Hospital & Merrion Fertility Clinic, Dublin
Ms. Michelle Barry, Clinical Nurse Specialist, Fertility Hub, The National Maternity Hospital, Dublin
Ms Catherine Dunne, Administrative Lead, Fertility Hub, The National Maternity Hospital, Dublin
Dr Sorca O’Brien, Clinical Aspire Fellow in Fertility, The National Maternity Hospital and Merrion Fertility Clinic
Infertility is the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his or her partner. The World Health Organisation (WHO) has characterised infertility as a disease affecting 48 million couples and 186 million individuals globally. Over 80% of couples in the general population will conceive within one year if the woman is aged under 40 years. Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%). The Health Service Executive (HSE) has estimated that one in six heterosexual couples will experience infertility in Ireland.
The causes of infertility can be due to problems with the female and/or male reproductive systems. Female causes can relate to abnormal ovulation (polycystic ovarian syndrome, premature ovarian failure, hypothalamic or pituitary disease), fallopian tube damage (pelvic surgery or infection) and uterine disorders (endometriosis, polyps or fibroids, congenital disease). Male causes can relate to reproductive tract obstruction (trauma, infection), testicular failure (chemotherapy), genetic disorders (cystic fibrosis), hormonal disorders (hypothalamic, pituitary) and medications (steroid use). In approximately one quarter of all cases, the cause is unknown or ‘unexplained’.
Advice
It is important that people who are concerned about their fertility know that both female and male fertility decline with age. Couples should be informed that they should have sexual intercourse every two to three days to optimise the chance of pregnancy. Lifestyle factors may negatively impact fertility and should be optimised for anyone trying or planning to try to conceive prior to any investigations or treatment.
Drinking no more than one to two units of alcohol once or twice per week and avoiding episodes of intoxication can improve fertility. Those who smoke should be informed that this is likely to reduce their fertility. In addition, passive smoking is likely to affect their chance of conceiving. There is currently no consistent evidence of an association between consumption of caffeinated beverages and fertility problems.
Time to conception can be delayed in people with a body mass index (BMI) of 30kg/m2 or over. Group programmes involving exercise and diet are the most optimal ways to achieve weight loss which may also improve ovulation in women.
Women intending to become pregnant should be informed that dietary supplementation with folic acid before conception and up to 12 weeks gestation reduces the risk of having a baby with neural tube defects. Some patients require 5mg folic acid as they are higher risk (e.g epilepsy or BMI ≥30kg/m2 ). Women should ensure their cervical cancer screening is up to date, that they have been vaccinated against rubella if they are susceptible and that sexually transmitted disease is performed if applicable.
Investigation and Management
Regional fertility hubs within the six hospital groups are being rolled out across Ireland. These hubs allow for investigation and management of a large proportion of fertility patients.
The National Maternity Hospital is delighted to announce the launch of its new Ireland East Fertility Hub supported by funding from the National Women and Infants Health Programme (NWIHP). Our vision is to continually strive to provide high quality care that places our patients at the centre of their management. Our approach is to promote a culture of evidence based practice to assist patients to navigate their fertility journey.
Our hub accepts direct consultant and GP referrals from within the Ireland East Hospital Group for patients who meet the following criteria as defined by NWIHP:
– If they have been unable to achieve a pregnancy after 6 months of regular unprotected sexual intercourse and are 36 years of age and older.
– If they have been unable to achieve a pregnancy after 12 months of regular unprotected sexual intercourse and are under 36 years of age.
– If there is a known clinical cause of infertility or a history of predisposing factors for infertility i.e. endometriosis, previous fertility treatment to conceive, not having periods or very few periods per year, pelvic inflammatory disease or undescended testes.
Investigations prior to referral can be extremely helpful in the early identification of fertility problems. Women with regular monthly menstrual cycles should be informed that they are likely to be ovulating. Women should be offered a blood test to measure serum progesterone in the mid-luteal phase of their cycle (day 21 of a 28-day cycle) to confirm ovulation. Women with irregular menstrual cycles should be offered a blood tests to measure serum gonadotrophins (Follicular stimulating hormone (FSH) and Luteinising Hormone (LH)). If polycystic ovarian syndrome (PCOS) is suspected, a hormone profile including FSH and LH, testosterone, sex hormone binding globulin, and free testosterone index levels should be assessed. Women should have thyroid function tests performed and optimised if there is presence of subclinical or clinical thyroid dysfunction.
Once a referral has been accepted, a fertility hub pack is posted to the patient/s for their completion and following completion of further investigations, an initial consultation is offered to ensure that all the necessary investigations have been completed and to advise on an individualised management plan. The range of services provided by our hub include investigative support to GPs (semen analysis and pelvic ultrasound), and secondary level investigations including testing of tubal patency, hysteroscopy, laparoscopy, fertility related surgeries, ovulation induction and follicle tracking.
There are a number of quantitative measures that can be performed as an assessment of ovarian reserve. Serum Anti-Müllerian hormone (AMH) testing may identify women with a lower ovarian reserve than expected for age. These women can be provided with fertility management options in a timely manner. AMH testing can also be a predictor for ovarian response in in vitro fertilization (IVF). AMH testing can be offered through GP practices or through our hub. Another measure of ovarian reserve is the antral follicle count (AFC), which can be assessed by transvaginal ultrasound. Transvaginal scanning can also assess the endometrium for the presence of polyps or fibroids.
Fallopian tubal patency can be checked by hysterosalpingography (HSG: pelvic x-ray with dye injected through cervix) or hysterosalpingo-Contrast Sonography (HyCoSy: pelvic ultrasound with dye injected through cervix). If there is a suspicion of tubal damage (endometriosis or pelvic inflammatory disease), a diagnostic laparoscopy and dye test can be performed as it allows for a both diagnosis and treatment. A diagnostic or operative hysteroscopy can be performed if endometrial pathology, such as fibroids and polyps, is suspected. These services are provided on site at the National Maternity Hospital.
Men experiencing fertility problems should have a semen analysis performed assessing the sperm concentration, count, morphology, motility, and volume as defined by the WHO. Repeat samples or further investigation and work up may be required if the first result is abnormal.
Ovulation induction with oral and injectable ovulation agents and follicle tracking is offered through our service to patients with suspected anovulation. Letrozole, an aromatase inhibitor, stops oestrogen synthesis resulting in increased ovarian stimulation via the pituitary gland. Other second line oral medications that are used include Clomid and Tamoxifen. Injectable ovulation induction agents, including FSH, LH and human menopausal gonadotropin (hMG) are available. It is necessary that ultrasound follicle tracking is performed to monitor follicle growth, ensure that the response is optimal and to significantly reduce the risk of multiple pregnancy. Metformin can be used in anovulatory women with PCOS as an adjunctive therapy, with evidence for women with good evidence of restoration if ovulation in women, particularly with BMI of 30kg/m 2 or over. If a male sperm factor is identified, adverse lifestyle measures should be addressed and treatment of the underlying disorder may be required.
Some patients may need to be referred for further treatment with assisted reproduction such as Intrauterine Insemination (IUI), In Vitro Fertilisation (IVF), or Intracytoplasmic Sperm Injection (ICSI). IUI involves a semen sample being produced and then placed into a woman’s uterus around the time of ovulation after laboratory preparation. In IVF, the eggs are removed from the ovary before ovulation and fertilised with sperm in a laboratory with the embryo transferred to the uterus a few days later. ICSI is a specialised form of IVF where a single sperm is directly injected into the egg to allow fertilisation. These treatments require referral to a specialist fertility clinic after initial workup and management in the regional fertility hubs. We are continuously auditing these referral rates to ensure that we provide NWIHP with the most up to date information to facilitate planning for publicly funded assisted reproduction.
Conclusion
Infertility is a common disorder that affects many individuals and couples. The newly established
regional fertility hubs provide evidence based fertility work up and management. Through the National Maternity Hospital fertility hub and with its network of regional hubs, we will continue to advocate for the equitable evolution of comprehensive public fertility services, including IVF, in Ireland in the future.
For more information visit
https://www.nmh.ie/
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