Case History

Case #1 26 y/o P0010, previous SAB in 2 years’

trying BMI 18.2, healthy habits, no comorbid

conditions Usual cycles 40-45 days Husband good health No STDs or GYN surgeries Normal exam

Case #1 Previous evaluations

– Normal FSH and LH– Low progesterone level on “day 21”– Normal semen analysis and HSG

Previous treatments– 6 cycles of clomid, hCG injections,

AIHS, luteal PG Resulted in one pregnancy with SAB

– IVF was recommended as next step

Case #1 Recommended:

– CrM NaPro Tracking– optimal timing of intercourse– Vitamin B6 to enhance mucus

production– Timed hormonal evaluation, based on

charting– Fasting serum insulin and glucose– Follicular ultrasound series

Case #1

Results – NaPro Tracking- limited mucus pattern– Good timing of intercourse– Severe PG and E2 deficiency in luteal

phase– Fasting serum insulin- normal– Follicular ultrasound series- slightly

small follicle prior to rupture, no PCO on US

Case #1

Recommended – Support of luteal phase with postpeak

hCG injections, 2000 Units IM on peak +3, 5, 7, 9

– Continue vitamin B6– Continue fertility-focused intercourse– Reassess after 2 cycles of hCG

support

Case #1

Results – On second cycle of postpeak hCG

injections, she conceived– At 5 weeks EGA, she felt like she was going

to miscarry. The progesterone level was very low. Human-identical progesterone was given IM twice a week and tapered as her levels returned to normal.

– She delivered a healthy baby girl at 39.5 wks EGA

Comments

NPT cohort pregnancy rates (crude and lifetable) similar to IVF cohort studies.– Crude rates underestimate success;

lifetable rates overestimate NPT takes more time than IVF, but is

far less costly, and has much lower rates of prematurity and neonatal morbidity.

Comments

With confirmatory studies, NPT should become a mainstream approach to infertility.– NPT does require additional training.

International multi-practice studies are in planning.

Case Presentations

Dr. Phil BoyleMICGP MRCGP CNFPMC

1. 40 year old Female – implantation?

2. Failed fertilisation with IVF – Egg Quality?

3. FSH Above 20 IU/L4. 100% Antisperm Antibodies5. Very Low Sperm Count

1. 40 year old Female –implantation?

Dx: Unexplained infertility for 5 years Hx: Gravida 1 para 0 Misc 1 3 Failed IVF – 3 embryos replaced each

time

Problem with Implantation?

40 year old Female – implantation? NPT Dx: Corpus Luteum insufficiency Conceived 3rd Cycle HCG Healthy Girl born, 9lb 5 oz. Mum aged 40yrs

Tried again age 42yrs. Conceived 12th Cycle HCG Healthy Boy, 8lb 6 oz. Mum aged 43yrs

2. Failed fertilisation with IVF – Egg Quality?

Dx: Moderately severe Endometriosis Trying to conceive for 5 years

Female Age 40 Yrs. Hx: Gravida 1 para 0 Misc 1 1 Failed IVF – 3 eggs, None fertilised Had successful adoption

Egg Problem?

Failed fertilisation with IVF – Egg Quality?

NPT Dx: Poor Follicular Fx / LTD Mucus Rx: Clomiphene, B6, Carbocisteine,

Amoxicillin Conceived 10th Cycle NPT Healthy baby girl 6lb 8 oz Full term.

Mum aged 41 at delivery.

3. FSH Above 20 IU/L

Dx: Secondary infertility for 5 years, Hx: Gravida 2 para 1 Misc 1, Female

Age 40 Yrs.

1Failed IVF – No follicular development FSH – 23 IU/L

Problem – Perimenopause

FSH Above 20 IU/L

Rx: Clomiphene 50mg x 5 days, B6.

Long Irregular cycles Conceived Day 50 of second Rx cycle Healthy Boy 5lb 13 oz at 38 weeks

Never Menstruated again!

4. 100% Antisperm Antibodies

Dx: Infertility for 8 years, Female Age 37 100%Antisperm Antibodies Hx: Gravida 0 para 0 Misc 0,

2 Failed ICSI – 3 embryos each time

Problem – Male Factor

100% Antisperm Antibodies NPT Additional Dx: Low Prog. And Low E2 Conceived 12th Cycle NPT, (5th Cycle Male

Prednisolone Rx) Healthy Girl born, 8lb 1 oz. Mum aged 39yrs

Spontaneously conceived again age 39yrs, but miscarried.

Spontaneously conceived 3rd time age 40yrs, again miscarried.

How significant were the antibodies?

5. Very Low Sperm Count Dx: Infertility for 5 years, Female Age 34yrs

Count 50,000 per ml10,000 per ml

200,000 per ml 4,000,000 per ml 800,000 per ml

Hx: Gravida 1 para 0 Misc 1, (ICSI Pregnancy) 3 Failed ICSI, 2 – 3 embryos each time

Problem – Male Factor

Very Low Sperm Count NPT Additional Female Dx: Low Prog. And Low E2 Conceived 8th Cycle NPT, 8th Cycle Male Tamoxifen, L carnitine, Pycnogenol

Volume 4 mls Count4 Million/ ml Motility 45% Morphology 4% Normal

Healthy Girl born, 8lb 8 oz. June 2004 Mum aged 35yrs Progesterone support during pregnancy until 28 wks Very important to treat the female…often combined

problem

IVF - UK. Declining success with increased ageIVF - UK. Declining success with increased age