Assisted conception and MRKH syndrome

1. Assisted conception and MRKH syndrome Dr Anna Carby Fertility Specialist IVF Hammersmith

2. Overview • Reproductive options • What is surrogacy treatment • Treatment pathway • Investigations • Treatment cycle • Outcomes at IVF Hammersmith

3. Reproductive Options • Freezing embryos for surrogacy (currently in a relationship) • Freezing eggs for surrogacy (not currently in a relationship) • Adoption

4. What is surrogacy? • Term used to describe situation where a woman agrees to become pregnant and have a baby for another couple • Woman who carries the baby is the surrogate • Couple who intend to be the parents are called the intended parents

5. Types of surrogacy arrangement • Full/host surrogacy – intended parents use IVF treatment to create embryos form their own eggs and sperm and these are replaced in to the uterus of the surrogate • Partial /straight surrogacy – surrogate’s eggs are used with intended fathers sperm for IVF or IUI

6. Pathway IVF Hammersmith • Referral from GP/specialist • Out-patient appointment within 4 weeks NHS (or private appointment if desired) • Assessment - initial consultation, medical history and investigations • Follow-up appointment • Application for funding if NHS • Counselling and nurse appointments • Pre-treatment blood tests • Treatment cycle • Quarantine embryos • Transfer in to surrogate

7. Investigations – ultrasound scan • May be either internal or transabdominal • Internal gives better picture of ovaries and allows assessment of accessibility • Volume of ovaries and activity

8. Investigations – blood tests • AMH testing –marker of “ovarian reserve” ie how well ovaries may respond to stimulation • FSH testing – cycle specific therefore more difficult to test

9. Investigations – semen analysis • Extremely important! • Produce sample on-site • Analysis of count and motility

10. Review appointment • Results of investigations • Plan for funding and treatment • NHS funding approved? • Referral to counsellor • Referral to specialist nurse

11. Funding of treatment • All surrogacy treatment cycles must be approved by the female partners PCT (primary care trust) • PCT is defined by the female partners GP location • If funding is granted it covers the cost of producing embryos and most usually freezing and storage for the first year • The costs of the surrogate transfer are not included and this has to be performed privately

12. Role of the specialist nurse • Communication with GP for surrogate and commissioning female – medical history, welfare of the child • Screening blood tests - obligatory • Karyotyping (chromosomal testing for commissioning couple), blood grouping, cystic fibrosis screening • Potential transfer of infectious diseases with embryos (HIV, HTLV 1 and 2,Hep B and C, syphilis, chlamydia, gonorrhoea, CMV). Testing within 3 months of treatment • Repeat infectious diseases testing after 6 months quarantine of embryos

13. The treatment cycle for you • Aim is to stimulate ovaries to produce upward of 5 follicles • Requires control of ovulation • May use contraceptive pill prior to treatment • Then a series of injections for 2-4 weeks to reach egg collection

14. The treatment cycle (injections) • Sub-cutaneous • Daily at home • Similar to diabetic pen with dial-up dosage

15. The treatment cycle - monitoring • Transvaginal or transabdominal scans and hormonal blood tests (estradiol) • Approx 4 visits per treatment cycle • Early appointments – from 7am • Perfectly possible to work whilst stimulating

16. The treatment cycle – egg collection • Either transvaginally or laparoscopically • Transvaginal - better egg yield, intravenous sedation, possible for majority. Quick recovery time • Laparoscopically – for ovaries that can’t be reached safely transvaginally. Requires general anaesthetic, day case operation • Average numbers collected – approx 10 but may be anything from 0-20+ !

17. The treatment cycle - fertilisation • Partner produces sample on the day of egg collection • Purified to remove non-viable sperm and achieve concentrated sample • Egg fertilised - normally by a process called ICSI

18. The treatment cycle - freezing • Embryos frozen either day 1, 3 or 5 • Quarantine period of 6 months • Repeat viral screening • Available for subsequent transfer in to surrogate • Can be frozen for use for up to 10 years

19. The treatment cycle - risks • No treatment is without risk • But risks with IVF are low • Over-response OHSS (ovarian hyperstimulation syndrome) approx 3-5% cycles • Under-response and cancellation – approx 3% • Bleeding – less than 1% • Damage to other structures (bowel, bladder) less than 1% • Infection – less than 1%

20. The treatment cycle – for the surrogate • Preparation of the womb for transfer of embryos • Transfer in the natural menstrual cycle if regular • May be achieved with control of menstrual cycle and hormonal support with estrogen patches and progesterone pessaries up to 12 weeks of pregnancy

21. Chances of success with frozen embryos

22. Outcomes of treatment • 21 stimulation cycles completed • Average age at treatment 30.6 • 4 patients laparoscopic egg collection • 13 transvaginal egg collection • 244 eggs collected in total! • 135 embryos and 10 eggs frozen

23. Outcomes of treatment • 13 transfer cycles completed • 3 livebirths • 1 pregnancy 27 weeks

24. Any questions • Contact IVF Hammersmith 0203 313 4411 • Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna Carby • Referrals fax 0208 749 6973 • www.ivfhammersmith.com • www.hfea.org.uk