Puberty is the name given to the physical and emotional changes which take place in most boys and girls between the ages of 10 and 14. These changes occur so that the body is able to make a baby. This is called reproduction, and can only occur when a boy and girl are sexually mature.
One of the main physical changes of puberty is the growth and development of the sex organs – the parts of the body that are used to have sex and make babies. Sex organs that can be seen on the outside of the body are called ‘genitals’ while those that are inside the body are usually called ‘reproductive organs’.
Between a girl’s legs there are three small holes. At the front is the urethral opening which a girl urinates through, and at the back is the anus which she defecates from. In between these two holes is a third hole, her vaginal opening. From the vaginal opening there is a small passageway or tube, called the vagina, which leads to the reproductive organs inside the body.
When a girl has her period the blood comes out through her vagina. Inside the vagina there is a small piece of thin skin called the hymen. The hymen partly covers the vaginal opening, but there is still enough of a gap for blood to get through. Sometimes the hymen breaks and bleeds slightly when a girl has sex for the first time.
Some other important parts of a girl’s sex organs are:
The clitoris, which is at the front of a girl’s outside sex organs and is about the size of a pea
The outer lips (labia) of a girl’s sex organs
The labia, the clitoris and the vaginal opening are together known as the vulva.
The boy’s sex organs outside his body are his penis and testicles (testes).
A boy’s penis hangs down between his legs at the front of his body. The main parts of a penis are:
The shaft - the main, long part of the penis
The glans - the tip or head of the penis
The foreskin - skin which covers the glans
The foreskin can usually be pulled back quite easily. If it is tight it can be stretched by gently pulling it over the glans. All boys are born with a foreskin, but some have it removed when they are a baby, or later in life. The removal of the foreskin is called circumcision.
Underneath the penis is the scrotum – a loose, wrinkly pouch of skin that hangs down behind a boy’s penis. It contains his testicles. As a boy goes through puberty his testicles move lower down his scrotum. One of the testicles usually hangs lower than the other.
Eggs and Sperm
Inside a girl’s body are two small organs called the ovaries. Contained in these ovaries are hundreds of tiny sex cells called eggs, each no bigger than the head of a pin. At some point during puberty, the ovaries will begin to release these eggs. Usually one egg is released every month. This process is called ovulation.
A boy’s sex cells are called sperm and they are even smaller than a girl’s eggs. At puberty a boy's testicles will start making sperm. Sperm leaves a boy's body through his penis when it is hard and erect. This is known as ejaculation and it happens when a boy reaches the height of sexual excitement and has an orgasm. When a boy ejaculates, millions of tiny sperm are sent from his testes, up through his penis and out through the end. The sperm are contained in a sticky white fluid called semen.
When a boy’s sperm meets with a girl’s egg they usually join together, and a baby will begin to grow.
How do egg and sperm meet? – Sexual intercourse
The most common way that sperm get inside a girl’s body is through sexual intercourse. Sexual intercourse is when a boy puts his hard penis inside a girl's vagina. It is also often called having sex or making love.
Having sex (which usually involves moving the penis in and out of the vagina) is usually very pleasurable for both a boy and a girl, and it will often result in an orgasm for one or both partners. If a boy ejaculates while his penis is inside the girl’s vagina (or if semen gets inside the vagina any other way) then the millions of tiny sperm in the semen will swim up the vagina, through the cervix (the entrance to the uterus) and into the uterus (also known as the womb). From there they will swim into the fallopian tubes. In one of the fallopian tubes the sperm may find an egg that has recently been released by the ovary. The sperm will surround this egg and try to get inside it. Eventually just one sperm cell will succeed, and the egg and sperm will join. This joining is also known as fertilisation or conception.
This joined sperm and egg then travel back down to the uterus, where they will settle in the thick, blood-rich lining and start to grow into a baby. It is at this point that we say a girl is pregnant.
What happens if the sperm and the egg don’t meet? - Periods
On average, the whole menstrual cycle (from the first day of the period to the day before the next) will last 28 days.
Girls generally only release an egg once a month, and it will normally take a few days to travel down the fallopian tube. If the sperm and the egg don't meet during this time, then she won’t become pregnant.
Without a new baby to nourish, the thick lining of the uterus is no longer needed. So, approximately 14 days after a girl’s egg is released, the bloody lining of the uterus will begin to come away, and will flow down through the cervix and out of the vagina. This process is called menstruation, and this is the blood that a girl will notice when she has her period. During puberty, a girl’s first period is a sign that she has released her very first egg, and is now able to have children.
Periods will usually last somewhere between 3 and 10 days. Around 14 days after the start of her last period, a girl will ovulate (release an egg) again, and will once again have the chance to become pregnant. This process of period, then ovulation, then period, is known as the menstrual cycle. On average, the whole menstrual cycle (from the first day of the period to the day before the next) will last 28 days, although variations between 21 and 35 days are quite normal.
More about pregnancy
Though an egg is usually released about the same time each month, this doesn’t mean that a girl can predict exactly when she will (or won’t) become pregnant. This is because girls usually have no way of knowing exactly when they are ovulating. Not only can the day of ovulation vary from girl to girl, it can vary from month to month in an individual girl.
In addition, sperm can survive for several days within the body, so they can ‘hang around’ waiting for an egg to be released if there isn’t one there already.
All this means that if a girl wants to avoid pregnancy but still have sex, she and her partner will need to use contraception. Sexually transmitted diseases, which can be passed on from one person to another during sexual intercourse, are also something that both boys and girls need to consider if they decide to have sex. Condoms are widely used because they help to prevent both pregnancy and sexually transmitted diseases.
Using contraception every time you have sex is very important if you want to avoid pregnancy. It is also important to remember that a girl can become pregnant even if:
It is the first time she has sexual intercourse
She has sex before she has her first period (it could be that she is ovulating for the first time)
She has sex during her period (sperm can stay alive for several days)
A boy withdraws his penis before he ejaculates (pre-come, the fluid that leaks out the penis before a boy ejaculates, can sometimes contain sperm)
She has sex standing up (sperm can swim in any direction – up or down!)
Because periods stop during pregnancy, the first sign that a girl may be pregnant is usually a missing period. If a girl doesn’t start her period at the usual time, it is probably a good idea for her to talk to her doctor or another adult as soon as she can. Periods can come late for other reasons (for example when a girl is stressed, on a very strict diet or has been unwell), but if she has had sex in the past month, then it may be a good idea to take a pregnancy test to be sure.
Sexual feelings during puberty
It isn’t just the body that changes during puberty - our feelings can change too, and like the changes to the sexual organs, these feelings prepare us to have sex and make babies.
What are the main physical signs of sexual feelings?
When boys get sexually excited, the main sign is that they get an erection. The main sign for girls is that their vagina begins to get moist, and their clitoris gets bigger. For both boys and girls when they are sexually excited or "turned on", extra blood comes to the surface of the skin, particularly around the penis and vagina. This can cause areas of the body to feel more sensitive, and some people find they get a warm sensation.
Sexual feelings and masturbation
A person can have sexual feelings any time in their life, but these change around puberty. You might find some sexual feelings just seem to happen to you. But sexual feelings mostly come about from things you choose to do, either on your own or with someone else.
A main way that people express their sexual feelings is by touching their own genitals. Girls can get pleasure from touching their clitoris, and boys from touching their penis, particularly the tip. This is called masturbation. Some people masturbate very often, maybe every day. Some people do it less often, and some don't masturbate at all.
Masturbation is a normal and natural activity and is not bad for you unless you masturbate so much that you make your genital area sore.
When a person is masturbating they become more and more sexually excited. They may then reach a peak of sexual excitement which is called having an orgasm or "coming". This is when all the tension and excitement that has built up is suddenly released. Boys ejaculate when they have an orgasm and their penis will then go limp. Everybody has their own way of masturbating that feels good for them. For many masturbation is their first sexual experience.
There are many myths about masturbation which make some people think it is wrong. However, masturbation is a normal and natural activity and is not bad for you unless you masturbate so much that you make your genital area sore. Masturbation does not damage you health: it cannot cause cancer, give you a sexually transmitted infection, affect your eyesight, or make you go mad. It does not cause hair to grow on your palms or any other part of your body, and it doesn't stunt your growth. If it did, the vast majority of people in the world would be very short and unhealthy!
Sexual feelings in relationships
When people have sexual feelings for each other they will usually want to do sexual things together. There is no set time or order in which to do these things.
People often enjoy kissing, cuddling and holding hands. 'French kissing' is when both people open their mouths when they are kissing and their tongues touch together.
Many people also like to stroke or rub each others bodies, particularly their genital areas. Some people like to touch each other directly, and some prefer to do it through their clothes.
There are a variety of other sexual activities that people will also do including sexual intercourse.
It can seem natural to bring sexual feelings into a relationship. You might want to do something because you feel curious about it. Or because you think it will make you feel good. And you might want to do it because you feel very close to someone.
"It just felt like the right moment…it wasn't great, but it was special, because it was with someone who I loved very much and trusted completely."Clemantine
But it can also change how people feel about each other and about themselves. It's important not to do any of these things because you feel under pressure. And it's important to think about the consequences and how you will feel afterwards.
"I seriously wish I had waited because, even now, our relationship is starting to be completely physical."Jessica
To read more personal stories about sexual experiences, see our First Time page.
Fertility
Over the past twenty years, fertility problems have increased dramatically. At least 25 percent of couples planning a baby will have trouble conceiving, and more and more couples are turning to fertility treatments to help them have a family.
What is the cause? From a medical point of view, infertility is believed to be caused by the following factors, and in these proportions.
Problem Percentage of cases:
If the mathematics don't add up, it's because many couples experience more than one problem when trying to conceive: for example, you may suffer from endometriosis, but your partner may also have a low sperm count.
Interestingly, the most common cause of infertility is 'unexplained', which means that following thorough investigations, doctors can find no specific or identifiable medical problem at the root. But this is where a natural approach can come into play. If a couple fails to become pregnant, there is obviously something causing the problem. It's no good labelling infertility 'unexplained'. The answer is to look deeper - at lifestyle factors, nutritional deficiencies and even emotional elements.
What are your choices?
The natural approach to fertility is and has been enormously successful, largely because fertility is multi-factorial, meaning that there are many, many elements that can be at the root of your fertility problems. A study conducted by the University of Surrey showed that couples with a previous history of infertility who made changes in their lifestyle, diet and took nutritional supplements had an 80 percent success rate Given that the success rate for assisted conception is around 20 percent, it's worth considering these options.
Natural treatment plans are, by their nature, extensive and really do need to be adjusted to suit your individual needs. I will, however, go through the most important points below. Remember that it takes at least three months for immature eggs (oocytes) to mature enough to be released during ovulation. It also takes at least three months for sperm cells to develop, ready to be ejaculated. This means that when you are trying to improve your fertility, you need to have a four-month period before conceiving. This is called 'pre-conception care' and it's as important to take as much care during this period as it is during a pregnancy itself.
If you are going for IVF treatment or another assisted conception procedure, you should follow the recommendations listed below in order to increase the chances that the procedure will work.
One test which is particularly useful for infertility is the Female Hormone Test (saliva). Female Hormone Test (saliva)
A total of eleven saliva samples are collected at home at specific times across one cycle, and sent to the lab for analysis. This simple test will chart the level of the hormones oestrogen and progesterone across the month, to work out a pattern that may reveal:
early ovulation
anovulation (no ovulation)
problems with the phasing of the cycles, such as a short luteal phase (second half of the cycle)
problems with maintaining progesterone levels
This test can be done even if you have irregular cycles.
Diet
Both you and your partner should follow the dietary recommendations explained in the Nutrition Section (The Foundation of Health) Although it goes without saying that a healthy diet is crucial to a successful pregnancy and a healthy baby, many people are unaware of the fact that diet can help to correct hormone imbalances that may affect your ability to conceive. There are also certain foods and drinks that are known to lower fertility.
Alcohol
Alcohol will affect both you and your partner. In fact, drinking any alcohol at all can reduce your fertility by half - and the more you drink, the less likely you are to conceive. One study showed that women who drank less than 5 units of alcohol a week (equal to five glasses of wine) were twice as likely to get pregnant within six-months compared with those who drank more.
Research has also shown that drinking alcohol causes a decrease in sperm count, an increase in abnormal sperm and a lower proportion of motile sperm. Alcohol also inhibits the body's absorption of nutrients such as zinc, which is one of the most important minerals for male fertility.
As difficult as it may seem, you should eliminate alcohol from your diets for at least three months in order to give yourself the best possible chance of conceiving.
Caffeine
There is plenty of evidence to show that caffeine, particularly in the form of coffee, decreases fertility. Drinking as little as one cup of coffee a day can halve your chances of conceiving. On study showed that problems with sperm: sperm count, motility and abnormalities, increase with the number of cups of coffee consumed each day. Once again, it's important to eliminate all caffeine-containing food and drinks for at least three months before trying to conceive. That includes colas, chocolate, black teas and coffee, among other things.
Xenoestrogens
Xenoestrogens are essentially environmental oestrogens, coming from pesticides and the plastic industry. When you are trying to conceive, one of the most important things you need to do is to balance your hormones. It is extremely important to avoid anything that might cause an imbalance, and one of the main culprits is the xenoestrogens. One of the best ways to eliminate an excess intake of xenoestrogens is to buy organic produce for the pre-conceptual period.
Smoking
Smoking has definitely been linked with infertility in women. It can even bring on an early menopause, which is a particularly important consideration for older women who may be trying to beat the clock. Smoking can decrease sperm count in men, making the sperm more sluggish, and it can increase the number of abnormal sperm. With men, the effects on fertility are increased with the number of cigarettes.
Supplements
There is now a great deal of scientific knowledge about the use of nutritional supplements and their beneficial effects on both male and female fertility. As you will see, these supplements can be very effective in re-balancing your hormones, as well as improving you and your partner's overall health, which are so vital for successful conception.
Supplements are necessary because even the best diet in the world will not contain all the nutrients you need to give you the best chance of conceiving.
Folic Acid
It is now known that folic acid can prevent spina bifida in your baby, and it is essential that you get plenty both before and during pregnancy. And that's not all: folic acid is undoubtedly important, but it is just part of the very important B-complex family of vitamins that are necessary to produce the genetic materials DNA and RNA. Together with vitamin B12, folic acid works to ensure that your baby's genetic codes are intact. Remember: it's not enough to take folic acid alone when you are trying to become pregnant. All of the B vitamins are essential during the pre-conceptual period. Research has shown that giving B6 to women who have trouble conceiving increases fertility and vitamin B12 has been found to improve low sperm counts
Zinc
Zinc is the most widely studied nutrient in terms of fertility for both men and women. It is an essential component of genetic material and a zinc deficiency can cause chromosome changes in either you or our partner, leading to reduced fertility and an increased risk of miscarriage. Zinc is necessary for your body to 'attract and hold' (utilise efficiently) the reproductive hormones, oestrogen and progesterone.
And it's equally important for your partner: zinc is found in high concentrations in the sperm. Zinc is needed to make the outer layer and tail of the sperm and is, therefore, essential for the health of your partner's sperm and, subsequently, your baby. Interestingly, several studies have also shown that reducing zinc in a man's diet will also reduce his sperm count.
Selenium
Selenium is an antioxidant that helps to protect your body from highly reactive chemical fragments called free radicals. For this reason, selenium can prevent chromosome breakage, which is known to be a cause of birth defects and miscarriages. Good levels of selenium are also essential to maximise sperm formation. Blood selenium levels have been found to be lower in men with low sperm counts.
Essential Fatty Acids (EFAs)
These essential fats have a profound effect on every system of the body, including the reproductive system and they are crucial for healthy hormone functioning. For men essential fatty acid supplementation is crucial because the semen is rich in prostaglandins which are produced from these fats. Men with poor sperm quality, abnormal sperm, poor motility or low count, have inadequate levels of these beneficial prostaglandins. Vitamin E
Vitamin E is another powerful antioxidant and has been shown to increase fertility when given to both men and women. Men going for IVF treatment with their partners have been given vitamin E, and fertilisation rates have, as a result, increased from 19 to 29 percent. It has been suggested that the antioxidant activity of vitamin E might make the sperm more fertile.
Vitamin C
Vitamin C is also an antioxidant, and studies show that vitamin C enhances sperm quality, protecting sperm and the DNA within it from damage. Some research has indicated that certain types of DNA damage in the sperm can make it difficult to conceive in the first place, or it can cause an increased risk of miscarriage if conception does take place. If DNA is damaged, there may be a chromosomal problem in the baby, should the pregnancy proceed. Whether or not DNA damage does have these effects has not been conclusively proven, but it's worth taking vitamin C and the other antioxidants as a precautionary measure.
Vitamin C also appears to keep the sperm from clumping together, making them more motile.
One study has shown that women taking the drug clomiphene to stimulate ovulation will have a better chance of ovulating if vitamin C is taken alongside the drug. Clomiphene does not always work in every woman, but the chances are often increased when vitamin C is supplemented.
L-Arginine
This is an amino acid found in many foods and the head of the sperm contains an exceptional amount of this nutrient, which is essential for sperm production. Supplementing with L-arginine can help to increase both the sperm count and quality.
Note: People who have herpes attacks (either cold sores or genital herpes) should not supplement with arginine because it stimulates the virus.
L-Carnitine
This amino acid is essential for normal functioning of sperm cells. According to research, it appears that the higher the levels of L-Carnitine in the sperm cells, the better the sperm count and motility.
Vitamin A
This vitamin needs to be mentioned because there is a lot of confusion about its use before and after pregnancy. Many health practitioners now advise that no vitamin A is taken during pregnancy. This advice is incorrect, and it can be dangerous to assume that any vitamin or other nutrient should be avoided during the gestational period. Vitamin A has important antioxidant properties, and the consequences of Vitamin A deficiency during pregnancy can be devastating. For one thing, vitamin A is essential for healthy eyes. Animals studies show that vitamin A deficiency during pregnancy has produced new-born animals with no eyes, eye defects, undescended testes and diaphragmatic hernias.
It is only when the vitamin A is in the form of retinol (in other words, the animal form of vitamin A) that there is a problem. It has been found that retinol can cause birth defects if taken in excess of 10,000iu a day. Beta-carotene, which is one of the vegetable forms of vitamin A, does not carry any risks.
Herbs (see caution below)
Herbal treatment is aimed at restoring hormone imbalances, and encouraging ovulation if it is not occurring. It will also give you the best possible chance of maintaining a pregnancy, should you conceive. Agnus Castus (Vitex or Chaste tree berry)
This is the herb of choice for helping to restore hormone imbalance and increasing fertility. In one study 48 women diagnosed with infertility took agnus castus daily for three months, 7 of them became pregnant during that time and 25 of them regained normal progesterone levels.
Agnus castus is particularly helpful for those women who have a luteal phase defect (shortened second half to the cycle) or those with high prolactin levels, because it stimulates the proper functioning of the pituitary gland which controls the hormones.
Agnus castus works to restore hormonal balance and can be used where there are hormone deficits as well as excesses it:
Regulates periods
Restarts periods which have stopped
Helps with heavy bleeding
Increases the ratio of progesterone to oestrogen by balancing excess oestrogen.
Note:
Don't take any herbs while you are using drug treatments or going through assisted conception (such as IVF), unless prescribed by a qualified practitioner.
Caution
You should not take any of the above herbs if you are taking, The Pill, Fertillity drugs, HRT or any other hormonal treatment or other medication unless they are recommended by a registered, experienced practitioner.
I suggest that you follow this four-month plan and do not try to conceive within that time. Why? Because when you follow the plan, your fertility will begin to increase. Everything needs to be working at optimum level before you conceive, both to prevent a miscarriage, and to give you the best possible chance of having a healthy baby.
Case history Susan and her partner were 30 and 31 respectively, and they'd been trying to have a baby for four years before coming to see me. They had been diagnosed with 'unexplained fertility' and had had four unsuccessful attempts at IUI. Susan had many problems with her periods: she had a regular cycle, but bled heavily with spotting and headaches before her period. At ovulation, her abdomen swelled up and she felt nauseous.
I asked them to arrange screening for infections and the tests came back positive to one infection, which was easily cleared up by antibiotics. Susan was deficient in a number of nutrients, including zinc, selenium, calcium and magnesium, and her partner had low zinc and high aluminium levels. I therefore recommended that he cut out tinned soft drinks (see page 00) and switch to an aluminium-free deodorant. Because I was concerned that the imbalance causing the problems with Susan's cycle could also be a factor in her inability to conceive, I also used a combination of balancing herbs, such as agnus castus, to alleviate Susan's spotting and heavy bleeding. Susan and her partner followed the four-month programme (outlined on page 00) and waited until their mineral levels were back to normal. Nine months from their first appointment day, they conceived, and, not surprisingly, had a baby another nine months later. If you have been trying to conceive for six months
If you are under the age of 35 and have been trying unsuccessfully to conceive for six months, follow the dietary and supplement suggestions given below for four months. At the end of this period, begin trying to conceive again. Give yourself six months before embarking on any fertility treatments or investigation by your doctor or a gynaecologist.
If you have been trying for six months and are over 35, follow the recommendations but visit your doctor and ask for tests to begin during that first four-month period. If you are given a diagnosis of unexplained infertility, then try for six months on your own before going for medical treatment. If you have been trying to conceive for 12 months or more
If you are under the age of 35, follow the suggestions below for four months. Then try on your own for six months before embarking on fertility tests.
If you have been trying for six months and are over 35, follow the recommendations but visit your doctor and ask for tests to begin during that first four-month period. If you are given a diagnosis of unexplained infertility, then try for six months on your own before going for medical treatment.
Tests
There are a number of tests available that are extremely useful and are well worth considering. These tests can give you invaluable insights into understanding what is going on in your body at the moment and can tell you what vitamin and mineral deficiencies and heavy toxic metal excesses you may have. They can let you know what your general condition is and how well your digestive system is functioning and then explain what action you need to take to rectify any imbalances the results may reveal. The analysis of these results lets you know what supplements you need to take in order to bring your body back into balance and into optimum health. This is also designed to help prevent these problems from recurring in the future. Mineral Analysis Test with Supplement and Nutritional Assessment Programme
This test measures the deficiency and excess levels of 7 different minerals and 5 heavy toxic metals that may be present in your body. Online Personalised Supplement Assessment Programme
The analysis of this comprehensive questionnaire will give you a three monthly supplement programme to help balance any vitamin and mineral deficiencies you may have. Female Hormone Test
Several saliva samples are collected over one cycle. When analysed, the levels of your oestrogen and progesterone hormones are mapped for that month to determine whether they are in balance or not.
After three months you would then have a re-test in order to monitor your progress and adjust your supplement programme according to your new condition.
If you need help in obtaining any of the supplements, herbs or tests mentioned above, click, Infertility options at The Natural Health Practice. They can supply all of them for you online or if you prefer to talk to somebody first you can also order by mail order on the telephone. The products supplied by this company are always of the highest quality.
Plan of ActionNutrition
Ensure you are getting the right nutrition:
Follow the dietary recommendations outlined in The Foundation of Health Supplements
The supplement programme below should be taken for at least three months in order to achieve best results.
Your supplement plan
Nutrients
You
Your Partner
Folic acid
400mcg
400mcg
Zinc
30mg
30mg
Selenium
100mcg
100mcg
Fish oil
1000mg
1000mg
Vitamin B6
up to 50mg
up to 50mg
Vitamin B12
up to 50mcg
up to 50mcg
Vitamin E
300-400iu
300-400iu
Vitamin C
1000mg
1000mg
Vitamin A
up to 2300iu
-
Manganese
5mg
5mg
L-arginine
-
300mg
L-carnitine
-
100mg
L-Taurine
-
100mg
To avoid having to purchase single supplements for all of the above, and to make the process easier, I have formulated two supplements that contain all of the most important nutrients for fertility. For more information about these clickFertility Plus for Womenand Fertility Plus for Men
At the end of three months you should reassess your condition and adjust your supplement programme accordingly. Tests
If you need help in obtaining any of the supplements, herbs or tests mentioned above, click, Infertility options at The Natural Health Practice. They can supply all of them for you online or if you prefer to talk to somebody first you can also order by mail order onthe telephone. The products supplied by this company are always of the highest quality.
The section above forms part of a larger complete ebook on Infertility. In the rest of the e-book you will learn what the medical approaches to Infertility are and how to combine them with the natural approach. This is called Integrated Medicine and is the way that healthcare of the future is moving towards. You will also learn what medical tests will give you an accurate diagnosis of your condition and if you really need to have them. The medical treatments for Infertility are then examined which can include looking at either drugs or surgery. Each treatment is then discussed and the pros and cons of the options explained. The Integrated Approach to Infertility is considered in some detail so that if appropriate you can know how to combine the best of both conventional and natural medicine.
So the time has come and you think you `re ready to have sex. Well think again. I use the word think because it represents uncertainty. There is a huge difference between knowing and thinking it`s time to have sexual intercourse. You have to be absolutely sure about losing your virginity. More often than not uncertainty has seen many unwanted pregnancies and, sexually transmitted diseases caught. Readiness can relate to a multitude of things, for example: ready for wedlock or to give birth or, leave home? Some teens think they know it all and for a great deal of them (know it all`s,) we know what thought done. Most of them that did more "thinking" than "knowing" now nurse a baby or treat an STD.
Readiness is a personal matter between you and you only. Knowing when the time feels right for having sex is a personal decision, whether you're in a long standing relationship or having casual sex. Casual sex can be very unhealthy indeed and you need to monitor your frequent romps and bring them down to a level of safety to keep safe. Your sexual partners should be kept to a minimum and condoms used at every convenience. Before finalizing any decision about coupling think about your health and make sure you are content with the situation. It is said "safety in numbers," not what it comes down to sex it`s not.
Having sex is not compulsory, so remember this if you`re being bullied into losing your virginity. Sexual intercourse has to be a joint agreement between both people regardless of gender. Readiness means being aware of the risks involved from having unprotected sex and more importantly, understanding what these risks are and the consequences that derive from them.
Sex isn't just a physical act it`s a mental doing which affects your feelings on the inside. For some people who having sex for the time seem to think it is a physical thing – where the sexual encounter is a quick 2 minute fumble of wham bang wallop and it`s over. Sex is all about loving and caring, not groping. You need to talk to your partner and express what you're feeling before the loving or groping starts - this will bring you both closer together and help you both understand what you expect from each other. If your body is to connect intimately with a person of the opposite sex then the bond of closeness needs to be a true wanting. You need to be aware of each other's expectations, and by doing this you can satisfy your sexual partner in the department they want satisfying in. If you're a virgin then make it a priority to tell your sexual partner this. If you tend on losing your virginity then it is best to lose it to someone you love and trust and not to any Tom Dick or Harry. The number of young girls/boys who regret this moment ever happening is quite high. Losing your virginity should be special; it is a time when you give yourself. Is this not reason enough to give yourself to someone you love, and not to someone whose name you don`t know.
The key to satisfying sex is to be open and honest with your partner.
Girls who believe they are "ready" for having sex still "query" particular issues. From this alone it tells us you`re not ready. Readiness is about knowing all there is to know. If you have last minute questions or doubts then is the time to "re-think" about the uncertainty we spoke of.
1 There is no chance I can get pregnant if the penis is retracted before ejaculation. What cloud are you on luvvy, of course you can so be weary. Sperm can still be present in pre-cum. It only takes one sperm to connect with the egg to fall pregnant. Some men will not always be honest and will ejaculate just to please themselves. In other cases men can forget or not quick enough to withdraw the penis to prevent sperm entering the vagina.
2 I can`t fall pregnant while menstruating. Of course you can. We have more teen mums with babies because they believed this to be true. Pregnancy can occur during a period and especially towards the end of the menstrual cycle. This does not mean for you to have sex in the early days of your period.
3 I know for sure you can`t get pregnant having sex while standing up because I did it once this way and didn't get pregnant. Well lucky you because you can. You may have had what we call a near miss and you should be thanking you're lucky stars. If you have unprotected sex while standing, crouching or even while doing a handstand you can get pregnant.
4 I use condoms which are 100% safe. Sorry but they are not. Although considered an effective form of contraception, they can split. Use condoms in conjunction with other forms of contraception (the pill.) If you`re worried because a condom has split while having sex, you will see your next monthly if you act quickly. Take emergency contraception, the morning after pill. This should be taken within 72 hours of having sex.
5 I take the contraceptive pill and therefore can`t fall pregnant. If you miss a pill popping session it can result in pregnancy. Particular contraceptive pills can take time to work. This can range from 0-14 days. Use contraception methods during this time.
The birth control pill should be taken daily at the same time if possible. If you forget to take your pill at the regular time you normally do, then take it as soon as, nevertheless if there is a time lapse of 12 hours then it is seen as a missed pill (three hours late for the mini-pill, although with the mini pill Cerazette you have a 12-hour window.) If you have been really forgetful and forgotten to take more than one pill then the last missed pill should be taken and the rest of the pill packet taken as normal.
If you have heard that weeing after having sexual intercourse washes out sperm, well it doesn`t. Urine leaves the bladder through the urethra, which lies over the vaginal opening so sperm is not affected by this. If you are ready for having sex then you will know it because there will be no uncertainties to address, however if there is, cancel all plans which include popping your cherry.
Abortion figures in England and Wales in 2007 was made openly public in June 2008 and approved by the UK Statistics authority which can be checked out by you if you would like to know the numbers. Unprotected sex has us look at more and more people infected with gonorrhea. Over the last decade there has been a huge jump in sexually transmitted diseases in the UK. Uncomplicated gonorrhea increased by 42% between 1998 and 2007, while genital Chlamydia increased by 150%. STD (Chlamydia) is primarily the most reported sexually transmitted disease since 2001, spreading genital warts. Bacterial infections have rapidly shot up partly due to a general deterioration in sexual health amongst young people and homosexual men.
What is anejaculation? Anejaculation is the inability to ejaculate semen despite stimulation of the penis by intercourse or masturbation. It is a fairly common problem and can be very distressing to a couple trying for a child.
What causes anejaculation?
Anejaculation may be situational or total. (a) Situational anejaculation - in this condition the man is able to ejaculate in some situations but not in others. Typically, situational anejaculation is stress-induced and occurs selectively in the infertility clinic or at the time of ovulation or egg pick-up during an IVF (In Vitro Fertilization) cycle. Thus, a man who is able to ejaculate at home may be unable to do so in the clinic because he is self conscious and anxious. Similarly, some men become tense when they know they have to give a semen sample and hence usually fail "on demand” even though they are able to ejaculate on other occasions. Another common type of situational anejaculation when a man can ejaculate during intercourse but is unable to collect a sample by masturbation because he is not accustomed to do so. (b) Total anejaculation – in this condition the man is never able to ejaculate semen consciously, either during intercourse or by masturbation, at home or in the clinic. Total anejaculation is further divided into anorgasmic anejaculation and orgasmic anejaculation.
Anorgasmic Anejaculation - these men never reach orgasm in the waking state (either by masturbation or by intercourse), and hence do not ejaculate. However, nocturnal emissions are usually present. There is no physical defect. This failure to reach orgasm is sometimes due to psychological inhibitions. Alternatively, some men need a high amount of stimulation before they reach orgasm and do not get this stimulation during intercourse or masturbation. Orgasmic Anejaculation - these men reach and experience orgasm but they do not ejaculate semen, either because there is failure of emission of semen (due to a block in the tubes or damage to the nerves) or because there is retrograde ejaculation (flow of semen back into the bladder due to weakness of the bladder neck).
How is anejaculation treated ?
Situational anejaculation can often be prevented or treated by simple measures. The semen collection room in an infertility clinic should be in a quiet, discreet location and there should not be a queue of men waiting to use it! If you find the clinic environment is unfavorable discuss it with the doctor and ask if you can bring the semen sample from home (if you stay close by) or from a nearby hotel room.
What to do if you cannot give a semen sample
Sometimes Viagra helps. Viagra by itself does not facilitate ejaculation. However, if you are having difficulty getting an erection, Viagra could help you with that, thus making it easier to masturbate. If you anticipate having difficulty giving a semen sample (based on past experience) on the day of egg pick-up you could request your doctor to collect and freeze your semen beforehand on a day when you are relaxed. In fact, some centres routinely freeze a semen sample from all couples undergoing IVF (In Vitro Fertilization) since unexpected failure to collect semen, due to the stress of IVF (In Vitro Fertilization), is quite common.
If you have difficulty masturbating, but can ejaculate during intercourse, do not be disturbed. Many men are unable to masturbate. Discuss this with your doctor and arrange to collect the semen at home by coitus interruptus. This means having intercourse till the moment when ejaculation is about to happen. Withdraw the penis at that moment and catch the semen in the collection beaker. If that does not work, you can request your doctor for a non-spermicidal non-toxic condom made of silastic. You can buy one from our Online
Store ! This would allow you to have full intercourse and ejaculate into the condom from which the semen is then collected. NOTE: Condoms that are routinely available are coated with a chemical that kills sperm and should not be used for collecting semen.
Finally, some men with situational anejaculation are just not able to collect a sample when required. Discuss this with your doctor beforehand. He will teach you how to use a vibrator to stimulate the penis and collect a sample. A couple of practice sessions should be done before the actual day of collection.
Anorgasmic Anejaculation can be difficult to treat. If there has been a traumatic sexual episode in the past that you are aware of, discuss it with your doctor or ask for a referral to a sexologist or psychologist. If your doctor feels that you are sexually inhibited he may suggest a similar referral.
However, in most cases, counseling is not required. The main treatment for anorgasmic anejaculation is the use of a vibrator. The vibrator acts by providing a strong stimulus, for a long duration, to the penis (use of the vibrator is described below). Due to the stimulation the man reaches an orgasm and ejaculates. Vibrator stimulation results in ejaculation in about 60% of men.
If vibrator therapy fails, electro-ejaculation can be performed. Electro-ejaculation involves the direct electrical stimulation of the nerves to the seminal vesicles and terminal vas. The most commonly used device is the Seager electro-ejaculator which delivers a sine wave, alternating current. The procedure is carried out under general anaesthesia (except in paraplegic men with no sensations). The electrodes are mounted on a cylindrical rod which is lubricated and introduced per rectum with the electrodes facing the prostate gland. The voltage is turned up to 5 volts, held for a second and then turned back to 0 volts. For the next stimulus the voltage is increased to 6 volts. The stimulus is progressively increased till ejaculation occurs. If the antegrade ejaculate is scanty, the bladder is catheterized to check for retrograde ejaculation. Electro-ejaculation will always succeed in men with anorgasmic anejaculation since there is no physical defect. However, electro-ejaculation needs general anesthesia and the semen quality may be inferior. Hence, it is always a second choice to be used only if repeated sessions with the vibrator fail.
Orgasmic Anejaculation Since this condition is due to a physical problem, treatment will depend on the type of problem.
If the nerves are damaged sometimes medicines can help. If medicines do not work, vibrator stimulation or electro-ejaculation will usually be successful in obtaining a sample.
If there is a block due to infection, this can sometimes be cleared by surgery. If surgery fails, or is not possible, then pregnancy can be achieved by aspirating sperm from the epididymis and using these sperm for ICSI (test-tube baby procedure).
Clinical / Corporate / Public Health / HR & Employment Law
Document Number
Policy Author
Cyprian Okoro, Consultant in Public Health Medicine
Approved and Authorised By
Jackie Chin & Ruth Barnes, Joint Director of Public Health
Date Signed
Ratifying Committee
Board
Date Ratified
Review Date
Three yearly, or as indicated by clinical or NICE developments
Document Application
Trust-wide
Related Documents
Distributed To
All GPs, Gynaecologists at local acute Trusts, service managers, assisted conception provider units and PCT intranet.
Data Protection Act 1998
Data Protection issues have been considered with regard to this policy. Adherence to this policy will therefore ensure compliance with the Data Protection Act 1998 and internal Data Protection Policies.
Freedom of Information Act 2000
Freedom of Information issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with the Freedom of Information Act 2000 and internal Freedom of Information Policies.
Health and Safety Act 1974
Health and Safety issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with Health and Safety legislation and internal Health and Safety policies.
Mental Capacity Act 2005
The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. It makes it clear who can take decisions, in which situations, and how they should go about this. It enables people to plan ahead for a time when they may lose capacity. Guidance set out in the Act should be considered when implementing this policy.
Human Rights Act 1998
The Human Rights Act 1998 has been considered with regard to this policy. Proportionality has been identified as the key to Human Rights compliance. This means striking a fair balance between the rights of the individual and those of the rest of the community. There must be a reasonable relationship between the aim to be achieved and the means used.
Race Relations Amendment Act 2000
The Race Relations Amendment Act 2000 has been considered with regards to this policy. Adherence to this policy means that the Trust will eliminate discrimination on the grounds of race and will promote race equality and good race relations.
Diversity Policies
Equality issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with Equal Opportunity legislation and internal Equal Opportunity policies.
1.0INTRODUCTION
1.1 This policy sets out revised criteria for NHS funded treatment for infertility using assisted conception techniques such as in vitro fertilisation (IVF) for Ealing Primary Care Trust’s registered population.
1.2 IVF is now an established treatment option for infertility and the specialty is characterised by rapidly changing, albeit expensive health technologies. Demand for IVF services has also been increasing nationally.
1.3 The NICE 2004 Guideline recommended that eligible couple should have 3 cycles of IVF treatment but only few PCTs have been able to fully implement this. About 20% of PCTs fund 2 cycles of treatment but the Department of Health has recently urged PCTs to increase access to IVF services and to take necessary actions towards the full implementation of the guidelines.
1.4 This policy update is a response to the drivers identified above and the recommendations below are based on the best available evidence. The policy has undergone extensive consultation and the views of service users, lay public, local GPs, specialists, service managers and PCT senior management are all reflected in the recommendations.
1.5 The issue of offering IVF treatment within the 18 week environment was discussed during consultations. With necessary service changes, it is possible to achieve the 18 weeks target in this context. This policy will therefore apply to all patients referred under the 18 week rules.
1.6 The cost of increasing IVF provision from 1 funded cycle to 2 cycles has been analysed and is included in the appendix to this policy document. A policy shift to 2 funded cycles will not necessarily equate to a doubling of the cost of the current service. This is because given the current service outcomes, we can expect a third of couples to achieve a live birth following the first attempt. The cost will be even lower at units with higher success rates.
1.7Patients / Public, Stakeholders & Staff Involved in the Document
We widely consulted on the policy options paper and held a Policy Options Workshop in November 2007. Stakeholders at the workshop included service users, lay public, local GPs, service managers, PCT senior management, gynaecologist from EHT, and assisted conception specialists from HammersmithHospital, Chelsea & WestminsterHospital and UniversityCollege, London.
1.8Review Date
This policy should be reviewed within 3 years or to respond to a specific purpose, such as new guidance etc.
The following sets out the duties and responsibilities of staff with respect to each of the types of procedural documentation developed by the PCT.
2.1Duties within the Organisation
·Jackie Chin, Joint Director of Public Health, is responsible for the implementation of this policy
·Carol Hall, Assistant Director of Commissioning, will be responsible for issues relating to commissioning in this policy.
·Dympna Tansinda, Clinical Risk Manager, is responsible for issues relating to clinical risks and patient satisfaction in this policy.
· Cyprian Okoro, Consultant in Public Health Medicine, is responsible for dealing with the technical aspects and review of this policy.
3.0POLICY PROCESS
3.1Improving access and patient choice in IVF provider units
The PCT will increase access to IVF treatments and encourage patient choice by commissioning IVF and other assisted conception services with 3 London specialist centers namely; The Imperial College Hospitals Trust (formerly Hammersmith Hospitals Trust), Chelsea & Westminster Hospital and the University College Hospital, London, in the first year. Each year we shall evaluate the success rates, in age bands across London providers and offer couples a choice from the three best providers in London (or one of C&W or Imperial, and two best if the local providers are not in the top three).
3.2Definition of a treatment cycle
This policy adopts the Human Fertilisation and Embryology Authority definitions of a ‘cycle’: Under this guidance, a fresh IVF treatment cycle starts when drugs are administered for ovarian stimulation or, if no drugs are used, when an attempt is made to collect eggs. A frozen cycle is one which starts when a cryopreserved embryo is removed from storage in order to be thawed and then transferred.
3.3Number of cycles to be funded
Ealing PCT will fund 2 fresh cycles of IVF with or without ICSI at the designated provider units. One treatment cycle will ideally be followed by the other, but a successful first cycle (in terms of a live birth ) would make the couple ineligible for a second cycle. Similarly a spontaneous conception while on the waiting list will make the couple ineligible for further IVF treatment. Where a woman has previously privately funded one or two cycles the PCT will still fund two cycles, until a maximum of three cycles has been completed, after which the chance of success decreases substantially.
3.4What constitutes assisted conception treatment
The PCT will fund the assisted conception techniques listed below. These techniques are continuously being developed and not every centre is able to offer all the techniques. The list is therefore not exhaustive but they represent the proven and available treatments in current clinical practice.
·In-vitro Fertilisation (IVF)
·Intra-cytoplasmic sperm injection (ICSI)
·Stimulated or unstimulated intra uterine insemination (IUI).
3.5Referral and treatment pathways for infertility
Majority of the investigations for sub-fertility will be undertaken in primary care by the patient’s own GP. The list of investigations in primary care recommended by NICE is given in appendix 1. The PCT will expect GPs to have organised these investigations before referring patients to secondary care.
Smoking and weight loss advice, and relevant vaccination should occur before referral – where age factors indicate that referral is a priority then referral to dietetics and infertility could be instigated at the same time, but normally weight loss towards BMIs with greater chance of success should occur before referral.
Where tests indicate a sub-fertility problem, the GP will refer the patient to the PCT’s acute hospitals for further investigation and any sub-fertility treatment required. The referral will go via CAS (or FP Service) to ensure all necessary tests have been completed and infomation included in the referral. Where no cause has been identified in the initial tests the CAS doctors will refer to Imperial for a hysterosalpingogram. The results will be reviewed by the Primary Care Infertility Service (PCIS) If tubal occlusion is found then the patient should be reviewed and referral to a infertility centre for consideration of laparoscopy and tubal surgery should be initiated at a suitable specialist unit.
Where no cause for infertility has been identified, following HSG, the PCIS will refer to Ealing PCT’s local acute hospitals - for these purposes - Ealing Hospitals Trust, West Middlesex University Hospital Trust, or Queen Charlottes at Imperial..
Sub-fertility treatment at the local acute trust will usually not include assisted conception, although intrauterine insemination (IUI) could be tried for cases of unexplained infertility if the acute hospital is licensed for this treatment. Up to six cycles of IUI can be tried at this setting as part of the pathway before referral to an assisted conception unit. Although NICE recommended unstimulated IUI, the PCT will fund clomid stimulated IUI at licensed centres with facilities for ovarian monitoring where necessary because this improves pregnancy outcomes.
If initial treatments for sub-fertility are unsuccessful, and the patient is considered appropriate for IVF or ICSI, the gynaecologist at the local acute trust must refer/discharge the patient to the PCT’s Primary Care Infertility Service (PCIS) with a summary of all the investigations and treatments. The PCIS will review this information and discuss referral options with the couple. They will provide patients with all necessary information such as success rates at the provider units, including the option of visiting units before making up their mind in order to encourage informed choice. A list of information sources couples might need is provided in the appendix. Including the PCT’s PCIS in this pathway is a sound management strategy that will ensure couples have real informed choice of providers with no adverse impacts on the 18 week rules.
Once a referral has been made to an assisted conception unit, all drug costs will be met by the chosen unit, and the patient’s GP must not be required to prescribe any ovulation induction drugs.
4.0Eligibility criteria
The four principles that underpin the recommendations for eligibility for assisted conception within the provisions of this policy are:
·The welfare of the child
·Evidence in support of improved treatment outcome (higher chances of success)
·Equity of access to services for those meeting the criteria
·Constraints on PCT resources. Section 97(A) and 97(D) of the NHS Act of 1977 makes it statutorily incumbent on the NHS to balance its budget at the end of each financial year.
4.1Referral criteria
All couples or at least the female must be registered with a GP within Ealing PCT boundary and be eligible for NHS treatment. All such patients are eligible for consultation, investigation, advice and treatment in primary and secondary care in line with NICE guidelines (appendix1).
Couples will only be referred for assisted conception if they meet the eligibility criteria below and when all appropriate tests and investigations have been successfully completed in primary and secondary care in line with NICE guidelines.
4.2Compliance criteria
The referring clinician must ensure that patients are aware of the implications of IVF treatment and the commitments required before making a referral for assisted conception. Those where compliance is deemed to be a problem must be referred for counselling in the first instance.
4.3Duration and cause of infertility
Couples who have not conceived after one year of unprotected sexual intercourse will be offered investigations in primary and secondary care as appropriate and referred for AC if they meet other criteria. Investigation after 6 months may be indicated if maternal age is approaching the maternal age referral criterion.
Couples with diagnosed or known cause of infertility that precludes natural conception must not wait before referral for AC. This includes couples who cannot achieve full sexual intercourse due to disability.
Couples in whom one or both partner have been voluntarily sterilised will not be eligible for IVF treatment under this policy.
4.4Social access criteria
Where either of the potential parents has not had had an opportunity to experience parenthood ( defined as a direct role in caring for a child up to the age of 5 years) the couple will be eligible for NHS funded IVF treatment. Couples who have adopted a child together will not be eligible for assisted conception under this policy.
4.5Welfare of the child
Treatment will not be funded in any circumstance where there are known adverse factors that might affect the welfare of the child who might be born, including any child who might be affected by the birth. This will include substance and alcohol misuse.
4.6Age of couple (see Appx 4b)
The PCT will fund IVF treatment for women aged 23-39 years by the time of referral for assisted conception in line with NICE guidelines. No female patient will be placed on the waiting list within 18 weeks of their 40th birthday. There will be no limits on the age of the male partner under this policy.
4.7Life style factors
The woman must have a body mass index (BMI) of between 19 and 30 at the time commencement of treatment. Women who are overweight or underweight will be offered referral to dieticians in order to improve their BMI before referral to AC. Women with a BMI less than 19 and greater than 30 will not be funded.
Women who smoke must be referred to our smoking cessation service to support their efforts in stopping smoking. The PCT will not fund IVF treatment until women have stopped smoking. Referral for smoking cessation will be the responsibility of the GP/hospital consultant and confirmation of compliance with this criterion will be included in the referral letter to the tertiary provider. We recommend that households are encouraged to be smoke free.
4.8Frozen cycles
The PCT will normally only fund fresh IVF cycles because of the higher chances of success. The PCT will fund frozen cycles when it is the only option (such as for patients undergoing chemotherapy or other treatment for cancer).
4.9Gamete & Embryo storage
The PCTs will fund sperm banking for post-pubertal males who have not yet completed their family, and are about to undergo treatment which is likely to result in long-term sub-fertility.
Ovarian stimulation and embryo cryopreservation will be made available to women who are about to undergo treatment likely to cause infertility, provided they are in a stable relationship and wish to pursue this option.
4.10Number of embryo transfers
The PCT will support the transfer of up to 2 embryos during an IVF treatment cycle as an interim measure pending further national guidance from the Human Fertilisation and Embryo Authority (HFEA).
4.11Intra Uterine Insemination (IUI)
Intra Uterine Insemination (IUI) for unexplained infertility is part of the care pathway leading to IVF/ICSI. Therefore previous treatment with IUI will not preclude access to PCT funded IVF treatment. Ealing PCT will fund up to 6 IUI cycles as a treatment option for couples who wish to avoid the invasive procedures associated with IVF. Clomid stimulated IUI cycles will be funded at licensed centres with facilities for ovarian monitoring when indicated. In order to be eligible for IUI, couples must meet the eligibility criteria in this IVF policy.
4.12Egg donation
Ealing PCT will commission IVF using donated eggs from UK clinics licensed by the HFEA (but not from clinics abroad) for women with premature ovarian failure due to an identifiable pathological or iatrogenic cause or in order to avoid the transmission of inherited disorders to a child where the couple meet the relevant eligibility criteria.
4.13HIV and sperm washing
Ealing PCT will commission sperm washing for IUI/IVF/ICSI in couples where the male partner is HIV positive and the female partner is HIV negative.
4.14Surgical sperm retrieval
Surgical sperm retrieval will be commissioned by the PCT in appropriately selected patients, provided that the azoospermia is not the result of a sterilisation procedure.
4.15Preimplantation Genetic Diagnosis (PGD)
This Policy excludes PGD treatment. Although PGD is delivered through assisted conception techniques, patients that require PGD treatment have different clinical circumstances. A clinical group has been formed as a sub group to the Genetics Consortium to consider Individual cases for Pre-implantation Genetic Diagnosis treatment across London. Treatment requests should be sent to Sandra Tribe, Specialist commissioner for genetics at Bexley Care Trust (sandra.tribe@bexley.nhs.uk).
4.16Surrogacy
IVF using a surrogate mother will not be funded by Ealing PCT.
4.17The role of the PCT’s ITP in assisted conception
In rare or exceptional circumstances where a clinician feels that a couple represent a special case and do not meet the criteria set out, an application can be made in writing to the PCT’s Individual Treatment Panel (ITP).
5.0Provider Unit responsibilities
The designated assisted conception provider units must:
·Confirm that any referred patient is registered with an Ealing PCT GP
·Check that the couple meets the eligibility criteria stated in this policy
·Have up to date patient information leaflets including information on treatment outcomes for patients
·Develop their own clinical criteria for success and discuss implications with patients before starting treatment. For example a woman with an FSH level > 12 have a significantly reduced chance of success using her own eggs, and such patients should be counselled on the option of donor eggs in order to maximise their outcomes.
·Check that BMI and smoking status comply with PCT policy, in addition to excluding problem drinking or alcoholic addiction through usual enquiries with the patient’s GP.
·Provide the PCT with timely monitoring and audit data as listed below.
·Ensure all information exchanges with the PCT comply with Caldecott standards for confidentiality and the requirements of the HFEA Act.
5.1Monitoring and audit
The PCT will require assisted conception units to provide six-monthly returns on their activity levels with emphasis on the following:
·The number of couples treated
·Age profile of patients treated
·The conception rate per cycle
·Live birth rate per cycle
·Multiple birth rate per cycle
·Waiting times for routine IVF treatment.
·Numbers of abandoned treatments with reasons for abandonment.
·The number of couples receiving treatment where the cause of infertility has been explained (& the causes identified).
·The number of couples receiving treatment where the cause of infertility has not been explained.
·Number of women undergoing laproscopic salpingectomy prior to IVF treatment in women with hydrosalpinges.
5.2Indicators of service quality for audit purposes
The PCT will use the following national norms as indicators of a good assistance conception service for audit purposes.
·Pregnancy rate around 42% per cycle
·Live birth rate around 35%
·Multiple birth rate less than 25%
·Proportion of abandoned cycles
6Key PCT Contacts
For service related queries, contact Carol Hall, Assistant Director of Commissioning, on 020 3313 9185 or Carol.Hall@ealingpct.nhs.uk
For issues relating to clinical risks and patient satisfaction, contact Dympna Tansinda, Clinical Risk Manager, on 020 3313 9312.
For technical queries, contact Cyprian Okoro, Consultant in Public Health Medicine on 020 3313 9180, and Fax 020 3313 9618 or Cyprian.okoro@nhs.net
7Dissemination and implementation
The Ealing Matters newsletter will be used to create awareness of this policy within primary care and PCT management.
This policy document will be sent to all Ealing GP practices, local acute trusts and the PCT’s designated providers of assisted conception services.
8Policy review date: December 2011
9List of abbreviations
AC Assisted conception
BMI Body Mass Index
CAS Clinical Assessment Service
DI Donor insemination
ET Embryo transfer
GIFT Gamete intrafallopian transfer
HFEA Human Fertilisation and Embryology Authority
ICSI Intracytoplasmic sperm injection
IVF In Vitro Fertilisation
IVM In vitro maturation
IUI Intrauterine insemination (IUI)
NICE National Institute of health and Clinical Excellence
PCIS Primary Care Infertility Service
PCT Primary Care Trust
PGD Pre implantation genetic diagnosis
ZIFT zygote intrafallopian transfer
10Appendices
Appendix 1 Investigations to be done in primary care
1.When to refer
Couples who have not conceived after 1 year of regular unprotected sexual intercourse must be offered further clinical investigation including semen analysis and assessment of ovulation. Where there is a history of predisposing factors, (such as amenorrhoea, oligomenorrhea, pelvic inflammatory disease or undescended testes), or where a women is aged 35 years or over, earlier investigation should be offered.
Where there is a known reason for infertility (such as prior treatment for cancer), early specialist referral should be offered.
2.History
It is essential to obtain good clinical history from both partners to determine presence of obvious cause or associated disease, and plan appropriate investigations and treatment.
3.Body Mass Index
This is the patient's weight in kilograms divided by the square of their height in metres.
BMI = kg / m2
There is a definite correlation between body mass and fertility. Body mass for optimum fertility is 19 - 25. Ability to conceive decreases and miscarriage rate rises if BMI is over 27. Patients with a BMI >27 should be strongly advised to lose weight prior to treatment. BMI >30 may exclude them from investigations or treatment, as the risks associated with ovulation induction and pregnancy increase with BMI.
4.Rubella status
Rubella status of all female patients should be checked. Any woman without rubella immunity should be offered vaccination. ? Hep B screening (otherwise needs doing in secondary care)
5.Chlamydia screening
Before undergoing uterine instrumentation women must be offered screening for Chlamydia trachomatis by the GP, family planning service or at a secondary care provider. ? Also ensure Cervical Smear within 3 years ?
6.Female ovulation
Regular cycle:
Women under 39 years of age, with a regular menstrual cycle of 26 - 32 days duration, have a 90% chance of ovulating.
The only blood test to ensure ovulation is occurring would be a mid-luteal phase progesterone level, which must be performed 7 days before the onset of the period. eg. Day 21 for a 28 day cycle.
Irregular cycle:
If the patient has an irregular cycle, then mid-follicular gonadotrophin levels, LH/FSH must be performed between days 2-7 of an average cycle. Prolactin levels must also be performed for these patients. Only one prolactin level needs to be done by the General Practitioner, if it is markedly raised it will be repeated by the secondary care provider. If elevated referral to endocrinology rather than infertility is indicated. Discussion may need to occur with the chosen specialist unit where there is only mild elevation.and maternal age indicates a need to progress infertility treatment – high levels would however preclude IVF until treated.
7.Semen Analysis
Semen analysis will be performed by the General Practitioner.
8.Hysterosalpingogram as organised by the Primary Care Infertility Service. The digital images should be made available to the treating clinicians.
9.Recording of Laparoscopic Findings undertaken in secondary care
Where extensive investigations e.g. laparoscopy have been conducted prior to a GP making a referral for assessment and treatment of sub-fertility / infertility then the findings of previous investigations must be shared with the provider of secondary or tertiary care. In the case of laparoscopic findings:
Either:
Video
This is the preferred option whereby laparoscopic findings are recorded on a video at the time of the procedure and the video forwarded to the tertiary centre.
Or
Film/ electronic recording
Good quality images of laparoscopic findings are recorded on film or electronically and forwarded to the tertiary centre.
Or
Comprehensive diagram
Of the findings with particular attention to each portion of the tube, starting from the cornua, isthmic, ampullary isthmic junction and ampulla and fimbria.
It must also be noted whether there are any peritubular adhesions, however filmy, on any portion of the tube and whether there is any delay or problems injecting the dye.
Any endometriosis must be clearly marked on the diagram and if there are any other abnormalities, these must be marked. The upper abdomen must also be examined for signs of previous infection.
10.Tubal surgery
Laparoscopic findings may indicate the need for tubal surgery. This is to be done at the tertiary provider unit if considered appropriate by the clinician there. There may be occasions when the tertiary centre will consider tubal surgery appropriate on examination of the findings and on these rare occasions, the patient will receive the micro-surgery at the tertiary centre.
11.Urgent referrals
Urgent referrals such as requests for embryo freezing prior to chemotherapy treatment must be sent to Carol Hall on Telephone 020 3313 9185 or email Carol.Hall@ealingpct.nhs.uk giving clinical details and contact telephone numbers for the patient.
Appendix 2 Information resources for patients and PCIS
1Provider unit web sites and service/business manager contact details
3Up to date information on birth rate per cycle for each provider unit – usually available from ACU provider and HFEA websites
4Patient information leaflets from provider units
5PCT smoking cessation service contact number – 0845 111 0155
6Information on local weight management and physical activity programmes
Appendix 3 Analysis of the cost of implementing a 2-cycle IVF policy
Useful planning information
Number of new referrals we can expect per year ~ 100
Trends in demand increasing
Cost (at 2006/2007 prices with current provider) £3,010 per cycle (IVF & ICSI)
Success rate (live birth rate for all ages)
with current provider 31%
SCENERIO 1: Continue with funding for 1 Fresh Cycle of IVF & ICSI
100 cycles will cost (100 x £3010) = ~ £300,000
About 31 of these cycles will lead to a live birth.
Cost of 31 IVF live births = ~ £ 300,000
Approximate cost per live birth = £9,709.7
SCENERIO 2 Increase funding to 2 cycles of Fresh IVF & ICSI
Using the information on success rate as above, after the first cycle, 31 out of 100 women will have a baby, leaving 69 women who will need a second cycle. A second cycle of treatment in these 69 women will result a further 21 live births, leaving 48 women who would have completed 2 cycles of treatment but no live birth.
Therefore, cost of funding 2 cycles for 100 couples = (169 cycles x £3010) = £508, 690
The 2 cycles of IVF in 100 women will lead to 52 live births
Cost per live birth if 2 cycles = £9,782.5
What is the marginal benefit of shifting to 2 cycles per couple?
21 extra live births at the cost of extra £208, 690 per year
Appendix 4 Other cost considerations
4a The Opportunity Costs of funding 2 IVF cycles
Procedure/intervention
Cost (£)/annum
Comments
2 cycles of IVF/ICSI at £3,010/cycle for 100 couples per year).
508, 000
Will involve expansion of service to reflect growing need/demand, address waiting time issues and a shift towards full implementation of NICE guidelines.
1 cycle of IVF & ICSI for about 100 couples per year
300, 000
Maintains recent increase in funding to clear waiting list. But will not signal any shift towards full implementation of NICE guidelines and waiting list is likely to remain at least 1 year.
Orthopaedics
Fund bilateral hip replacement operations for extra 78 people at £6, 500/case
505,000
78 additional elderly people will benefit and have improved quality of life.
Neonatal care
837 extra SCBU (special care baby unit) places at EHT at £603 per case
706 extra NICU (neonatal intensive care unit places at WMUH at £715 per case
253 extra ITU places at GOSH at £2000/case
505, 000
Increase in neonatal costs could result from an expansion in IVF provision but the awaited national (HFEA) guidance on number of embryos to be transferred during IVF treatment could mitigate against this.
Adult Intensive care services
505 extra adult ITU places at EHT at £1000/case
428 extra cardiac ITU places at Imperial Hospitals NHS trust at £1,179/case.
505, 000
Primary prevention of cardiovascular disease
About 55,000 adults aged > 35 years could be screened for risk factors for cardiovascular disease.
500,000
Cardiovascular diseases are responsible for a third of all deaths in the population.
Appendix 4b
Women should be informed that the chance of a live birth following in vitro fertilisation treatment varies with female age and that the optimal female age range for in vitro fertilisation treatment is 23–39 years. Chances of a live birth per treatment cycle are: (NICE clinical guideline 2004,pg 85)
It is a judgment of cost benefit and outcomes where in this graph a maternal age criterion is chosen. Success begins declining at 32 years.
At 40 years there is over 90% failure rate, at 37 the success rates are 50% higher than at 40 (i.e 15% success).
Current Guidelines from NICE recommend treatment before the age of 40. .
Appendix 4c Effect of maternal age on cost per live birth: IVF births cost more with increasing maternal age.
