Effectivenesss
of a Structured Fertility Diagnosis Package
Sarah Baker –
Fertility Midwife, Jackie Loveridge –
Senior Fertility Nurse,
Jude Adeghe – Consultant Gynaecologist, Rasiah
Sriskandakumar – Senior Clinical Embryologist.
Introduction
Without
reaching a diagnosis, appropriate treatment of subfertility cannot be
rationally determined. Therefore, an effective plan of fertility investigations
to establish a diagnosis is a sine qua non for the management of
subfertility.
St Jude’s Clinic offers the
One Stop Fertility Diagnosis Package to facilitate the TTC (Trying To
Conceive) journey for couples. The essence of the package is to assess the keys
pillars of fertility – Ovarian reserve / function, tubal patency and sperm
quality.
The package includes:
-
Blood tests for Anti-Müllerian Hormone (AMH) to check reserve of
eggs in the ovaries
-
Blood test to check Rubella immunity
-
Pelvic Ultrasound Scan
-
High Vaginal Swab (HVS) to screen for infection
-
HyCoSy (Hysterosalpingo-contrast-Sonography) procedure to assess
tubal patency
-
Semen analysis
-
Review by Consultant to discuss results and treatment options
Objectives
Our clinic has been offering this package of
investigations for many years but no formal audit has been conducted so far. The reason
for conducting this audit is to assess the effectiveness of the package in terms
of the following:
·
Reaching a diagnosis
·
Time taken to complete all tests within the package
·
The range of abnormalities identified by the tests
·
Any complications arising from HyCoSy procedure
·
What treatments those who took up the package went on to have and
their relative success rates in conceiving
Data
Collection
All
women who had HyCoSy procedures at St Jude’s in 2019 were identified by
reviewing the theatre record book. These notes were then pulled from file to
assess which patients had the one stop package.
Data
was collected on the following parameters:
-
Name
-
Patient ID number
-
Age
-
BMI
-
Duration of Infertility
-
AMH result
-
HVS result
-
Pelvic Ultrasound Result
-
HyCoSy findings
-
Semen analysis results
-
Subsequent Fertility Treatment
-
Treatment Outcome
-
Pregnancy Outcome
Data
Analysis
Data
was collated by category to summarise frequencies of different outcomes and
calculate percentages for applicable parameters.
Mean
values were calculated for patient characteristics to assess the demographic of
women included in the audit and cross reference outcome data.
Results
A
total of 41 women who took up the One stop Fertility Diagnosis Audit in 2019
were included in the audit. The mean age of the women included in the audit was
33 years (range 20 years – 46 years) and average BMI was 26.5 (range 19.4 –
48.5) . Mean AMH level was 18.0pmol/L (range 0.7 – 85.4pmol/L). 21% of AMH
results were classed as low (<5pmol/L). This is an important discovery
to best advice patients on the most effective treatment options and ensure they
act sooner rather than later to prevent further decline in ovarian reserve.
41%
of HVS results came back abnormal (17 out of 41), with results varying from
Candida species, Bacterial Vaginosis Grade 2-3, Ureaplasma/mycoplasma and GBS.
All abnormal swab results were treated with over the counter treatment or
antibiotic cover. By doing so any abnormal flora or bacteria are removed and
the chances of conceiving are improved. GPs were informed of GBS positive
results for future reference in pregnancy.
As part of the HyCoSy procedure, broad spectrum antibiotics are routinely given
intravenously with sedation medication (Cefuroxime 750mcg). Where abnormal HVS
results are identified, HyCoSy procedures are postponed to enable adequate time
for treatment to be effective.
17%
of trans-vaginal Ultrasound Scans identified abnormalities in pelvic anatomy:
most commonly Polycystic Appearance of the Ovaries; other abnormalities
included the presence of simple ovarian cysts, multicystic ovaries, fibroids
and in one case an arcuate uterus.
The
vast majority of HyCoSy procedures concluded Bilateral Tubal Patency (85%),
only one patient had Bilateral Tubal Blockage (2%). Five patients had one
blocked tube and one patent tube (12%).
Semen
parameters were normal in 54% of the men included in the audit. The remaining
46% had reduced parameters of some kind. Results varied from marginally reduced
parameters in only one parameter, or increased WCC only, to multiple sperm abnormalities
requiring ICSI treatment. Azoospermia was
recorded in one case.
50%
of patients went on to have simple ovarian induction treatments with clomifene
or letrozole tablets after the one stop package. 11% of patients proceeded to
have IUDI treatment (all single women or same sex couples), 17% of couples had
IVF/ICSI treatment after the one stop package, usually in cases where there was
a tubal blockage or semen parameters were reduced.
The
remaining 22% of patients had no treatment at all subsequent to the One Stop
Diagnosis Package. Some of these women contacted clinic to inform us that they
had conceived naturally, however many did not follow up at all, therefore it is
unclear is these women conceived and therefore required no further input from
St Jude’s or whether they decided not to pursue fertility treatment or to go to
another clinic.
Results
show that the percentage of patients included in the audit who conceived after
taking up the One Stop Fertility Diagnosis Package was 34%. However a further
22% of women had no follow up. Of the 14 couples who conceived, four conceived
with no treatment at all (29%), seven couples conceived following simple
ovarian stimulation with clomifene or letrozole (all fewer than 4 cycles) (50%)
and three couples conceived following IVF or ICSI treatment (maximum one fresh
cycle) (21%).
Due
to the timescale of the audit, some treatments are still ongoing therefore some
outcome data is not yet available.
Discussion
Current
guidelines support the use of the investigations included in the one stop fertility
diagnosis package.
AMH
is a widely recognised blood test to assess ovarian reserve and does not
fluctuate based on the timing in the menstrual cycle therefore results are
likely to be more reliable in comparison with other hormone levels which
fluctuate depending on cyclical changes and reply on patients attending at the
right time in their menstrual cycle.
High
vaginal swabs are collected in line with guidelines to identify any potential
infection prior to the HyCoSy procedure so any abnormal results may be treated
to prevent further spread of infection.
Trans-vaginal
ultrasound scanning is used to assess pelvic anatomy, looking at the size and
contour of the uterus and ovaries, and noting follicular activity and
endometrial thickness in reference to the timing in the cycle.
HyCoSy (Hysterosalpingo Contrast Sonography) is an investigation of the fallopian tubes to check if they
are open (patent). Ultrasound scanning is used to check for spillage from the
fallopian tubes. It is done under
intravenous conscious sedation to ensure it is not painful for patients. It is
an alternative to the traditional HSG procedure (X-ray Hysterosalpingography) offered
on the NHS and uses X-ray to check for spillage of radio-opaque media from the
fallopian tubes.
Semen analysis is carried out by the Senior Clinical Embryologist
in line with WHO 2010 standards. All semen parameters are tested including: volume,
concentration, count, morphology, motility, pH, agglutination and leucocyte
count.
some
patients who had no fertility treatment after the one stop package were lost to
follow.
Conclusion
The
audit supports the use of the One Stop Fertility Diagnosis Package. A number of
patients conceived following the package with no treatment at all, which may be
partially attributed to the positive effect of the HyCoSy procedure flushing
through the Fallopian tubes. Patients are also offered advice at initial
consultation and at review on optimum frequency and timing of intercourse which
may play a part in improving fertility outcomes for some patients.
In
most cases, the tests were completed within 2months.
The
package is successful in identifying the fertility status of couples
considering fertility treatments and helps to determine which treatments are
available to them.
HyCoSy
is a safe procedure to assess tubal patency. It is performed under conscious
sedation, and well tolerated. There were no complications during and after the
procedure, in all cases.
The
package is excellent value for money – the package cost is only half of the
total cost if the tests were done individually outside the package.
KEY
POINTS
· The one stop
package is successful in reaching a Fertility Diagnosis for patients, with a
significant proportion of test results showing some kind of abnormal results,
which may then be treated.
- 21% of AMH blood test results were defined as ‘low’
- 41% of High Vaginal Swab results were abnormal
- 15% of HyCoSy results showed problems with tubal patency
- 46% of semen analysis results showed reduced parameters
By diagnosing the problem, appropriate options for fertility treatment can be
discussed to maximise your chances of conceiving.
· 34% of couples
conceived after the One Stop package, the majority of whom had no treatment at
all or simple ovarian induction treatment with tablets and ultrasound
monitoring scans.
The One Stop package alone increases your chance of conceiving due to
the positive effect of flushing the fallopian tubes through during the HyCoSy
procedure, treating abnormal High Vaginal swab results, lifestyle reviews and
use of supplements with abnormal Semen Analysis results, and giving advice on
preconception health and optimal frequency of intercourse.
· The package is
completely safe.
No patients had any adverse reactions or complications arising from any
of the investigations done as part of the One Stop Fertility Diagnosis Package.
No patients required additional review appointments or readmission.
