Mr. Tim Child

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Fertility

  • 1 in 7 couples have problems conceiving 
  • Common causes are ovulation problems, tubal damage, male factor, endometriosis and 'unexplained' 
  • Investigations are based on confirming ovulation (Day 21 progesterone), 'ovarian reserve' (Day 2-5 FSH and LH, also prolactin, TSH and testosterone), tubal patency, and sperm function
  • Tubal patency may be checked with a hysterosalpingogram (HSG) or a laparoscopy and dye. A lap and dye is preferred if endometriosis or pelvic adhesions are suspected
  • Treatments depend on the underlying cause:
    • No ovulation: laparoscopic ovarian diathermy, clomifene or injectable gonadotropins. IVM for women with PCO (see below)
    • Tubal damage: Tubal surgery or IVF
    • Endometriosis: Surgical excision of endometriosis or IVF
    • Male factor: IUI or IVF
    • Unexplained: IUI or IVF
  • I perform a weekly NHS fertility clinic in addition to clinics in the Oxford Fertility Unit and the Manor Hospital
  • I undertake IVF in the Oxford Fertility Unit, based in the new Institute of Reproductive Sciences. Our IVF website details the procedures and costs of treatment http://www.oxfordfertilityunit.com
  • A useful website with a lot of information on fertility and treatments is that of the Human Fertilisation and Embryology Authority http://www.hfea.gov.uk/cps/rde/xchg/hfea
  • The HFEA publish an excellent guide to fertility for patients which can be downloaded at http://www.hfea.gov.uk/docs/Guide2.pdf
  • Fertility problems and treatment can be stressful. Many of my patients have found the patient-support website Fertility Friends of use http://www.fertilityfriends.co.uk/

Polycystic ovary syndrome

  • 5% of women have PCOS
  • PCOS is diagnosed when at least 2 out of the following 3 features are present:
    • Irregular periods at least 6 weeks apart
    • acne, excess body hair, or raised blood testosterone levels
    • ovaries of polycystic shape on ultrasound
  • Investigations include blood tests to look for other cause of the symptoms (FSH, LH, Testosterone, Prolactin, Thyroid function) and an ultrasound scan of the ovaries
  • Treatment depends on the woman's priority as most medications for hirsutism cannot be used if the woman may be pregnant
    • Normalisation of weight should reduce symptoms and is an important first step
    • Fertility
      • Clomifene citrate tablets for 6 months to induce ovulation. Multiple pregnancy rate 10%
      • Metformin tablets. Live birth rate may be lower than clomifene but lower multiple pregnancy rate
      • Gonadotropin FSH injections
      • Laparoscopic ovarian diathermy
      • Intra-uterine insemination with ovulation induction
      • IVF or IVM
    • Hirsutism (excess body hair, acne, or testosterone levels)
      • Oral contraceptive pill
      • Cyproterone acetate (can be combined with the pill in Dianette)
      • Vaniqa for facial excess hair (topical cream)
      • Spironolactone
      • Metformin
  • I am lead clinician for a 'one-stop' PCOS clinic at the John Radcliffe Hospital. The clinic is multidisciplinary and, in addition to gynaecologists, has input from endocrinologists, dieticians, and ultrasound. We are undertaking research projects into the genetics of PCOS.
  • IVM. In-vitro maturation (IVM) of oocytes is an exciting new fertility treatment for women with polycystic ovaries. It should be noted that c.30% of women in fertility clinics have polycystic ovaries on ultrasound even though the majority have regular ovulatory cycles. I spent two years researching IVM in Montreal, Canada. In Oxford we have the UK's only IVM programme, performing 1-2 cycles per week. No ovarian stimulation is used and immature eggs are retrieved from the ovaries under ultrasound guidance. The eggs are then matured in the laboratory, fertilised with ICSI, and 1-2 embryos replaced to the uterus 3-4 days later. There are no risks of OHSS and no need to buy FSH drugs. IVM is available for women <36 years or so who have PCO on ultrasound scan and have <3 failed fresh IVF cycles. Women outside of these groups will do much better with IVF. Our IVM clinical pregnancy rate (heart beat on scan at 6-8 weeks) is around 25-30% per cycle.
  • Many of my patients have found the PCOS-support group Verity to be of use http://www.verity-pcos.org.uk/

Recurrent Miscarriage

  • Recurrent miscarriage occurs when there are three consecutive pregnancy losses before 12 weeks gestation or one loss after 12 weeks
  • 1% of couples experience recurrent miscarriage
  • Around half of cases are due to chance or 'bad-luck' alone. For the remainder there will be an underlying cause though we may not be able to find it
  • Investigations include:
    • Karyotype. This is a chromosome check for both partners. It is abnormal in ~2% of couples. Treatments may include prenatal diagnosis, preimplantation genetic diagnosis (as part of IVF), or egg or sperm donation
    • Pelvic ultrasound scan. If the uterus has a septum dividing it in two then this can be treated surgically
    • Thrombophilia (blood clotting) screen. A proportion of women with recurrent miscarriage have 'sticky' blood that can prevent normal placental development. This can be treated with daily aspirin and injections of heparin during pregnancy
    • Hormone screen. We check for normal function of the ovaries, and thyroid and prolactin levels.
  • I am lead clinician for the 'one-stop' Oxford recurrent miscarriage clinic at the John Radcliffe Hospital
  • A useful patient information brochure can be downloaded from the Royal College of Obstetricians and Gynaecologists http://www.rcog.org.uk/index.asp?PageID=530
  • The patient-support group the Miscarriage Association has been helpful to many of my couples http://www.miscarriageassociation.org.uk/ma2006/index.htm

Reproductive Surgery

Most gynaecological procedures can now be performed via keyhole laparoscopic surgery. Advantages include a quicker time to recovery, smaller abdominal scars, and fewer internal adhesions (scarring). Most women go home the day after laparoscopic surgery.

  • Procedures available include:
    • Myomectomy (removal of fibroids)
      • Fibroids can cause heavy periods, infertility, and pressure symptoms on the bladder/bowel
      • If poking into the uterine cavity fibroids may be removed using an instrument (hysteroscope) passed through the cervix
      • Larger fibroids in the wall of the uterus may be removed laparoscopically via 3-4 small cuts in the abdomen. If the fibroids are >4 in number or >10cm in size then a traditional open operation via a 'bikini-line' cut may be needed
      • Myomectomy carries a low risk of bleeding requiring blood transfusion and rarely, in life saving circumstances, hysterectomy
    • Ovarian cystectomy
      • Ovarian cysts can be of many types. I often find endometriosis cysts in my patients with fertility and/or pain problems. It is better to remove ovarian cysts laparoscopically than via a traditional open operation
    • Tubal surgery
      • Blocked tubes are a common cause of infertility. Often IVF is the best treatment. Sometimes, if the blockage is at the end of the tube with the rest of the tube in good order, the tube can be opened and satisfactory rates of fertility achieved. This is best performed laparoscopically
      • Tubes sterilised. Options are IVF or removing the sterilisation clips and sewing together down a powerful microscope the tube. Reversal of sterilisation is not available on the NHS and requires an open operation
    • Endometriosis
      • Endometriosis is a common cause of pain and/or infertility. It is usually diagnosed at surgery, unfortunately often after a long delay. Laparoscopic excision of endometriosis reduces pain scores and increases the chance of natural conception. Working with my colleagues Mr Enda McVeigh and Professor Phillipe Koninckx (Leuven, Belgium) we have developed Oxford into a National endometriosis centre. We work as part of a multidisciplinary team and so, when necessary, operate with laparoscopic colorectal and urological surgeons.
    • Hysterectomy
      • Hysterectomy's are generally performed for heavy periods, fibroids, or pain. The majority of hysterectomy's can be performed laparoscopically with discharge from hospital the following day. The cervix can either be removed (total hysterectomy) or left behind (sub-total) and the same is true for the ovaries. An alternative to hysterectomy for heavy periods is removal of the lining of the womb (endometrium) via the cervix (TCRE) or inserion of a Mirena coil.
    • Adhesiolysis
      • Adhesions are scar tissue in the abdomen and are a common cause of pain and/or infertility. They are best removed laparoscopically.
 

Oxford Fertility Unit, Institute of Reproductive Sciences
Oxford Business Park North, Oxford OX4 2HW
Phone: 01865 782800
Fax: 01865 782890