Sarah: Hello, it is Sarah Whitburn. We just started broadcasting. So I am just going to introduce myself to everyone, hello. And then hopefully we will be able to give this presentation.
Hi everyone and thank you for being so patient with us. Welcome to the RACGP National Webinar Series. My name is Sarah Whitburn and I am a GP here in Melbourne and have a special interest in women’s health and I will be facilitating the webinar tonight. I would like to start – I am just trying to start with Acknowledgement of Country. We would like to acknowledge the traditional custodians of the land. We acknowledge and respect their continuing culture and the contribution they have made to the life of this city and this region and we pay our respects to Elders past and present.
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This webinar is proudly supported by Healius, and tonight’s webinar is called Infertility and the GP. This webinar will focus on how the GP can best assess the infertile couple, including the tests to order and how to appropriately refer. The webinar will particularly focus on areas of difficulty for GPs, endometriosis, fibroids and interpreting ovarian reserve tests, which I myself will be very happy to hear about. It is always an area I struggle with. The webinar will give a broad overview of treatment options available, but will focus more on what the GP can do to maximise a couple’s chances of falling pregnant naturally or with treatment.
I would like to introduce our presenter for tonight’s webinar, Dr Paul Atkinson. Dr Paul Atkinson is the National Medical Director of Adora Fertility and is passionate about people having access to high quality and affordable fertility treatment. Dr Atkinson is a certified sub-specialist in reproductive endocrinology and infertility and holds a Masters of Reproductive Medicine from the University of New South Wales. Dr Atkinson received his medical degree from the University of Sydney and completed his general obstetrics and gynaecology training as well as his sub-speciality training in fertility medicine at the Royal Hospital for Women in Sydney. And over to you now, Paul.
Paul: Great, thanks very much. Can you all hear me via the phone? I assume so.
Sarah: We can hear you here. Hopefully if anyone has any problems they can just pop it in the questions.
Paul: Okay, no problem. And for advancing my slides, I just press the arrow I assume.
Sarah: Yes. Paul, just click your mouse on the screen and the slide should progress then.
Paul: Okay I am just clicking on the screen, it is not allowing me to progress… perfect. So that has progressed me to the first slide. Alright, well thank you very much everybody for joining our webinar tonight. It is a great pleasure for me to present to you. My focus for tonight is really to really focus in on what GPs can do, assessing the infertile couple and then when it is appropriate to refer to a sub-specialist like myself and what you can do really to maximise their chances to fall pregnant naturally because ideally I would prefer if they did not come to see me. But if they do need to come to see me, how I can maximise their chances of success if I have to undertake any treatment with them. So the first part of the presentation, I am really going to go into what are the really important elements in the history that you need to do and what appropriate investigations you need to order. Now these investigations I will probably break into two parts which are sort of the more basic investigations and then if you are maybe a more rural GP or a GP with a special interest in women’s health, what would be the more advanced investigations that you may want to order as well.
So I guess an infertile couple is a very tricky problem. We have studies from psychology that have been presented at a number of meetings that says the anxiety levels that these couples go through is almost akin to be diagnosed with a cancer diagnosis. So it is a really tough diagnosis for them to deal with. The fact that you are having trouble starting a family. And in particular for a lot of the male patients I see, they see it as a real failure of them as a father or as a man, that they are not able to father a child. So, when I am assessing the infertile couple, the first thing I do is I pick up the file and as I bring them into my room, the first thing I like to look at is the female age because by far that is the biggest prognostic indicator for whether they are going to be successful in having a baby. The next thing I like to look at in the file is maybe how long they have been trying for, and thirdly if they have had a baby before because those three things immediately give me a bit of a stratification in my mind about what my chances of success are going to be. When you are going through the history, if you are like me, you run a busy practice and you do not have time to you know, go through those medical school histories like we used to do where you ask a million and one questions. You have really got to, and you GPs are excellent at doing this, is focus quickly into what are the important points.
How I approach the couple with the infertile history, is I really try to in the first instance, I try to get a bit of a read of the body language. I try to see how they are in the room with me. If the man is folding his arms and looking at the wall, well to honest he is the guy I start the history with. Or similarly, if the female is disengaged, I start with her. Because you have really got to have both partners in the couple on board when you go through the history and treatment because it really is unlike a lot of other areas in medicine, you really need to have both people on board as you go through the treatment.
My advice for you as GPs, now a lot of you will have good relationships with your patients, but if you are seeing them for the first time, my advice is that you probably do not start delving into the menstrual history or the sexual history right off the bat, because they are quite personal questions and my approach is I usually, because I usually have not met them before, I usually start with the more general things and build up some rapport and then I delve right down into the menstrual and sexual history which is a lot of the time where you are going to get the best bang for your buck.
So the first questions I go through are really the obvious things so I will not dwell on that too much. The past medical history, the past surgical history, Pap smear history, medications and in particular I am worried about medications that might be an issue if she then falls pregnant, and then once I have done that, that is sort of my segway into talking about the menstrual history. Now the menstrual history is really all about the regularity of the cycle because you are looking for any red flags of polycystic ovarian syndrome, any signs of a very irregular cycle and ovulation, or any signs of not getting periods at all, i.e. is there a more serious underlying hormonal problem. I also use this menstrual history at this point to do a bit of a screening for are there any signs or symptoms of endometriosis. So, you are probably aware that there is a big push at the moment around endometriosis in Australia, there has been a lot of Federal Government funding around this. But specifically, the question we like to look for is, do you have a painful periods or pain with sex? And this pain is particularly oblique and side pain, so not superficial vaginal pain but a deep inside pain. Is there pain doing a bowel motion, particularly around the time of the menses? Or is there any sort of premenstrual spotting, premenstrual brown spotting? So there are some questions that may give you a clue as to that this lady may have some underlying endometriosis.
I sort of use this history then to go into the sexual history, because if you sort of asked a woman about her painful periods, and you have built up some rapport already, that is usually sort of a natural segway into looking then at the sexual history. So you know, I sort of say you know, the reason I ask you this question is because you know there is this condition of endometriosis which is associated with painful periods, you know is there any trouble when you have sex together? You know is it painful for you? Is it difficult for you? As a man, do you get any difficulties, you know maintaining an erection, achieving or maintaining an erection? And to be honest, it is surprising if you have developed a bit of rapport with these patients, how you can actually discover that the real cause of their infertility is not actually that they have underlying you know, major infertility problems, but they might just not be having sex enough or they might not just be having sex properly or at the right times of the month. There are a lot of couples that I see where they are so stressed out about having a baby, that sex becomes so mechanical and medical for them, that they forget about their relationship and it turns into a vicious spiral of pressure, erection issues, cannot get it up at the right time, and you know as the GP, you guys can really be the sort of gate keeper. Because those people do not need to come and see me for IVF, they need you guys to sort of help them with their sexual health problems or then potentially if you do not feel comfortable doing that, then referring them to a sexual health physician. Because it may be an issue more around getting an erection or libido problems rather than needing IVF.
So, the other thing that sometimes get missed in the history is any genetic conditions that run in the family, because obviously we are in a very privileged position with IVF where we can test embryos before we put them back, and potentially we could prevent genetic conditions being passed on in the family. So we are moving onto the next slide.
The initial management that you guys can do as GPs and, this is the obvious thing that sometimes we forget them, is really all about optimising the lady’s, and the man’s for that matter, body mass index. At our centre, Adora Fertility, we do not treat women with a BMI over 35, and mainly that is because as you know, the chances of fertility success is low, the chances of miscarriage are higher, and if they were to fall pregnant they are much more likely to have a problem in the pregnancy with regards to diabetes, still birth, miscarriages, pre-term birth, caesarean section, clots, infections et cetera. So it is not just about getting them pregnant. It is also very much about that we develop, have a healthy pregnancy and delivery of a singleton, healthy baby at term.
The other thing is that we see a lot of patients as you do I am sure in primary health care, who have insulin resistance or undiagnosed diabetes and as you are all aware, glucose is a terrible teratogen and we really need these ladies to have perfect sugar control before we embark on getting them pregnant because it is very well associated that high level glucose is associated with foetal anomalies and difficulties in the pregnancy. So for primary health people, it is really important if you can to optimise the sugar control in these patients before they embark on falling pregnant.
The other things are pretty obvious. Obviously both patients should not be smoking. Minimising alcohol and minimising coffee. And by coffee, I mean probably no more than one coffee a day. You are very well aware that women embarking on pregnancy need folate. The standard dose you know from guidelines is 0.5 mg per day up to 5 mg per day if they are overweight or had a previous baby with a neural tube defect an then also the recommendations about iodine which is 150 mcg per day. So making sure they are on the right supplements. Most women are very familiar with this and they are on Blackmores or Elevit or one of the other Swiss multivitamins. I do work in a local centre, so I often tell my patients that the cheapest way for them to do this is just buy a big bag of folate from Chemist Warehouse and then just go to Coles and get the iodine salt and make sure they put a couple of pinches of that on their meal at night time, and that is a much cheaper way if they are financially stretched as a lot of my patients are, to make sure they are getting the adequate replacement. If they eat a healthy diet, then the other things they have in Elevit and those vitamins are probably covered by that.
Pap smears obviously should be up to date. There is nothing worse for a woman than if she has an abnormal Pap smear while she is pregnant and needs to deal with the stress of that. And the other primary health care thing is obviously making sure they are immune to rubella, chicken pox and to vaccinate them against the flu. The next thing is obviously if you are able to diagnose their PCOS because that is very prevalent in our community, particularly in rural areas with ladies who are a little bit overweight. Very important to diagnosis the polycystic ovarian syndrome, because often if they are overweight, just by being able to lose the weight their cycle regulates and these young women are able to fall pregnant naturally. So we will just advance the slide if we can.
Then it is a bit of an assessment about you know, can I just educate this couple about the right time to be having sex? And you will be surprised how many people do not know the fertile window to have sex, and this is something that the GPs can definitely do and you will not need to send them on to me. As you all know, when you have a standard 28 day cycle, the second half of the cycle is fairly fixed at 14 days. And the second part of the cycle is once the follicle has ovulated, then what is left behind in the ovary is the corpus luteum and the corpus luteum secretes progesterone. It is that progesterone that transforms the initial menstrual lining from the proliferative endometrium to the more receptive endometrium that is ready for an embryo to implant. Now the corpus luteum as you know, has that shelf life of 14 days. So if there is no pregnancy and no pregnancy hCG which would then feed back to the corpus luteum and keep it secreting progesterone, what will happen is the progesterone level will fall and that will trigger the menses. So the second half of the cycle, the corpus luteum has a fixed life, usually of 14 days, which means that if you have a 28 day cycle, which would be the standard cycle for a woman, then the first half of the cycle is also 14 days. 28 minus 14 is 14. So it is taking 14 days for the initial part of the cycle which is the follicular recruitment and the follicle to grow. Obviously then if you have a lady that has for example a 32 day cycle. Then if the second half of the cycle is fixed at 14 days, then it is most likely, 32 minus 14, is 18. So then it is likely that she ovulates on day 18. The key then that I tell my patients is that you need to put the love and the romance back into your relationship. So I tell them that having sex every day is not necessary and too exhausting. What I tell them is that the key to all of this is to remember that when an egg ovulates, it lives for about 12 up to 24 hours and if it is not fertilised, then it will die. The other key to remember is that sperm lives for three up to five days within the female reproductive tract. So the key then is to tell these patients that okay, if you are having sex every two to three days from about day 10 of the cycle up until about day 18 if they are a standard cycle and you obviously adjust it depending on their cycle, then you are always going to have sperm in the fallopian tube around the time of ovulation. You do not necessarily need to have sex every day and you do not necessarily need to be peeing on ovulation sticks and then running home to have sex with all that pressure. There will always be sperm in the female reproduce tract around the fertile window. And it is amazing how many couples do not have sex for a month and then they just have sex once when they get the LH surge and sometimes if they are detecting that LH surge they may have already missed the ovulation and they are not timing it correctly. I think the better way to do it is to get the romance back into their relationship, and start having sex around day 10 to 12 of the cycle every two to three days up until day 18. Advance to the next slide.
So, these are the female investigations that I think are useful for the general practitioner to order. Some of these are quite extensive. We work with a number of GPs within our organisation at Adora and these are the investigations that these GPs order. They do not necessarily have to be ordered on this day, we just space them out over these days so that you the patient is not having you know, a million and one blood tubes on the one day. So what we do for the female investigations is at the start of the cycle we measure the AMH, the prolactin, the FSH, the LH, the TSH and the oestradiol level. We do a full blood count, iron studies, check their immunity to rubella and then we also do the first two of the antenatal bookings which is syphilis and varicella. We then once the period is finished, so day five to eight of the cycle, then the lady needs a Pap smear. It is a good time to do it then or obviously any time when the lady is not bleeding, and then at that point it is quite useful to get a pelvic ultrasound. It is important that you know when you put your radiology forms in, the more info you put on the radiology form the better. So if you are telling them that it is an infertility case and you specify that you want an antral follicle count, then the radiologist or the sonographer will count up how many antral follicles there are which will give you guys a bit of an idea about ovarian reserves. We will go into that a bit later. The other thing we do is that we do a mid-luteal blood. Now if she has got a 28 day cycle, the mid-luteal phase will obviously be day 21, but if she does not have a 28 day cycle then obviously you could do this blood a week before the period is due, then that will be in the mid-luteal phase. What you are really looking for in that blood and why you are doing it on that day is to see that they have a progesterone rise, because if you went back to that graph of the menstrual cycle, you know that the progesterone is secreted a little bit by the growing follicle but it is mainly secreted by the corpus luteum and so it goes up in the luteal phase. And so what you are looking for is that you have a nice progesterone rise, and by nice I mean maybe more than 30 at the mid-luteal phase and that would indicate that the lady has ovulated. Because the three basic tests that we know in fertility are really, does this woman ovulate? Does he have a good semen test? And are the tubes open? They are your three really basic tests in infertility, the three sort of cardinal questions. Any signs of tubal blockage, is the sperm test normal, does this women ovulate? They are the three primary tests around, basic investigations. Because as I said, we do not want them to have one million and one blood tubes done on one day, we also add on to day 21 bloods, we also do the blood group and antibodies which is as you know an antenatal blood. We test them for urine PCR for chlamydia and gonorrhoea as a screening test, again relating back to patent tubes, and then we also look at fasting glucose. We look at Hb Electrophoresis mainly for thalassemia screening and then the completion of the antenatal screening bloods with hep B and Hep C and HIV, and as we spoke about already the mid-luteal progesterone. So if you just advance the slide for me.
The male investigations, the most important male investigation is the semen analysis. The semen analysis should be done after three days of abstinence ideally. You have a lot of blokes try to save it up for a week and then they get a good count, but then they get a really poor motility so the best balance of all the three factors, which is count, motility and shapes or morphology, is really after three days of abstinence. So the semen analysis is by far the cardinal investigation in male infertility. The other thing we often test for, now this may not be so relevant for you guys, but if a couple is about to undergo any form of ART, so IVF or IUI or anything, it is a health requirement that the man has had an infection screen as well, so that is why the HIV, hep B, hep C, syphilis and we also do a chlamydia and gonorrhoea urine PCR screen as well. As I said, if I then have abnormalities on the semen analysis, it is probably at that point then that I would order some more advanced male investigations, you know which we go into a bit later if we have time. So male hormones, you know, genetic testing is the main one. But really, if the semen analysis is normal, then there is no real major need for any further male investigations. The other thing of course is just because you have a normal semen analysis does not necessarily mean that that sperm is fertilising an egg. The only way you really know whether a sperm has fertilised an egg is with history, like have they had a pregnancy before. Obviously if they have had a pregnancy before then you know it was at some stage in the past the husband has fertilised his partner’s egg, or you know, obviously we can test for fertilisation in IVF the day after we take the egg. The following day we know how many eggs have fertilised, so we can see whether that sperm and egg, whether they interact well. Can we advance the slide please?
Sarah: Not a problem, Paul. We are just having a little bit of trouble hearing you. If you could just adjust the microphone just a little bit please?
Paul: Okay, is that better?
Sarah: Yes, that sounds good, thank you.
Paul: Okay. So let us get onto ovarian reserve testing, because I know for GPs this is a bit of a tricky area. You guys are at the coal face of all this and you know around PSA and all these tests that specialists order, and then you know, CA 125 is a classic example as well, where you guys are faced with these results and what to do with them. So I would like to spend a bit of time around ovarian reserve testing, specifically AMH. So I will cover off the last two first, antral follicle count and the day 2 FSH and then we will spend a bit more time on AMH. But antral follicle count is when we do an ultrasound, usually in the first part of the cycle, and what the sonographer is doing is they are counting up how many antral follicles are found within the ovary as a marker of how many eggs are left in the primordial pool in the ovary. Now, the antral follicle count is useful, the problem with it is that it is quite subjective, so you have to sort of rely on the skill of the sonographer, and the other thing is that it is very age-dependent as well. If you did scans on a lot of really young women, you will find that a lot of young women will have a very high antral follicle count, you know, meeting the criteria of polycystic ovarian syndrome, or polycystic ovaries I should say. And particularly now that the sonography machines have become so, you know, have such high resolution that you will find that you get very antral follicle counts. So it is a useful thing that we use for ovarian reserves, but it is probably quite subjective and so AMH is usually better.
The other thing we often look for, and this is why we order it at the blood test at the first part of the cycle, day two or three of the cycle, is we look at the baseline FSH. So if you go back to medical school and you remember the hypothalamus stimulates the anterior pituitary with the GnRH, and anterior pituitary makes LH and FSH, and that acts on the ovary. FSH obviously standing for follicle stimulating hormone. It is the hormone that stimulates the follicle. Inside the follicle is the egg. Surrounding that is the granulosa cells, and the granulosa cells make oestrogen. So in response to follicle stimulating hormone, the follicles grow and those granulosa cells you know, make oestrogen. So when you look at the day two or day three FSH, what you are looking at is at the start of the cycle, how much stress is the brain under in order to get that ovary to make the follicle that cycle? So, usually anything sort of above 12 is high. As you know a post-menopausal woman, when your ovaries kind of run out of eggs, the FSH is 40. Yes? But in a younger woman, if you are looking at day two or three FSH where it is sort of above 12, that can give you a bit of an idea that the brain is under some stress to get those eggs out of the ovary. The biggest trap that I see from GPs is when they have a lady who has got a very low ovarian reserve, i.e. she has got a very low AMH and her antral follicle is very low. But then the FSH is quite normal, you know, they send them along to me and they say you know, FSH is three so I do not think she has run out of eggs, but then what you must do always when you are looking at your day two or three FSH is you must couple it by looking at the oestrogen level. And that is a trap that a lot of not just GPs to be honest, a number of general gynaecologists fall into as well. Because if you are running out of eggs, then what will happen is that the follicle start to recruit themselves quite early, that is, even before the period. So by the time you get to day two or three, that follicle is already along the pathway. So it might already by 16 mm and the oestrogen might already be 500. So what has happened is that 500 oestrogen has said back to the brain, and has dropped the FSH. So the FSH is artificially, well it is low because the follicle has been prematurely recruited. Okay? So it is always important that when you look at the FSH, that the oestrogen is also baseline. And by baseline, I mean an oestrogen level of under 200. Under 250. That is, the follicle has not already started to grow, has not been prematurely recruited and that is what is causing the FSH to be low.
So let us go into a bit of detail about AHM. Do you mind progressing the slide for me please?
Sarah: Paul, just before we move on, a few people have questioned if you would not mind just defining AMH please? I think as you said, this is sometimes tricky, sometimes it is new for general practice, so if you could just define that. And also, I have just had a question just to clarify when you ask for the antral follicle count, you are doing it on the ultrasound that you are hopefully doing on day five to eight. Is that the best time to ask for the antral follicle count?
Paul: Yes. So antral follicle count, yes. Ask for it sort of ideally sort of early in the cycle, so from about day three up to day eight. You know, day three to six, day three to seven is usually ideal. The reason we ask it sometimes a little bit later is then the lady has finished her period, so when she is having her transvaginal ultrasound you know, she does not have to have blood on the scan and be embarrassed really. So, sort of around day five is usually a nice compromise between getting it at the start of the cycle plus also hopefully that her period is just you know, finished or just down to spotting so she is less embarrassed when she has her scan.
Defining AMH. Yes. If you advance the slide for me we will go through that in detail. So, AMH stands for anti-Mullerian hormone. Now you might be wondering where the hell that name comes from. The name actually comes from when you are six to seven weeks old inside your mum’s tummy, when you are just a little you know, foetus at six to seven weeks old, the gonad that you have as a six to seven week old foetus, that gonad is bi-potential. Okay? So it could go down the path of becoming an ovary or go down the path of becoming a testes. What happens is that in males, there is a Y chromosome obviously. In relation to the Y chromosome there is a sex-determining region of the Y chromosome, and in relation, because of that Y chromosome, the gonad then goes down the path of becoming a testes. Within the testes there, there are different cell types, the Sertoli cells, Leydig cells. The Sertoli cells secrete something called AMH. AMH anti-Mullerian hormone. The Mullerian structures within the female is the uterus, the tubes and the upper third of the vagina. So obviously in a male baby you want those structures to regress. So the male gonad secretes AMH and that is what causes those female structures, the Mullerian structures to regress. So that is where the name comes from. But what fertility has discovered is that the follicles when they are growing along their path, also secrete this same substance, AMH. And so it has become a very useful marker of ovarian reserve testing.
This diagram is very, very important. So I am going to spend a bit of time now talking. And I go through this diagram a lot with my patients. So this is a bit of a take home message I think from this webinar. If you look at this diagram, it is really important when you are talking to a female patient to let her know that the most number of eggs that she ever had in her entire life was probably when she was 20 weeks old inside her mum’s tummy. At that stage, she might have had on average maybe four million eggs. By the time she was born, half of those eggs have already gone. So she has about two million eggs at the time of her birth, and then maybe five hundred thousand when she is a teenager, and then every day some of those eggs are emerging from this pool and then they are going along the pathway of development. The really important thing to remember is, that when that egg starts to emerge from the primordial pool, until it is the egg that ovulates, that time period is about 120 days. Okay? Now we do not know exactly what the signals are that cause that egg to leave the primordial pool, or those signals along the antral sort of follicle phase. But what we do know, is that it is really only the last two weeks of that follicle development there that is actually under the hormone control from the brain. Okay? So it is really just that last two weeks of 120 days whereby that follicle has the receptors whereby it can respond to FSH. So this is a really important diagram to show patients, because it tells, because you will often get asked this, you know if you do IVF on me, are you going to use up my eggs? Because if you are going to take 15 of my eggs, you know, aren’t you just going to use up my eggs? Well the answer is no, because if I did not take them with the FSH, then well they were going to die anyway. The other question you will often get asked as GPs is, well if I go on the pill, will that preserve my egg number? Well again, the answer is no because you know, it is only the last two weeks that is under hormone control. The eggs are always emerging from the pool and then some of them keep advancing and some of them undergo atresia.
Where AMH comes into it, is as they are growing along that pathway from a small pre-antral follicle to a follicle that then can sort of be recruited by the hormones that come from the brain, all of those follicles are secreting a small amount of AMH. Okay? So the follicles that are in the primordial pool and the follicles that are you know, under the hormone influence of the brain, they do not really secrete AMH. It is the ones that are growing along that sort of antral pathway. So what we are using AMH for is an indirect marker of how many eggs are left in the primordial pool. So as you can see from this diagram, it is not the perfect test, okay? The only way you can really tell a woman’s ovarian reserve is if you took out her ovaries, you looked under the microscope and you counted up the number of eggs. Now obviously that would be you know, counter intuitive to trying to get a woman pregnant. So we have to use these sort of more indirect tests to give you a bit of an idea about how many eggs are left. The critical thing with AMH is that there is variation in AMH. The curve for AMH is probably 95%, so it is not perfect. It is good, it is very good, but it is not perfect. And AMH you must remember, AMH is really a marker more of quantity and not of quality. Okay? So AMH does not really give you any idea about the quality of the eggs, it is really more a qualitative number and the thing we use it in IVH most for is that we really use AMH in order for me to pick my best starting dose of FSH, that is, you know high dose if it is low AMH or low dose if there is high AMH. So you know, I do not under or over stimulate the ovary during the cycle. So by far the biggest factor for egg quality is usually female age, you know and underlying problems such as endometriosis or you know, epithelial things.
But AMH in and of itself is not necessarily a marker of egg quality. So you will often be presented I think as GPs with women who come to you with quite low AMH levels, you know women around the age of 30 or something and they say I have had my AMH test because my friends on Facebook started to get it done and I sent it off to this company in the US and they sent it back to me saying my AMH is small and they are panicking because they are like, well what do I do? I agree that it is a very tricky problem. So you can refer them to us and we will have the discussion with them but you can also have a very important discussion with them about well, what can you do? That is why we get a bit careful about ordering AMH tests on women who are not necessarily wanting to start a family straight away, because, well what do you do with the results? Do you, you know, alright I have got a low AMH and I am not with a man, do I just you know go out and you find the nearest guy at the bar tonight you know and have a baby? You have got to look at you know, will the test results influence my decision making moving into the future? So there are some subtleties around that test.
Most fertility specialists will tell you that we would much prefer a young woman with a low egg number than an older woman with a high egg number. It is really more about quality than quantity. You know, a woman that has a low AMH and she still has a regular cycle, that means that she is still ovulating an egg every month and that egg is probably still of good quality. So the AMH is not necessarily a reflection of the natural fertility in the next six months. It is probably you know, more of an indication that okay, well if you know you are 30 and you have got a low AMH, and you are planning to have a family of two or three kids, you know, you probably need to think about that and start planning for that. Or potentially there is obviously that option to undergo you know, fertility treatment and freezing of eggs but you also need to be careful because in a lady who has got a low AMH and goes through an IVF cycle, we obviously will not expect to get a high number of eggs in that stimulation cycle. So it is not like okay, low AMH you can give FSH and get the eggs, because this again goes back to the diagram, and this is what I show my patients all the time, that if the eggs are not there at the point at which I give you the FSH and IVF, I can give you a million trillion, billion units of FSH but if the egg id not there, it cannot respond to my hormones. But some patients just think well okay, of we just keep going up with the FSH you are going to get more eggs. The answer is no. You cannot, if the egg is not there and does not have the receptors for FSH, well then you cannot get the egg. So what everybody in IVF and what whoever gets the Nobel Prize for IVF is probably going to be the person who discovers how can you get those small, pre-antral follicles, how can you push them along the pathway to development so that you get more eggs at that point that can respond to the FSH. That is what all of us are trying to do. To see how we can get these antral follicles further along so that when I try to give them my high doses of FSH I might be able to recruit them for my cycle. And a lot of your patients who have been through fertility treatment, you might wonder, well what are these fertility guys doing? What are they doing putting them on testosterone, putting them on DHEA, putting them on all these things. None of these things have been proven to be in any definitive studies to increase egg yield. The science behind it is, are these things like DHEA, testosterone useful in pushing along those pre-antral follicles, along the pathway of antral development so that they can then respond to my FSH, and therefore be recruited.
Can we advance the slide? So then remember AMH gives you a number, but that AMH is just put on a graph. So it is age and AMH level. It is then usually divided into percentiles and then for the patients you can give them an, okay well you have a low ovarian reserve for your age, a normal ovarian reserve for your age, or a high ovarian reserve for your age. And as you probably are all aware, a high AMH is often associated with having polycystic ovarian syndrome because as you know, women with polycystic ovarian syndrome have a lot of antral follicles. That is why their antral follicle count on ultrasound is high. So they often have very high AMH as well. It is something to watch as GPs, but in the future you may I suspect in the next few years, it has been rumoured for quite a while, but I suspect that the Rotterdam Criteria for polycystic ovarian syndrome will probably change. So as you are all aware, the criteria for polycystic ovarian syndrome is that you need at least two out of three criteria, you need evidence of an irregular cycle or oligo or anovulation. You need to have clinical or biochemical evidence of imbalance of male hormone, so clinically that would manifest itself as pimples or acne and then you need to have evidence on a scan of polycystic ovaries, so lots and lots of antral follicles. Okay, what you may find in time and I think this will come, is that we now really know that polycystic ovarian syndrome is a real spectrum, and you know that insulin resistance is a part of it, and that things like AMH will probably become more useful factors in the diagnosis of polycystic ovaries and you know, maybe an antral follicle count into the future. So I think this is probably a bit of a watch this space. We can advance.
Sarah: Paul before we just go on to the more advanced investigations, I have just had a few questions about cost for the AMH test. Do you have any answers to that?
Paul: Yes. So the AMH test costs usually around $85. It is not Medicare rebatable. But as you may have heard recently that the Federal Government has recently announced a package around funding for investigations with regards to fertility. A number of the State Governments like New South Wales and Victoria have sort of been pushing for funding on this, so you may find at the moment it is about $85 but you may find in the future that that test becomes fully Medicare rebatable if these Government rebates, they are talking about putting maybe $400 or $500 dollar rebates for women or couples having fertility investigations. So you may find in time it becomes cheaper.
Sarah: Thank you.
Paul: The other thing about AMH is that you can get an artificially low AMH if the woman is on the pill. Okay so when AMH first came out in I do not know, seven years ago maybe a bit more, it was said not to be influenced by the menstrual cycle or the woman being on the oral contraceptive pill. There have been a number of studies that have come out since that have indicated that this is probably not the case and that it is effected by the pill or the time of the cycle. So if a woman in on the pill and she has an AMH test and it is low, and she wants to know her true ovarian reserve, my suggestion is that you take her off the pill and then retest the AMH after about two or three months. It could be up to about 30% lowered by being on the pill.
So, the more advanced investigations that can be done by the GP. As I said, the three Cardinal investigations in fertility are, is the woman ovulating? So that is you know a progesterone level. You get a pretty good idea about if the woman is ovulating if she has a nice regular cycle. The semen analysis for the man. And any sort of test of tubal patency, because obviously the first baby born in IVF, Louise Brown who is I think 41 this year, they did IVF for her in the UK because her mum had blocked tubes. IVF was invented in the first place because if a woman had blocked tubes, you had to get the eggs out, put them with sperm in the lab and put the little baby into the uterus. So if the tubes are blocked obviously, you cannot you know, get pregnant naturally. Now in general, women are not born with blocked tubes, it is rarely a congenital thing that you are born with blocked tubes. Usually blocked tubes comes about from usually one of two things, an infection, so chlamydia, gonorrhoea in the past, or you know a ruptured appendix or something that has spilt some nasty bacteria down into the pelvis that has caused inflammation and then blockage of the tubes. Or secondly, classically endometriosis. So endometriosis inflammation, endometriotic deposits in the ligaments around the tubes, swelling, inflammation and then scarring cause blockage of the tubes.
So the way we investigate the tubes, is you can investigate them in a number of ways. Personally the most useful test I find is the HyCoSy which is a detailed ultrasound where they put some bubbly salty water up through the cervix and they distend the cavity so it also gives me ideas about you know, is there a polyp or a fibroid or a septum in the uterus, and then under ultrasound they watch that bubbly, salty water flow out through the tubes. It also gives me some additional information about pelvic structures and things. HyCoSys are not accessible everywhere. Until we understand that, I think for some of you rural GPs, you may only have it in your hospitals or you know access to an HSG which is a hysterosalpingogram which is where the radiologist puts some contrast up through the cervix and pushes it and they do more like an x-ray to show the contrast coming out through the tubes. My personal preference is a HyCoSy because I believe it gives you more information. Obviously the other thing that can be done is a laparoscope so you can put a you know, a camera into the tummy and put in some fluid and watch it on vision come out through the tubes. That laparoscope can also be useful obviously if you are hunting around for endometriosis because then you can excise it at the same time. So we can advance the slide.
Karyotypes can be useful. It is a bit of a debate to be honest in fertility circles about whether this should be a routine test for infertile couples or sub-fertile couples. In the recurrent miscarriage population or in the sub-fertile population you may find that up to about 4% of couples have an abnormality with the chromosomes, now obviously if the man and woman are normal, well obviously their chromosomal compliment for themselves is normal, but as you know what can happen is some chromosomes stick on to each other, so like a translocation. So this picture here is obviously indicating to you a translocation where chromosome 15 is stuck on chromosome 13, so obviously within that individual there entire genetic compliment is full but then the genetic compliment then halves into their gamete. Well when that recombines as an embryo it is going to be unbalanced in the embryo and if that is you know a large, or a lot of genetic material, that embryo will never implant, or if it is a smaller amount of genetic material, then that person may have a predisposition to recurrent miscarriage. And that is why karyotype can be useful in the sub-fertile population or in a population that has recurrent miscarriage. Can you advance the slide for me?
Thyroid. I have just put this slide in because thyroid is very contentious, about whether you should be doing a routine TSH test on women who are trying to fall pregnant. I personally do do a TSH on any infertile couple that comes to see me. The endocrine societies around the world do not agree completely on guidelines for this, so I sort of use a bit of a guide, and as you know the best sort of thyroid guide in the world usually comes from the American Thyroid Association, they sort of give the most detailed and evidence based guidelines for these things. My standard practice that I do is that I do order a TSH because if it is elevated, that is indicates subclinical hypothyroidism, I mean it is obvious, if the woman has hypothyroidism obviously that is investigated and treated. But the controversy comes in with subclinical hypothyroidism, that is when your T4 level is normal, or your T4 level is 16 or normal but the TSH level is high. By high, I define high as more than 4. If it is more than 4, then I treat it, so I give them some Thyroxine. If the TSH is borderline high, and by that I mean that the TSH is between 2.5 and 4, then what I do is I test for antibodies and is antibody positive then I treat because they are much more likely to become symptomatic of their hypothyroidism if they are antibody positive. Now that is not an international guideline, that is just my own personal way of doing it which is sort of a bit of sort of looking at all the evidence. So if we advance the slide.
I would like to spend a bit of time talking about endometriosis.
Sarah: Sorry Paul, the audio connection just disconnected there for everybody. Could you repeat that last little bit?
Paul: If you could just advance the slide so I can talk about endometriosis. Okay. Well this might be our last little bit to talk about so we can have some time for questions. But, endometriosis is tricky. It is tricky for infertility people so I can understand why it is tricky for GPs, that is, you know, how much is this endometriosis having an impact on the patient and should I be referring them to a gynaecologist to have surgery or should I be referring them to an IVF guy to do IVF? Like what is the best answer? The thing I guess with endometriosis is first of all, number one, the GP is to recognise it. Okay? It is really, really underdiagnosed in people. Obviously if you are seeing a couple for infertility, then you know, a symptom of endometriosis is infertility. We have talked about it before, the classic symptoms of endometriosis, the painful periods, pain with sex particularly a deep inside pain, pain around the time of menses, doing a poo and some premenstrual spotting. So with endometriosis, the key here is to think well okay, endometriosis could cause blocked tubes, so that is how it could cause infertility, so you know, anatomical problems, anatomical blockages. But endometriosis definitely also has probably an effect on egg quality particularly if there is endometrioma within the ovary, and also the endometrium of the women with endometriosis is abnormal. So it responds differently and it probably has different implantation compared to women without endometriosis. The key here with deciding for a couple about, do you go down the path of surgery or do you go down the path of you know, IVF or other assisted reproductive treatments? Now that is not necessarily, you know you can send them along to us to have a discussion about that. but I guess the key thing to think about is that if we have two randomised control trials that show in women with minimal to mild endometriosis, if you do a laparoscope and you take out that endometriosis you do improve their chances of falling pregnant naturally. Okay? It was a very good study, it was done in the New England Journal of Medicine. It was published in 1997 out of Canada and it did show that you had about a doubling of the rate of natural conception if you took out the endometriosis. Now, it was doubling of the pregnancies, but it was not like it went from you know, it actually only went I think from memory, I think from 17% to about 31% over a nine month period. So there was a doubling of the rate, but the pregnancy rate was still not particularly high.
The key with endometriosis surgery though is that nobody has ever proved in a proper randomised control trial that taking out endometriosis prior to doing an IVF cycle improves their chances of falling pregnant by IVF. So, you do get some debate in IVF circles around you know, should you do IVF first, or should you be doing surgery first? Because there is no doubt that probably surgery can improve embryo quality, but the big down side of the surgery is that obviously you know, a lot of the blood supply that comes to the ovary comes along the broad ligament up from the uterus, and that if you start doing a lot of surgery around the ovary or in particular, you know taking out endometriotic cysts from the ovary, you can strip the ovary of a lot of eggs and then really decrease that woman’s egg number. And you know, IVF works best if you do get a good number of eggs. So if you end up being too aggressive with your surgery you might get an inflammation and therefore make success better but you might also strip that woman of her egg count which she is not going to thank you for. So my advice to you as GPs in this, is endometriosis surgery is complex surgery, like it is probably as difficult as cancer cell treatment. So I would advise that you establish a relationship with a good arthroscopic endometriosis surgeon. Now that is not me. I do not profess to be an expert in endometriosis surgery, so I am not touting my own business here. But I think it is very important that the surgeon who does this surgery knows what they are doing because you know it is very heart breaking for me that if a woman has gone along and had endometriosis surgery and that a person who is not particularly good at this does a lot of digging around and you know in a young woman that egg number has plummeted after the surgery, it can be a real tragedy. And if she has then got blocked tubes and no eggs, you know, I cannot help her. So as GPs, my advice is to establish a good relationship you know with someone that you trust to do good surgery in endometriosis because it is not easy surgery if it is severe endometriosis.
Okay with that we are probably running out of time. Do we need to move to questions?
Sarah: Sorry I am getting the message to keep going, but I am wondering if we perhaps spent you know, more time on some of the GPs questions unless you had something you could let us know quickly about the male tests in the role of general practice?
Paul: Yes, sure. So male tests are tricky. Now this is more a slide for those of you who are really keen on this area, like if you are getting a man with a terrible sperm test, like really low sperm, you know and by that I mean less than 5 million per mil, or really low motility, well then these are the tests that we would order. Because when you are looking at the male test problems, you have got to decide, well is the problem coming from the brain? Is the problem coming the ball itself, in the testes? Or is there a block? Okay? So as GPs, to make it simple for yourself I think that okay, is the hormonal problem a brain issue? Is the hormonal problem something primary, that is in the testes itself, or is there a block in the pipe? Okay? And these tests are designed to help you pinpoint where the problem might be. So there are hormone levels. So FSH, LH and testosterone. As you know, testosterone levels vary throughout the day so it is very important that when you order a male testosterone level that you order it at you know, 8 a.m. in the morning. Blokes wake up with morning erections because their testosterone peaks in the morning. So you want to order testosterone first thing in the morning. Other things that can looked at, and this is particularly if you have a man with a very low sperm count or no sperm, you need to rule out Klinefelter’s so XXY. And then there is also a region on the Y chromosome where there is what we call the azoospermic factor, so they are micro-deletions on the Y chromosome which we order if the man has very low sperm.
And ultrasound can be very useful and this is something that I probably would suggest you, the GPs, order, particularly maybe, we have had a few GPs that have picked up testicular cancers on men with very low sperm counts. So, I think medicolegally, I mean if you are really good at feeling testes and you know how to detect lumps and bumps, then you know you can rely on your examination but if you have a man with a very low or absent sperm count, I routinely order a testicular ultrasound. It gives you information about testicular size, if there is any atrophy and it also gives you any information about if there is any sort of significant varicocele, because varicoceles as you know are a distention of veins, particularly on the left side, because the left side does not have valves and that can surgically corrected and sometimes can improve the man’s sperm count. And obviously if there is evidence of a destructive pattern, that is, the testes are a good size, the hormone levels are normal, so you are thinking okay, well I think probably that bloke is making sperm, they are just not getting out. Well then you need to think, well okay, why is there a block. Is there a block because he has had a previous infection in the epididymis that caused scarring? Or the thing that you need to rule out specifically is, is he a CF carrier because being a carrier of CF is obviously associated with a congenital absence of the vas deferens. So we check them for CF carrier status in a man where we suspect is an obstruction or absence of the vas, because obviously then we can quite easily get sperm out of the testes by putting a needle into the testes and you know, taking up the sperm from the testes because it is there, it is just not getting out. We obviously then, if he is a carrier, we need to test the female to make sure she is not a carrier, because if he is a carrier and she is a carrier, then we need to talk to them about genetic counselling to potentially test those embryos to make sure we do not pass on cystic fibrosis to the next generation. Alright, so that is probably male tests.
Sarah: I notice that you have repeat the semen analysis, and there have been a few questions from the GPs. I was always taught to do two. I know we talked about one earlier and then I guess is that a repeat if it is abnormal? What is your standard rule of thumb?
Paul: Yes, it depends a lot on timing. But you are absolutely right. I mean if you are being a purest then yes you would repeat the semen analysis. The key to a semen analysis is that one sperm from the time it is like a germ cell of the sperm until it is the sperm that is ejaculated, you know much like that ovary where it is the egg starting along the path and it is 120 days until it is the egg that is ovulated. Same with the sperm. A sperm when it starts from its germ cell until it is the sperm that is ejaculated, that time frame is probably about 75 to 90 days. Okay? So any insult that that man has had over the last you know, two to three months, that sperm has been you know accumulating for the ejaculate, is going to affect that sperm count. So that is why we usually have about six to eight weeks in between semen analysis so that is the next wave of sperm that is coming through that you are testing. Because I have seen it myself, you know I have had blokes that have a terrible sperm test and then I look back at their history and then it turns about a month before they had their sperm test you know they were in hospital with a terrible pneumonia or something and it has really knocked off their sperm count for that. And then it has just come through in the ejaculate a month later. So, yes a purest would say six to eight weeks between sperm tests and repeat it. We have studies from the United States that you know basically have university students you know, give sperm samples every two to three days and then they graph, you know the count and the variation on the graph, you know it is like a saw tooth. Semen analysis do go you know up and down quite jaggedly if you graph them. But yes, if you get one abnormal result then I repeat the sperm test. I will order the ultrasound, I will order the carrier type. I will order the hormone and a repeat semen analysis. But just because things take you, carrier types about four to five weeks to come back, so these people who are coming to see me for fertility treatment, you know particularly if the woman is 39 or 40 and you know, time is of the essence, then sometimes I need to push the testing along. You know if you have got a much younger couple where you are not under that same time pressure, then yes you can wait that six to eight weeks before you repeat the test. And obviously you do all the primary care things, you get them to lose weight, you get them to stop smoking, you get them to stop pot, you find out you know, a lot of these guys particularly in Sydney you know with the Instagram generation, they are really on the steroids, so you know if you have got a big muscly guy with small testes and no sperm, you know you need to start enquiring about you know is he on steroids, is he on anabolic steroids and get him off them.
Sarah: I might let you keep going and then maybe we can answer some of these questions towards the end that are coming through. So I will let you keep going, Paul.
Paul: Okay, no worries. Do you mind advancing the slide then?
Okay, then I guess you want to know when to refer. And that really depends on, you know there are some of you who like infertility and there are some of you, I guess if you are tuning into this webinar you are probably more interested. So for you guys, you probably want to do a lot of the work up yourself which is great because there are plenty of things with regards to like losing weight and teaching these people about their natural fertility window and things where you guys can make a massive difference. Although fertility doctors get a bit of a bad rap in the press, particularly at the moment to be honest, particularly in Victoria to be honest, IVF specialists are very happy when patients fall pregnant naturally. We actually do not love doing IVF. We try to do a lot of other things before we push people on to IVF.
So the time to refer is a lot around female age as you know. If they are over 35 fertility declines. It deeply declines after 40 and then really drops off the cliff after 45. So if a female in particular is over 35 and they have been trying for six months, then that is probably the time to do some preliminary investigations, semen analysis, hormones et cetera, and then refer. If they are younger, more like 12 months. Just because they come and see me you know at the age of 30 and they have been trying for 12 months and all my tests come back normal, you know at that point there I really go into, could this be endometriosis, could they benefit from a laparoscope, or have they done tubal testing, in which case I often buy myself a bit of time by sending them off for a HyCoSy, because the stats would say if you have got a pretty young couple, and you know by young if you have got a you know, let us say a couple who are around 27 and all the investigations are normal, that is they have got unexplained infertility, which is a terrible term and patients hate it, but that term is unexplained infertility. If you have got those couples and they try for a year, about 85% of them should fall pregnant within that first year. But then there is that sort of 15% of couples that around the age of 30 then try for another year. About half of them will fall pregnant naturally and it will be only sort of you know half of the sort of that 15% that will require some sort of help from me in order to get a baby. So there is definitely a rationale in you know letting these people try longer naturally. And in that case what I often do is I send for a HyCoSy because there are some recent studies that are coming out now. Neil Johnson in New Zealand, Ben Mol from Adelaide. So some you know, Australian and New Zealand researchers have been showing that flushing of tubes with fluid or an oil-based medium called lipiodol can improve their chances of falling pregnant naturally after the tubal flush, particularly in the subgroup of people who may have endometriosis. So that is something that as GPs if the couple are keen on you know, if IVF is all a bit scary, well then refer them for the HyCoSy, the flush, you know signs and symptoms of endometriosis. You know can I send them for a lap for their natural fertility.
Other things obviously where you would definitely send them on to me or another specialist would be obviously blocked tubes. You know blocked tubes equals IVF really in modern practice. Probably gone are the days of unblocking tubes and tubal surgery. I mean there probably still are occasions and certain things, but given that IVF has become you know, successful and pretty accessible these days, blocked tubes is usually IVF these days. Severe endometriosis, obviously if you have diagnosed you know, no sperm well that obviously comes to us. They will not fall pregnant naturally. Or if you have identified a genetic condition. You know if you have identified you know something that they both carry, you know if you have got a nationality Jewish couple or there is a genetic thing you have identified you know, well then obviously send them for referral because with the power now for pre-implantation genetic diagnosis we can test the embryos and only put back embryos that are not affected by the condition. So that would be immediate referral.
Low AMH I have put in there and this is really depending on how comfortable you feel. I personally do not know how to counsel about high PSA, it is something I find tricky because I do not have the expertise in it. Similarly if you feel uncomfortable talking to a couple, or a woman about what a low AMH test means, then I do get a lot of referrals for women to come in and have a discussion with me about what low AMH means, and it does not necessarily mean that you know, I rush them into an IVF cycle or I tell them to use donor sperm if they do not have a man or anything, but sometimes it is a useful conversation for me to have with them around you know, just life planning and I mean that is tricky though isn’t it, because what do you say to a 30 year old girl in front of you who does not have a partner, you know it is a bit of a…
Sarah: Paul do you want to move on to the next slide?
Paul: Yes, sure. So this is the slide that I was going to go into more about the various treatment options that we offer. But I am not sure if you want me to go through that or if you want me to answer questions which I am happy to do.
Sarah: We have got quite a few questions that have come in. I mean, I wonder if we talk about some of those and I think if we have questions about procedures and things like that. I am just looking at admin. Are they able to email questions?
? Female voice: Yes, if there are any questions feel free to email them through and we can collate them and send them through to you, Paul. So that email address would be email@example.com which you would have got these emails from about your logging in, so that should be fine.
Sarah: And maybe if people have questions about treatments, we could get those emailed because we are probably just going to move on to some of the questions that have come in during the rest of the presentation of that is okay, Paul?
Sarah: So I might ask one question. A lot that came through were talking about patients who have got irregular cycles, perhaps not such long cycles that they are amenorrhic or have very long cycles like PCOS. But a lot of people asked about the investigations if the cycle is a little bit more irregular than say the standard 28 to 35?
Paul: So yes, by definition the long cycle is probably more than 35 days. So if you have a cycle over 35 days, the classic thing that causes that is yes, polycystic ovarian syndrome. So we would want to do the questions around that, so are there any signs or symptoms of you know, too much male hormone, so acne, hirsutism, and then you would send them for biochemical tests around that. So you know, testosterone levels. Other things that can cause an irregular cycle that GPs might want to investigate is a thyroid issue, so hypothyroidism in particular may cause an irregular cycle so I would send them for a TSH and the other thing that can cause an irregular is hyperprolactinemia so I would send them for a prolactin level as well. So you understand that prolactin which is the hormone that is released for breast feeding acts back on the hypothalamus and decreases the prolificacy of GnRH. So prolactin, that is why when they are breast feeding, it is contraceptive really because it keeps the high prolactin levels feedback to the brain and turns off those pulses of GnRH. So breastfeeding women classically do not get periods because they are not ovulating and they may also have low oestrogen. So the things for irregular cycles would be PCOS testing, thyroid testing, prolactin testing. Often you will find it is a phenomenon of being a little overweight and insulin resistant again tied up with that polycystic ovarian syndrome metabolic syndrome picture. So often the treatment is you know lose 5 to 10 kilos of weight and the cycle will become more regular. If they are having big gaps between periods and they have not had a period for a while, the one thing that we always forget is that maybe they are actually pregnant naturally. So you would be surprised how many women come along to see me and they say I have not had a period for three months and I add on my hCG and of course they are pregnant and that is why they are not getting a period. So do not forget that as part of your workup for amenorrhoea.
Sarah: Great. Another question was, someone asked about the test for hemochromatosis in male infertility and how that might impact?
Paul: Yes, so that is basically an iron deposition both within the brain and within the testes itself, so it can be cause of both primary testicular failure and secondary testicular failure, where the brain hormone levels are low. So it can act on both levels actually so iron deposition within the testes causing low sperm, or iron within the brain which has then caused a decrease in the FSH, LH and causing a low sperm count that way as well.
Sarah: Great. I had a question about HyCoSy and how accessible is that around Australia? Is that something that would be more present in urban settings?
Paul: Yes, that is sort of a little bit alluded to. It is very accessible in urban centres. You know, you can find it all over Sydney basically and Melbourne and Brisbane. It is very common. There are specialised women’s ultrasound places dotted throughout Sydney and Melbourne and the capital cities and some of the more regional towns. They are sort of specialised women’s ultrasound places where a HyCoSy is actually performed by a gynaecologist so there is a sonographer who does the scan and a gynaecologist is the one who instils the fluid. So yes, it is accessible very easily accessible within urban centres. The cost can vary greatly. Like the premium private clinics here in Sydney might charge up to around $600 for a HyCoSy with some rebate, but a lot of the big major hospitals, The Royal Hospital for Women, Prince Alfred North Shore, you know the big tertiary hospitals in the capital cities do offer it as well within their women’s health or ultrasound departments. You may find though as I said at the more regional centres, at those hospitals you may find it is more accessible to get an HSG because that is not a gynaecology test, that is a radiology test. So yes, I mean it is very variable around the country. Certainly all the urban centres would have access to one and some of the major regional towns would have access to HyCoSy as well. The key with HyCoSy is, it can be quite painful for women because you are instilling them, some women find a HyCoSy incredibly painful and that is very dependent on the centre you send them to. So the more specialised women’s ultrasound places that you know, the reports I get back from the patients are that that is a lot more tolerable. They are instilling you know, quite a few mil of fluid up into the uterus and when as you know if you distend the uterine cavity that can cause a lot of pain and cramping, so women do find the HyCoSy can be quite uncomfortable. The key with the HyCoSy and the timing of it is that it is done usually just after the period. The reason for that is obviously if the woman has then shed the menstrual lining, the gynaecologist or sonographer is going to get the best view of the cavity because lining is not as thick, so any submucosal fibroid or polyp or anything is going to be seen more easily and secondly obviously, the HyCoSy is flushing fluid up into the cavity so they always do it just after a period because they definitely do not want the woman to be pregnant. You know, nothing would be worse than an infertility patient who gets a HyCoSy in the second half of the cycle after she has ovulated and is essentially pregnant and you then instil the fluid. So is always, when they ring up these places it is timed to be just after their period finishes, or if they do not get a period, they do a pregnancy test before they do a HyCoSy.
Sarah: Thank you. We are just sort of starting to run out of time. As I said before, I checked with admin, and they are going to summarise the questions and get some answers from you Paul which can then go out to the attendees because there are a few more questions here about different techniques and things like that. I wondered if there was anything you would like to just sort of sum up as the take home point for GPs tonight, and then maybe they could ask you to talk again on treatments in more detail, because I think people would be very interested and unfortunately we did just run out of time there at the end.
Paul: Yes, no problem at all. I guess my take home message is endometriosis I think is a big take home message. Think about it and try to refer to have it diagnosed because it is underdiagnosed. My other thing would be really about I think GPs are really in a powerful position with the infertile couple and I think you can make a huge amount of difference in terms of really helping a couple not need our treatment. Just by optimising BMI I think would be a huge one, stopping smoking and getting their timing right. I think a lot of that can be hugely powerful in people avoiding IVF. The other thing I think as well for GPs, for you guys, is when you with your young women who you see if you know, it has almost gone a bit the opposite way now like we are always scared about teenage pregnancies, but now one of the big primary things that GPs can do is educate your young women you know who are coming to you for their first pap smear at 25, about family planning, because I think there is a bit of a misconception out there amongst women that okay, well if I delay my childbearing to you know, 35 or 40 well it is alright then I will have enough money to do IVF. Well that is no, not true, that IVF success rates are better than natural at that age, but IVF is certainly not the magic cure for age-related infertility. So another big powerful thing that GPs can do is with your younger women is start, you know once you have got them over the risk of a teenage pregnancy, then start educating them that okay, you start thinking about your family planning and do not leave child bearing too late because unfortunately the message that fertility specialists need to get out there is that modern life and the modern women and biology is not necessarily compatible with modern life. You know, women are successful and have equal rights and equal pay, well not equal pay, but they can do anything they want and so they should. You know they have degrees, they have travel, they have successful careers, but unfortunately what happens is they get to sort of 35 or 40 and they have delayed childbearing and then they sort of realise, oh gosh, IVF is not the answer and then it is very difficult to access donor eggs in Australia, so a powerful thing that GPs can do for the young women that you see is just sort of remind them that unfortunately that there is a biological clock and so, you know to be mindful of that if they are wanting one, two or three kids in their family.
Sarah: Thank you very much Paul and hopefully we will be able to get you to come back and talk about treatments because I know a lot of people were very keen to hear a bit more about that in detail. So thank you very much, it was very useful and I think the College will be in touch to get you to answer a few more in the future.
Paul: Yes, no trouble. Thank you.