NICE guidance CG156 fertility treatment

Question 1

What is the first line treatment for women with Group 1 ovulatory disorders?

Answer 1

Lifestyle advice – weight gain if BMI <19, moderate exercise if excessive
Rule out and treat other causes e.g. prolactinoma

Question 2

What fertility treatment is offered to women with Group 1 ovulatory disorders?

Answer 2

Pulsatile GNRH

Or, gonadotrophins with LH e.g. a daily injection of human menopausal gonadotrophin

Question 3

What is HMG and How are women receiving HMG monitored?

Answer 3

Human menopausal gonadotrophin is extracted from postmenopausal women’s urine and has an FSH:LH ratio of 1:1. It given to women with group 1 ovulatory disorders for ovulation induction by daily injection and is monitored with serial ultrasound assessment of the ovaries every 3-7 days to ensure 1 or at most 2 egg-containing follicles are developing

Question 4

What is the lifestyle advice management for women with Group 2 ovulatory disorders?

Answer 4

Weight loss if BMI 30 or greater because a) may restore ovulation b) better response to ovulation induction 3) better pregnancy outcomes

Question 5

What is the first line treatment for women with Group 2 ovulatory disorders?

Answer 5

Clomifene or metformin or both

Question 6

What kind of drug is clomifene?

Answer 6

An anti-oestrogen which provides negative feedback to the hypothalamus thereby increasing gonadotrophin release for ovulation induction in group 2 ovulatory disorders

Question 7

What are the risks associated with clomifene?

Answer 7

Risk of OHSS

Risk of multiple pregnancy (6%)

Question 8

How should patients using clomifene for ovulation induction be monitored?

Answer 8

Serial ultrasound in first cycle of use

Question 9

How many cycles can clomifene be used for?

Answer 9

Maximum 6 cycles

Question 10

What are the second line treatments for group 2 ovulatory disorders?

Answer 10

Add metformin to clomifene treatment if not already trialed
Laparoscopic ovarian drilling
Ovulation induction with gonadotrophins e.g. FSH

Question 11

What is the recommendation for patients with group 2 ovulatory disorders and gnrh agonists?

Answer 11

GNRH agonists should be avoided in women taking gonadotrophins for ovulatory induction with group 2 ovulatory disorder as it does not increase pregnancy rates and it does increase the risk of OHSS

Question 12

What is the risk of ovulation induction with gonadotrophins?

Answer 12

Risk of OHSS

Risk of multiple pregnancy

Question 13

What is the recommended treatment for women with a hydrosalpinx identified before receiving IVF?

Answer 13

Laparoscopic salpingectomy is recommended to improve pregnancy rates with IVF

Question 14

What is the recommended fertility treatment for women with unexplained subfertility?

Answer 14

Refer for in vitro fertilisation if unsuccessful in conceiving after 2 years of regular unprotected sexual intercourse

Question 15

15) What is the third line treatment for women with group 2 ovulatory disorders?

Answer 15

IVF

Question 16

What are the steps of IVF?

Answer 16

1) Down regulation to avoid LH surges and premature ovulation
2) Ovarian stimulation
3) Triggering ovulation
4) Oocyte and sperm retrieval
5) In vitro fertilisation
6) Embryo transfer
7) Luteal phase support

Question 17

How are patients downregulated before ovarian stimulation for IVF?

Answer 17

Long protocol involves 2-3 weeks of a GNRH agonist, with oestradiol and TVUSS monitoring to see that the ovaries are in a quiescent state before commencing gonadotrophin ovarian stimulation e.g. for women in with group 1 ovulatory disorders or unexplained subfertility

Short protocol is appropriate for patients at risk of OHSS e.g. PCOS and involves starting gonadotrophins and then administering a GNRH antagonist

Question 18

Which patients are appropriate for GNRH agonist down regulation for IVF?

Answer 18

Only patients at low risk of OHSS and a long protocol should be used

Question 19

What is the max dose of FSH that can be used for ovarian stimulation in IVF protocols?

Answer 19

450iu/l

Question 20

What is used to trigger ovulation in IVF?

Answer 20

Urinary or recombinant HCG

Question 21

What is letrozole and what is its role in fertility treatment?

Answer 21

Letrozole is aromatase inhibitor licenced for treatment in breast cancer treatment only. However, fertility specialists use it as an alternative to clomiphene if a patient is either resistant to clomiphene or produce too many follicles with clomiphene. It has been shown to have lower multiple pregnancy rates and does not cause endometrial thinning seen with clomiphene

Question 22

How thick does the endometrium need to be for embryo transfer?

Answer 22

> 5mm

Question 23

How many embryos are recommended for transfer in women under 37 years old?

Answer 23

Cycle 1 – single embryo transfer

Cycle 2 – single transfer if >/= 1 top quality embryo available, max 2 can be transferred

Cycle 3 – max 2 embryos transferred

Question 24

How many embryos are recommended for transfer in women 37-39 years old?

Answer 24

Cycles 1 & 2 - single embryo transfer if >/= 1 top quality embryo available, max 2 can be transferred

Cycle 3 – max 2 embryos transferred

Question 25

How many embryos are recommended for transfer in women 40 –42 years old?

Answer 25

Cycle 1 – consider double embryo transfer

Only 1 full cycle permitted on NHS

Question 26

What should be offered for luteal phase support?

Answer 26

Progesterone up to 8 weeks gestation

HCG is not routinely recommended due to risk of OHSS

Question 27

Who is ICSI recommended for?

Answer 27

Severe deficits in sperm quality
Obstructive and non obstructive azoospermia
Failed or very poor fertilisation during previous IVF cycle

Question 28

What is the fertility treatment offered to women with group 3 ovulatory disorders?

Answer 28

Oocyte donation