CW Journal March 2015 (Chelsea and Westminster Hospital Private Care)

the Journal

A premier service for private patients First Edition, March 2015

The ultimate IVF check list Optimising Caesarean Section recovery for patients Differential diagnosis for Chronic Pelvic Pain

Chelsea and Westminster Hospital

Welcome from Amanda Grantham

General Manager Private Patient Services

UPCOMING EVENTS

Welcome to the first edition of CW: the Journal, a quarterly publication where we share the latest research and developments about private patients services here at Chelsea and Westminster Hospital.

Everything you need to know about fertility and gynaecology GP education session, on Tuesday 24 March 2015 Full details available on pg 29

In each edition of CW: The Journal we will have a series of in-depth features on our private healthcare services within the hospital. With this being our inception edition of CW: The Journal, we have dedicated this edition to Conception and Womens Health.

Being located in one of the most modern teaching hospitals in the UK means that our private patients benefit from the peace of mind of having the clinical back up of a leading NHS teaching hospital while having the comfort and services of a private hospital.

I welcome your feedback on this publication, as well as extend an invite to attend upcoming education events or arrange a tour of our facilities.

Amanda Grantham, Private Patient Services General Manager Tel: 0203 315 8411 Email: amanda.grantham@chelwest.nhs.uk

Obesity Management: Fighting an epidemic - diet, psycology and latest surgical development. Hosted by Mr Evangelos Efthimiou.

Tuesday 28 April 2015 Trust Open Day. Tours of Private and Chelsea Children Hospital available on request.

Saturday 9 May 2015 Paediatric Surgery Education Session for GPs hosted by Professor Amyula Saxena European Head of Paediatric Surgery, Wednesday 20 May 2015 Medicinema Opening Summer 2015 For more information and to reserve your space at any of these upcoming events, contact justine.currie@chelwest.nhs.uk

Cover image courtesy by Boggio Studio.

Contents

A special bond with Chelsea and Westminster: Patient Casestudy Our 20 year journey helping couples to conceive Behind the scenes with Miss Paula Almeida, Consultant Embryologist Under the microscope: Mr Dimitrios Nikolaou, Specialist in Reproductive Medicine Headlines from the cutting edge of IVF research Does additional Lutenising Hormone activity improve outcome in poor responders IVF funding explained The ultimate checklist for parents starting assisted conception Assisted Conception Guide: Best treatment for your patient London’s most luxurious maternity suite now open for business Call the midwives! Private midwifery gains in popularity In the media Breaking News: Heard about PGD and three-parents embryos?

A cut above the rest: Optimising recover for caesarean section patients Borne: Saving lives Breastfeeding masterclass: What to do when it doesn’t go to plan The Newborn Baby ‘First Day’ Check Warts and all: The HPV Vaccination Think outside the uterus! Differential diagnosis of Chronic Pelvic Pain Who’s who: Chelsea and Westminster’s Consultant Obstetricians CW Private Patient Service Directory

5 6 8 10 12 14 15 16 17 20 21 22 23 24 26 27 28 28 30 32 34

A special bond with Chelsea and Westminster Mr Nikolaou was true to his word, and Claire’s assisted conception treatment was successful and finding out she was pregnant in December 2011 was

“the best Christmas present possible”.

Claire and Baby son conceived via IVF

Claire Peveraro-Morris recently celebrated her son’s second birthday and is undergoing her second round of In-Vitro Fertilisation (IVF) treatment in Chelsea and Westminster Hospital’s Assisted Conception Unit (ACU).

Her remarkable story began in February 2009, when she was rushed to Chelsea and Westminster’s Emergency Department (ED) and a suspected burst appendix turned out to be a burst ovarian cyst.

Claire was seen in ED by Mr Dimitrios Nikolaou who carried out the emergency surgery and had to break the news that it would not be possible for Claire to conceive naturally.

In Claire’s words:

“Learning that I couldn’t conceive a baby naturally was devastating at first, however the treatment I had from Mr Nikolaou was fantastic, and although he explained that it would not be possible to conceive naturally, he said that all was not lost and that motherhood was still a potential option through assisted conception.”

Her positive experience first time around was a key reason in Claire deciding to return to Chelsea and Westminster Hospital for further IVF treatment in the hope of conceiving a second child, despite now living in the Scottish Borders.

This latest course of treatment has involved a successful blastocyst transfer

by Mr Nikolaou, where two of the best quality blastocysts (embryos incubated in our on-site lab for up to six days after fertilisation) were selected and implanted into Claire’s uterus, after the initial successful fertilisation of six eggs.

In two weeks’ time, Claire will be tested to determine whether the transfer has resulted in pregnancy.

“I suppose it’s a bit superstitious” Claire adds, “but having been through such a successful round of treatment the first time, I really felt I had to return to Chelsea and Westminster Hospital. One of the things I like most about the ACU at Chelsea and Westminster is the peace of mind that comes from the unit being part of a working hospital, rather than a standalone private clinic –

but the main reason we can’t recommend Chelsea and Westminster enough is that we got a positive outcome first time around - our healthy baby - and that is everything.”

Editor’s note: We were delighted to hear from Claire with a further update: “You’ll be pleased to know that I am currently almost 12 weeks pregnant so my superstitions and faith in Mr Nikolaou paid off a second time!” We wish Claire a very healthy and happy pregnancy.

5

Our 20 year journey helping couples to conceive As the Assisted Conception Unit (ACU) service at Chelsea and Westminster approaches its 20th birthday, the team remains as passionate about offering bespoke patient care and the best possible clinical outcomes.

The Assisted Conception Unit provides a 6 day a week service, for treatment and investigation and is co-located with our private outpatient and inpatient wards on the 4th floor of Chelsea and Westminster Hospital. Since we understand that time is of the essence for couples seeking fertility treatment, new patients will usually been seen within a week of referral.

The lead consultants providing the assisted conception service are: • Mr Dimitrios Nikolaou – Specialist in reproductive medicine with a subspecialty interest in ovarian aging and the management of infertility in couples with blood borne viral infections, such as HIV and Hepatitis.

Emma and James Pearce with baby Oscar.

• Mr Julian Norman-Taylor – Specialist in reproductive medicine with a subspecialty in the management of fibroids during fertility and pregnancy.

• Mr Jonathan Ramsay – Consultant Urologist • Ms Paula Almeida – Person Responsible and Consultant Embryologist with a PhD in cytogenetic studies in human eggs and embryos

In summary • The unit treats NHS and private patients, thus offering the best of both worlds: Private medicine standards of service but also the science-based approach and high ethical standards of an excellent NHS and University-affiliated unit.

• The size and structure of the unit allows a truly individualised and personal approach, as the 2 consultants personally perform all procedures, make all decisions and supervise each step of each treatment.

• The unit has close links to Imperial College School of Medicine, as the clinical lead and the laboratory director are both senior lecturers, ensuring continuous update of practice on the basis of new scientific developments.

• We’re a sub-specialty training centre for Reproductive Medicine 6

and this means that all protocols are updated on the basis of best clinical practice.

• The unit has a quality management system to ensure safety of procedures (double-witnessing of all steps, validation of all procedures and equipment , risk management procedures).

• The unit has an active multi-disciplinary discussion forum, where a significant number of cases are brought for discussion so that patients with complex problems can be managed better.

• Its association with the NHS and its position within a tertiary hospital means the Unit can manage complex cases and get patients admitted if necessary. We offer the whole spectrum of treatments in the IVF laboratory, but also surgical treatment as necessary.

In assisted conception services, the success rates are self-evident:

IVF Success rates in London: Combined NHS and Private Clinics vs NHS Clinics Clinical Pregnancy Rate 2013 Q4 <35 years.

HFEA published data for fresh IVF/ICSI cycles

47.7%

Chelsea and Westminster Hospital

45.5% UCH

43.2%

Hammersmith

36.7%

30.2%

Bart’s

Guy’s

32.3% King’s

22.7%

Homerton

36.1% National Average

Clinical Pregnancy Rate (CPR) (%) Comparison of NHS assisted conception centre.

In 2012-2013, 118 babies were conceived from 349 couples looking to get pregnant

Our current pregnancy rate in 2013 in women under the age of 35 is 47% (compared to a National average of 36%);

40.3% couples (in all age groups) conceived on their 1st IVF cycle

For Blastocyst or Day 5 transfer pregnancy rates the pregnancy rate is 61.5%

95% of couples who have undertaken fertility treatment at the ACU would recommend our service to other couples

Waiting times to be seen privately are less than 7 days Clinic treatment and outcome data from Q4 2013 (as per HFEA website November 2014)

Per cycle started

Chelsea and Westminster Hospital (0158) Below 35 yrs

35 - 37 yrs

38 - 39 yrs

40 - 42 yrs

43 - 44 yrs

Over 44 yrs

Unknown age

47.1% (73/155)

36.8% (50/136)

28.2% (22/78)

17.8% (13/73)

++ (0/16)

++ (0/7)

**

What a patient had to say about our ACU service: ‘When my husband and I first visited the ACU..., I felt defeated in our battle to start a family and burdened by an overpowering sense of failure. Following our first appointment with Mr Jonathan Ramsay, I left the Unit with a feeling of safety and enormous relief. For the first time in our lengthy infertility journey, my husband and I felt cared for, reassured and most importantly in safe hands.

From that initial first discussion to my successful ICSI treatment, the experience of being in the care of the ACU has continuously

confounded my expectations. Where I expected to feel powerless and afraid, I unfailingly felt cared for, understood and supported.

This was not only the result of the exceptional levels of expertise of the team at the ACU, but also the merit of their extraordinary humanity, compassion and good humour. Thanks to each and every one of them, our infertility treatment was not the psychological and physical ordeal that it might have otherwise been.’ Healthy baby girl delivered in 2014 7

Behind the scenes with Paula Almeida, Consultant Embryologist The successful management of embryos is at the heart of any assisted conception service Consultant Embryologist, Dr Paula Almeida, plays a key role in ensuring Chelsea and Westminster offers clinically exceptional services to all our patients.

In Paula’s own words: “In the UK, there are currently less than a dozen scientific consultants running IVF laboratories, the majority of which are in the NHS. Having a consultant embryologist as an integral part of our Assisted Conception Service provides NHS and Private

patients with a level of assurance that a highly qualified and experienced scientist is making decisions about what happens to their gametes and embryos. Following rigorous assessment on three main areas: laboratory management, research and clinical skills, I attained Consultant Embryologist status in 2005.”

The ACU laboratories at Chelsea and Westminster are purpose built and crucially sit within the Assisted Conception Unit alongside our ACU clinical treatment facilities. The laboratory is run by 5 embryologists. Aside from clinical, financial and management responsibilities, a typical day for a Consultant Embryologist may appear routine, but each patient’s interaction carries its own unique challenge.

A day in the life of Paula Almeida: 8.30am: Arrive at the ACU following the school run and head into the lab team meeting to discuss clinical cases for the day.

Each case is discussed and a plan agreed as to the best laboratory procedure needed to maximise chances of a positive outcome for fertilisation. This could be through performing In Vitro Fertilisation (IVF) or IntraCytoplasmic Sperm Injection (ICSI) in cases of male infertility or previous poor fertilisation outcome. During case discussions we also evaluate any additional procedures the patient may benefit from, for example Blastocyst, Day 5 embryo transfer or the use of Embryoglue.

9.30am: Into the lab to perform fertilisation checks from previous day egg collection, and check embryo quality. I then phone patients to let them know the outcome and implications, and we plan when patient should come to the ACU for embryo placement.

8

10.00am: I head into the treatment room to commence egg collection procedures for the patients we have booked for the day .

11.00am: Prepare semen samples for In Vitro Fertilisation (IVF), IntraCytoplasmic Sperm Injection (ICSI) or Intrauterine Insemination (IUI).

12.00am: Discuss the next steps with patients post egg collection to confirm treatment type and obtaining appropriate consent for any supplementary procedures that may improve outcome.

1.00pm: Perform an embryo transfer procedure in our clinical treatment facility.

This procedure involves selecting the best embryo(s) for transfer and discussing with the patient about the quality and number of embryos to be transferred and the fate of surplus embryos. Depending on the quality of surplus embryos, there is the option for these to be cryopreserved for future use.

2.00pm: Thaw embryos for transfer by slow thaw or warming techniques.

3.00pm: Perform insemination in cases of In Vitro Fertilisation (IVF), or IntraCytoplasmic Sperm Injection (ICSI).

This is where cells surrounding the eggs are removed artificially, and then the eggs are injected with normal sperm.

4.00pm: Freeze surplus good quality embryos either by slow freezing or vitrification techniques.

6.00pm: Set up and prepare culture dishes for treatment the following day.

Debrief lab team and check all laboratory equipment is OK. During the evenings and out of hours, we have an on-call rota among the lab staff so that should any equipment fail, we will attend on site and check what needs to be done to avoid any risk to stored gametes and embryos.

Direct fertilisation - injecting an ovum.

Retrieving a sperm sample.

Centrifuging samples.

Counting sperm.

Sterile environment processing.

9

Under the microscope: Mr Dimitrios Nikolaou Mr Dimitrios Nikolaou is a member of the Royal College of Obstetricians and Gynaecologists’ working group developing guidelines for best clinical practice and research and co-editor of the book ‘Reproductive Aging’. Mr Nikolaou is the director of the sub-specialty training program in Reproductive medicine and surgery at Chelsea and Westminster Hospital.

We caught up with Mr Nikolaou to find out how research is informing clinical practice at Chelsea and Westminster’s Assisted Conception Unit.

Q: Assisted Conception is a fast moving field of clinical practice; can you give us insight into how research is informing care for patients at the Assisted Conception Unit at Chelsea and Westminster?

Our research programme is dedicated to optimising assisted conception treatment protocols to ensure the best possible success rates for patients. Three areas of research we are currently focusing on include: 1 The role of Lutenising Hormone on embryo quality.

With the exception of certain cases of endometriosis, we have adopted the ‘Antagonist Protocol’ to help increase embryo quality. The Antagonist Protocol basically enhances a women’s normal cycle by saving eggs that would otherwise be wasted and has few side effects for the patient compared to the traditional ‘Long Protocol’ which suppresses a women’s natural cycle and builds an artificial cycle.

2 The effect of fibroids on the way ovaries responds

to ovarian stimulation and whether fibroids are hormonally active. We see a number of patients with fibroids and one of the great advantages for patients being seen at Chelsea and Westminster Hospital is that the team have joint clinical expertise in reproductive surgery and assisted conception medicine so we are uniquely placed to ensure that patients receive the best possible combined fibroid and fertility management.

For this reason we are an accredited clinical training centre for reproductive medicine.

3 Adoption of new technologies where the evidence

base is promising. We are not interested in burdening patients with extra tests or costs where the benefit to the patient is not discernible. For example while we have adopted endometrial scratch and embryoglue, we have not been treating patients with immunotherapy or similar for ‘Natural Killer Cells’ as the evidence is not supportive.

10

Q: What is involved for couples choosing assisted conception?

The consultant will meet the couple to review their background and create a map of the issues involved in their case. They will then develop a treatment plan and explain it to them. Unless there is a reason to do something different, we normally go for protocols which build on a patient’s natural cycle (the antagonist protocols) rather than protocols that suppress the menstrual cycle. This way the patient has few or no side-effects and the treatment is short. After seeing the consultant, the couple will meet a specialist nurse who will explain the treatment. There is usually a period of up to 2 weeks when the woman has to have subcutaneous injections of a daily basis to make eggs grow. This is followed by a quick procedure to collect eggs under sedation and an even more simple procedure to transfer embryos inside the uterus a few days later.

Q: Embryo quality is clearly a pivotal part of assisted conception, can you explain the benefits of using frozen embryos versus fresh embryos?

Cryotechnology is now so sophisticated that the survival rates for frozen embryos is very good. The benefits of freezing embryos in some cases is that it allows an embryo to be implanted into a fresh ovulation cycle. This is desirable as it protects the women from ovarian hyperstimulation syndrome and crucially the endometrium develops better outside the stimulation cycle allowing the embryo to implant under the best possible environment.

Q: What specialist services do you offer?

We offer the whole spectrum of fertility treatments form the most simple to the most complex, including, for example, ICSI and IMSI. In addition, our consultants offer the whole range of surgical procedures and operations that can be necessary in cases of infertility, such as surgery for endometriosis, fibroids, laparoscopic surgery, tubal surgery, ovarian cysts etc. We deal with all cases of infertility. Additionally, we are a reference centre for infertility in older women, and have separate facilities and expertise that enable us to treat patients with hepatitis B, C and HIV. Q: What attracted you to work in the field of reproductive medicine and assisted conception?

When I was at Medical School, the IVF revolution was kicking off and Lord Robert Winston was my hero! I actually started my career in assisted conception working in his unit at Hammersmith Hospital. Throughout my career I am continually inspired by patients’ joy at overcoming their fertility challenges.

I am attracted to philosophy and especially to the philosophy of happiness, and fertility is so crucially linked to this concept, as well as life itself. I think that, ultimately, what we do should aim to optimise people’s enjoyment of life and, at the same time, achieving a positive mind-set increases our chances of being successful with our treatments.

Q: One in seven couples are affected by infertility according to Sir Andrew Dillon, Chief Executive of NICE. What advice would you give to GPs who have patients facing infertility challenges?

First I would recommend GPs assess patients as soon as they express a concern regarding fertility. In many cases there is an underlying reason relating to family history or previous medical history.

GPs are crucial in providing information and support to patients to optimise their health and wellbeing prior to commencing IVF and there are a number of preliminary investigations that GPs can initiate including: • Rubella immunity • Luteal Phase progesterone • Follicular Phase FSH. LH, oestradiol • Transvaginal Ultrasound of the pelvis • Semen Analysis Please see our best treatment guide on page 14 for details on the investigations we recommend to GPs. Q: What is the best piece of advice you can give couples who are finding it difficult to conceive?

Find a doctor who is properly qualified and you can trust. Work with him to understand the causes of the problem. Make a plan and have faith and trust.

Q: Finally, I hear you are about to publish on ‘what makes a good IVF clinic’, can you give us an exclusive?

This is an area of research I am passionate about and excitingly over the last twelve months we’ve been putting the research into practice here at the ACU at Chelsea and Westminster.

There are two key features to a great IVF clinic, first is to concentrate the senior clinical expertise on the elements in the process that matter the most for patient outcomes. For this reason our senior consultants undertake the IVF procedures and guide patients in their decision-making about their care.

Secondly, the patient’s preparation prior to IVF is crucial – most notably hormone and weight management and identifying issues such as uterine polyps or a septum in the uterus. This is where the team’s dual expertise in reproductive medicine and reproductive surgery becomes invaluable.

Mr Nikolaou is a recognised authority in the areas of infertility in the late 30s and 40s as well as in the assessment of the ovarian reserve and management of early onset infertility in younger women. He lectures internationally and leads an active research team.

To refer a patient to the Assisted Conception Unit, please contact 0203 733 0003 or email acu@chelwest.nhs.uk

Headlines from the cutting edge of IVF research • A study, presented at the annual meeting of the British Fertility Society, looked at the potential benefit of adding additional Luteinizing hormone activity to the ovarian stimulation regime for women who are poor responders to gonadotrophins. There was no statistical difference in the two groups that we compared and, if anything, the group who did not receive additional LH did better. This is in-keeping with our current clinical strategy which is to use recombinant FSH only for most cases, which is also in agreement with most of the recent publications. More details can be found on the next page.

• At the next annual conference of the European society for Human Reproduction and Embryology we will presenting our findings at reviewing the appropriate cut-off point for proceeding to egg collection versus cancelling the cycle in women with extremely poor response to ovarian simulation.

It includes long-term data for the current and next IVF cycles and the overall prognosis of women who cancelled the cycle and started again versus the women who carried on with very few follicles. The findings inform our current clinical strategy and the way we advise patients about their prognosis. We found that our previous cut off for cancelling cycles was too low, as women with only one follicle did not get pregnant in the current or future cycles.

• In a retrospective 12 month study examining the costeffectiveness of our current approach to managing women over the age of 40 who present with infertility. The findings, submitted to the European Society of Human Reproduction and Embryology, highlighted that although the various treatments using a woman’s own eggs were reasonably cost-effective up to the age of 42, for women aged over 42 the only effective and cost-effective intervention was egg donation rather than surgery or IVF using their own eggs.

• Audit findings, in conjunction with background literature checks have informed our current clinical strategy as follows:

✓

Effectiveness of endrometrial scratch for improving implantation

Works

Effectiveness and risks of using embryoglue

(jury still out)

Using cabergoline to reduce the impact of ovarian hyperstimulation syndrome in women at risk

Works

Using GNRH analogues rather than recombinant HCG for triggering the final oocyte maturation prior to egg-collection

✓ ✓

Works

Image courtesy by Boggio Studio.

11

Does additional Lutenising Hormone activity improve the outcome in poor responders?

Dr Mohar Goswami and Mr Dimitrios Nikolaou

Poor ovarian response is a clinical challenge and clinicians have been striving to overcome poor response and cycle cancellation, by innovating various treatment strategies.

There is some suggestion in the literature that use of hMG instead of rFSH, or supplementation of LH to the stimulation protocol is associated with better response and higher live birth rate in poor responders (1-2).

This claim is also fraught with conflicting evidence, as others did not find any significant difference with the use of hMG or rFSH, in the poor responders (3-4).

The aim of this study was to evaluate any difference in clinical outcome with the use hMG (Menopur) or rFSH (Gonal-F) in poor responders in our unit. Poor response was taken as the yield of <4 oocytes, with the use of at least 3000 U of FSH (5).

Methods

It is a retrospective study where all the IVF/ICSI cycles in the two years period from January 2012 to December 2013, were analysed, and the poor responder cycles identified from the electronic database. The confounding variables potentially impacting the clinical outcome including age, cause of infertility, AMH level were noted.

The types of intervention during the IVF/ICSI cycles 12

were noted; including the type of ovarian stimulation protocol used (down regulation/ flare / antagonist), type of gonadotropin used, total dose and duration of stimulation, type of ovulation trigger used, semen quality, IVF/ ICSI procedure, any difficulty during embryo transfer, number of embryos transferred, type of luteal phase support.

The cycles were analysed in 2 groups, depending on the use of Gonal F (group 1) or Menopur (group 2), and the confounding factors were compared, in order to ascribe any difference in clinical outcome, related to the use of rFSH or hMG. The primary outcomes analysed were CPR (clinical pregnancy rates) and LBR (Live Birth Rates), and the secondary outcomes analysed were number of mature pre-ovulatory follicles (=/> 17mm), highest E2 level, number of oocytes retrieved, fertilisation and failed fertilisation rates, endometrial thickness achieved, implantation rates, miscarriage rates and frozen embryo rates. Analysis was performed using SPSS 21 (IBM software).Comparison of continuous variables was made by using Independent sample T test. Pearsonâ&#x20AC;&#x2122;s chi squared test was used in case of nominal variables.

Results

9% cycles in this period were deemed to have poor ovarian response. In 52 cycles, Gonal F(group1), and in 25, Menopur (group2) were used. There were no significant differences in the variables between the 2 groups. 42.3% cycles in group1 were antagonist using Cetrorelix, 40.3% were long down regulation, and 17.3% were short “flare” protocols. This was not statistically different (p=0.16) to that in group 2, where 84% were antagonist cycles, and the rest long down regulation. There were no significant differences in

the dose of FSH, duration of stimulation, number of mature follicles, endometrial thickness, and oocyte retrieval rate/follicle between the groups. Both groups used human chorionic gonadotropin as ovulation trigger and progesterone suppositories for luteal support. There were no significant differences in IR (19.5 versus 11.1, p=0.7), CPR/ET (14.6 versus 11.1, p=1), LBR/ET (14.6 versus 0, p=016) and failed fertilisation rates (21.2 versus 28, p=0.57) between the 2 groups.

Gonal F (group 1)

Menopur (group 2)

p

Mean age

39.3(S.D.4.43)

38.7(S.D. 3.82)

0.6

Median AMH

2.9 (S.D 4.66)

2 (S.D 1.36)

0.29

Median dose of FSH units

4,500 (S.D 1277.9)

4500(S.D1498.7)

0.9

Median duration of stimulation days

12 (S.D 2.96)

12 (S.D 3.69)

0.9

ICSI %

42.3

52

0.47

Median no. of mature follicles (=/>17mm)

2 (S.D 1.53)

3 (S.D 1.45)

0.38

Endometrial thickness mm

10 (S.D 2.47)

10.5 (S.D 2.04)

0.36

Median no. of mature oocytes

2 (S.D 0.74)

2 (S.D 0.71)

0.74

Mature oocyte retrieval rate/follicle %

100

66.6

0.7

Fertilisation rate %

100

66.6

0.7

No. of embryos transferred

1(S.D 0.85)

1 (S.D 0.89)

0.9

IR%

19.5

11.1

0.7

CPR/ET%

14.6

11.1

1

LBR/ET%

14.6

0

0.16

Failed/abnormal fertilisation rate%

21.2

28

0.57

Embryo freezing rate%

2.44

5.55

0.5

Conclusion

Thus in this study, the two groups of women with poor response were similar with comparable AMH levels, identical demographic features including similar age groups , sub-fertility factors and no previous live births. Both the groups had IVF/ ICSI treatments with GnRHa down regulation protocol, flare protocol or antagonist protocol, using rFSH or hMG. All the confounding factors and interventions being comparable, there were no significant differences in the IR,CPR, LBR, as well as in the mature follicle and oocyte numbers, embryo freezing rates, endometrial thickness and maximum serum E2 achieved, or in the dose and duration of FSH stimulation required.

100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

Pregnant

Nonpregnant

Gonal F, Grpoup 1 Menoput, Grpoup 2

References: 1.De Placido et al. 2005.Recombinant human LH supplementation versus rFSH step-up protocol during controlled ovarian stimulation in normogonadotrophic women with initial inadequate ovarian response to rFSH. Hum Reprod. 20,390 – 396. 2.Ferraretti, A.P. et al, 2004.

Exogenous luteinizing hormone in controlled ovarian hyperstimulation for assisted reproduction techniques. Fertil Steril. 82, 1521 – 1526.

3.Barrenetxea , G. et al,2008. Ovarian response and pregnancy outcome in poor responder women: a randomized controlled trial on the effect of

luteinizing hormone supplementation on in vitro fertilization cycles. Fertil Steril. 89, 546 – 553. 4.Fan, W., 2013. Recombinant Luteinizing Hormone supplementation in poor responders undergoing IVF: a systematic review and meta-analysis. Gynecol Endocrinol.29 (4), 278–284. 5.Kailasam, C. et al, 2004. Defining poor ovarian response during IVF cycles, in women aged <40 years, and its relationship with treatment outcome. Hum Reprod. 19(7), 1544-1547. Epub 2004 May 13.

13

IVF funding explained The desired outcome for all patients seeking fertility treatment is a positive pregnancy.

The Assisted Conception Unit at Chelsea and Westminster Hospital has the highest pregnancy rate for any NHS unit in the UK, and amongst the best for all units nationally*. (*HFEA data)

Criteria for eligibility for NHS funding for IVF treatment varies among local CCGs: North West London CCGs NHS Funding

Wandsworth CCG NHS Funding

Privately Funded Assisted Conception Treatment

• • • • • • • • •

• The female partner will be between the age of 23 and 42½ at the referral date.

• Neither partner has a living child (including an adopted child) • The couple have not had 3 or more previous self-funded IVF cycles or any previous NHS funded cycle • Sub-fertility is not the result of a sterilisation procedure in either partner.

• Both partners will have been nonsmokers for at least 6 months • There is no evidence of low ovarian reserve.

• There has been a discussion of the additional implications of IVF appropriate to their age.

Privately we are happy to see everyone but we will only recommend fertility treatment for those who have a evidenced-based chance of success at assisted conception.

Age 23-40 No previous children either partner IVF indicated Welfare of the Child Reasonable chance of success Non-smoker > 6months BMI <30 No exceptions Eligible for one fresh cycle and one frozen cycle

For patients who are not eligible for NHS funding, we would be happy for them to contact us directly on 0203 733 0003 to make a private consultation.

Images courtesy by Boggio Studio.

14

The ultimate checklist for parents starting assisted conception Julian Norman-Taylor, specialist in reproductive medicine with a subspecialty in the management of fibroids during fertility and pregnancy is frequently asked for tips from parents-to-be starting conception treatment.

d checklist:

ende Here’s his recomm

y as possible.

health ✓ Both partners shouteldlygenot as d caffeine ☐ smoking, alcohol an This means absolu oderation. and excercise in m

. d for both partners de en m m co re is T MO ☐ A general health g tobacco/ particularly smokin s or ct fa le ty es lif a/torsion ew Revi n, varicosities, traum io at ic ed m y, er rg su lance. marijuana, ion or hormone imba ct fe in le ib ss po y an (men) lla and taking is immune to rube e -b to rhe ot m e ☐ Ensure th mins folic acids and vita

✓

✓

✓

stress. e or any ☐ Actively reduce n, yoga, acupunctur tio ita ed m h ug ro This can be th promote relaxation. help other method that time every day can nw do ’s ur ho an t Allowing at leas hormones. reduce your stress

✓

t d, ☐ Normalise weigh with a well-balance 28 d an 20 n ee tw A BMI be et is optimal. freshly-prepared di

✓ ☐ Social Situation d do they have an ng time together an – couple spendi active sex life?

Remember that your patient might conceive spontaneously, or through treatment, but either way they will then be facing 40 weeks of pregnancy with huge stresses on their body, so its beneficial to ensure they are as healthy as possible to start with.

15

First line fertility treatment options

Preliminary Investigations

Assisted Conception: Best treatment for your patient

Antimullerian hormone or Day 2-5 FSH, LH and Estradiol

To assess the ovarian reserve

Semen analysis

To assess the semen

(concentration mobility,

quality

morphology, anti-sperm

HycoSy or Hysterosalpingogram

To assess the anatomy of the reproductive organs

Day 21 progesterone

To confirm ovulation

Rubella IgG Ovulation Induction

To assess rubella immunity

antibodies)

LIfestyle modifications

Intrauterine Insemination (IUI)

If the only problem is anovulation

Laparocopy and treatment or other surgery

In anovolatory, unexplained or mild male infertility

Hormonal treatment with Clomid or

Second line fertility treatment options

abnormalities thought to be caused by lifestyle factors or drugs

Tamoxifen

If there is a treatable pelvic pathology

In certain cases of reduced sperm concentration or hormonal defencies

IVF: For tubal damage, severe endometriosis, prolonged unexplained infertility, older age, poor ovarian reserve ICSI: For Poor sperm ot low fertilization rate with normal IVF Egg donation*: For premature ovarian failure or older age >43, 44yo Sperm donation*: For very severe male infertility, ehrn there is no sperm or extremely poor sperm, or for single women or same sax female couples

How to Refer:

> You can refer patients to the Assisted Conception Unit at Chelsea and Westminster Hospital by calling 0203 733 0003 or by emailing: acu@chelwest.nhs.uk > Mr Dimitrios Nikolaou and Mr Julian Norman-Taylor, Consultant Gynaecologists and Specialists in Reproductive Medicine accept NHS and Private Patients.

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If there are sperm

> Waiting Times: Private patients will be seen within a week of referral. > Please note: that Egg donation and Sperm donation is available for selffunding patients only. These treatment are not covered by private insurance.

Londonâ&#x20AC;&#x2122;s most luxurious maternity suite now open for business

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The Kensington Wing is the second largest private maternity hospital in the UK. In addition to the private consultation rooms for antenatal appointments, a medical day assessment unit, three labour rooms, a water birthing suite, nursery and 14 postnatal ensuite bedrooms, we have raised the bar in delivering the ultimate in luxurious birthing experiences in the UK with our new Maternity Suite.

walls and B&B Italia furniture throughout to provide the ultimate luxury birthing experience.

This new luxurious Kensington Wing Suite is designed with the whole family in mind. Designed by David Bentheim, the Kensington Wing suite comprises of a spacious lobby, reception area and en-suite bedroom and no attention to detail has been spared from the marble detailed ensuite to the wood panelled

To refer patients to the Kensington Wing: contact 0203 733 0003 or kensington@chelwest.nhs.uk

The Kensington Wing is co-located with dedicated obstetric operating theatres, a Level 3 Neonatal Intensive Care Unit (NICU) and on-site adult Intensive Care Unit (ICU), and is recognised as one of the safest places to have a baby in London.

For more information please visit our website www.chelwest.nhs.uk/private-care/private-maternity-unit 19

Call the Midwives: Private midwifery gains in popularity Chelsea and Westminster Hospital offers private midwifery led care. We caught up with Lucy Wickham, Matron for the Kensington Wing, to find out why patients are choosing private midwifery led care.

Kensington Wing Midwives. Aimee Thurlow, Lucy Wickham (Matron) and Lucy Coe.

National Institute for Health and Care Excellence (NICE) announced in December 2014 that midwife-led care during labour is safest for women with straightforward pregnancies which has seen a rise in women choosing to have private midwifery led care births.

The Kensington Wing believes in patient choice and offers patients either Consultant led or Midwifery led care, with approximately 100 women a year choosing to deliver under the 20

team of private Midwives at Chelsea and Westminster Hospital.

The private midwifery team comprises of six highly experienced midwives who collectively book women into the Kensington Wing so we are able to guarantee women a highly personalised experience with easy access to a midwife.

Our dedicated midwifery team are primarily concerned with ensuring that each woman in our care has the best possible

experience throughout their pregnancy while achieving exceptional clinical outcomes. The team specialises in natural births with low-risk woman both on first and subsequent deliveries, achieving a 70% normal birth rate.

A midwife is always available to support women and the team get to know each patient over their course of 11 antenatal appointments. We also offer women and their partners the opportunity to attend our Waterbirth workshops and antenatal classes.

Patients are also sharing the news of our facilities:

Inclusion Criteria for MLC Kensington Wing Singleton pregnancy with cephalic presentation.

BMI ≤35 at booking.

Maternal age ≤40 years.

Women with known GBS and an otherwise normal course of events are not excluded from MLC; intrapartum antibiotics will be offered in established labour and can be administered as a Midwife exemptions.

• Normally situated placenta.

• Maternal observations within normal parameters.

• • • •

Exclusion Criteria for MLC Kensington Wing I’m at CW and the care is fantastic. The Kensington Wing is a lovely, relaxing ward. I would suggest having a visit to see what you think.

Full discussion thread of Chelsea and Westminster vs St Thomas’ for private maternity care available www.nappyvalleynet.com

• • • • • • • •

Previous C-section.

Gestational Diabetic.

Post-Partum Haemorrhage.

Multiparity ≥5.

Previous LSCS or uterine surgery.

Hb of less than 9g/dL. Platelet count less than 100 x10*9/L. Women who have had a previous PPH over 500ml, or over 750ml if bleeding was from a perineal tear and no uterotonics were required.

• Previous 3/4th degree tears.

• Previous cervical surgery.

• Previous Preterm delivery.

The Private Midwifery team includes: Ali Clarke, Lucy Wickham, Lucy Coe, Lucy Warner and Petra Nhau The team specialises in natural births for low-risk women and will also take on women with hyperthyroidism (so long as they are cleared by the consultant as safe for a natural birth). They are experienced and happy to work with doulas if patients have organised for a doula to assist them.

Lucy Wickham I have been a midwife since 1992. I began my career in Kings College Hospital as a community midwife within a home birth team. This experience has helped me become the midwife that I am today, and developed my passion for providing low-risk midwifery care. I appreciate the importance of continuity of care in providing a positive birth experience, and this is what my team and I endeavour to achieve.

Alison Clarke As a midwife I believe pregnancy, labour and birth is an experience that you will never forget. I aim to make this experience memorable for you and your family. Whether this means waterbirth, using complementary therapies or hypnobirthing, I am here to help facilitate your birthing choices. There is nothing more satisfying that supporting couples through pregnancy and birth and helping them welcome their new baby into the family.

Lucy Coe Throughout my career I have always been passionate in supporting normal birth and providing holistic, individualised care to women and their families. I believe that continuity of care and a trusting relationship with your midwife can enhance your experience of pregnancy and birth. I am skilled in waterbirth and complementary therapies, and love nothing more than creating a calm, relaxed environment in which to support women during your labour.

Coming soon: Monthly open evenings for patients to meet the team and visit the Private Maternity Wing including the world class midwiferyled unit.

For more information about our Private Maternity open evenings or to refer patients to Private Maternity, please contact the maternity patient liaison officers on 0203 733 0003.

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e, especially if you have a Caesarean and ra nights in hospital. So if you can afford a rmal’ birth but any more might stretch you, nk carefully and bear in mind that insurance ually only covers an emergency Caesarean. eigh up what you can afford and if it’s a ueeze, look into an NHS facility – we truly have some of the best care in the world.

It’s part of Imperial College Healthcare NHS Trust, a leading teaching hospital with an international reputation for

for any dietary need such as vegetarian and halal. There’s also a supervised nursery – should you need some sleep.

In the media The Portland

Theatre and you have the choice of one-toone consultant or midwife-led care during labour, plus there’s a range of antenatal and postnatal care.

Natasha Crystal was born at The Portland and twinsChelsea there in 2013.

“I’veWestminster always Baby London (formerly Little Darlings)had rates and as heard Mum talk about the wonderful ORGET ABOUT Its ethos is to put women in charge of onetheir of the best inwithin London for private maternity experience she had.care: When my gynaecologist own pregnancy a supportive HE PRICE TAGS suggested she deliver my babies there, I said environment.

There's team of experienced at does a private birth cost ‘yes’ immediately.

I couldn’t have had a more midwives, consultant obstetricians and London? As you’d expect rivate maternity care options says: “A positive birth experience.” anaesthetists and a dedicated Emergency one of the world's most ate clinic should be CQC (Care Quality pensive capitals, it doesn’t mmission) registered and the obstetrician me cheap – but what you do t be registered with the General Medical clinical in obstetric and neonatal Chelseaexcellence and Westminster Hospital’s staff, t for your money is worth it. at St Mary’s uncil, have undergone annual appraisals medicine.

“Whatif sets the Lindo Wing and equipment, it needs to. A full range STETRICIAN £3,500-£8,000 Hospital in completed the Continuing Professional apart,” says a spokesperson, “is the discreet, of blood tests and scans are offered as well at the Chelsea and Paddington has seen ANS, BLOOD TESTS £500 Westminster Hospital as an antenatal, birth and postnatal package. velopment (CPD) programme of the Royal traditional, individualised service provided.” the of many seesbirths more than DITIONAL BLOOD TESTS UP TO £2,000 Facilities are contemporary and luxurious illustrious babies, lege of Obstetricians and Gynaecologists All women receive continuous care andand 5,000 babies being including of course does not believe that eggconsultant freezing proactive about having a child but lack compare with finding oneself “involuntarily the team encourages mums istoand choose their delivered every year.

COG).

Private also be advice from their midwives SPITAL FEE midwives (normal should delivery) beneficial for those in their late thirties or eitherGeorge. the right partner or life situation. childless” – as an estimated one in threePrince birthing position (birth balls, beanbags, floor ,600and TOyou £5,900 ured should about the safety havemainly access tobecause a team the of maternal and early and forties, But does it work? And why are large womenask aged 40 can testify.

Little wonder, mats, birthing stools and pools are available) The Kensington Wing offers midwife-led deterioration the quality The of their eggs numbers consultant-led of medical professionals – and, then, UP that TO many will go to extraordinaryIt provides ord of the hospital.” foetalinspecialists. comfortable rooms care and DITIONAL SCANS £1,000 unlikely. the Royal Collegepregnancies of Obstetricians physical, emotional and financial lengths careindeed, and pain relief options. They also encourage for straightforward and makes fertilisation udget should also be considered.

If you’re have en-suite bathrooms, and postnatal can deliver babies whose births are DWIFE-LED CARE To understand why the numbers are so and Gynaecologists (RCOG) – urging to try(excluding to safeguard their fertility. And an useonly of complementary therapies. birth and can on the expertise of the low, youthe need know a little human caution overcall women in their late thirties industry has grown to help them do it.

The only fully private maternity unit in the UK, The Portland delivers around 2,000 babies each year.

little darlings pick 3 of the best

The Lindo Wing Kensington Wing

pregnant

pause

older mother, £8,550 or have pre-existing medical rooms have a reclining chair for your partner. straightforward or those needing more care. nsultant) biology. Fertility declines with age. taking advantage of this procedure?

The so-called “egg-freezing parties” blems, this will held pushbyupUS-based the cost of your services are provided and can cater They “Egg can also look after twins – or more! WomenHotel are at their most fertile in their freezing is being sold like an fertility preservation yearssuch of age, insurance says Dimitrios company (motto: “Smart women It’s , especially if you have Eggbanxx a Caesarean and dietary35need as vegetarian and part ofpolicy,” Imperial CollegeNikolaou, Healthcaretwenties.forAtanyaround fertility begins to decline very quickly. a consultant in reproductive medicine and freeze”) in upmarket hotels and clubs in adarlings nights in hospital.

So if you can afford a halal.

There’s also a supervised nursery – NHS Trust, a leading teaching hospital www.littledarlingsmagazine.com “To give you an idea, at a good fertility surgery and the clinical lead at Chelsea and New York were attended by hundreds of mal’ birth but any more might you woman, need some sleep.of an international reputation unit, forshould a 35-year-old the chance Assisted Conceptionfor Unit. professional womenstretch last year you, (the companywithWestminster’s a live birth after IVF is, on average, around “It’s a very good business. That’s what to mind bring that its cocktail parties to k carefully andhopes bear in insurance 50 per cent,” says Mr Nikolaou. “In the prompted the RCOG to look into this issue; Britain soon). Alongside the drinks and ally only coversinformation an emergency Caesarean. sameVogue, unit at age 42, it’s around a 10 per cent we felt a responsibility toJanuary assess the facts.” on payment plans, fertility are.v2.indd 51 08/04/2014 11:30 In Pregnant Pause, 2015 Mr Nikolaou highlights chance ofTheatre success. Ifand you you drawhave a line between In fact, the recommendation of the provideand presentations gh up what youexperts can afford if it’s a explaining the choice of one-toonly was fully statistics, that’s how quickly a college that egg freezing not be what the technique involves. For some largeThe freezing your eggsshould may notthe betwothe best fertility insurance policy: eeze, look into an NHS facility we trulyandwhy consultant midwife-led woman’sone fertility decreases.orWomen’s eggs care during offeredmaternity to women of any age as future companies – such as–Facebook Appleprivate are muchlabour, better ifplus they there’s are younger than 35, fertility insurance.

– the financing egg world. freezing is offered asunit in the UK, TheThe statistics, as have some of the best care inofthe a range of antenatal and similar of using None of which hasideally put off Samantha younger than 30.

On to thethat basis of a fresh egg in IVF. be ignored in the who they stand, make uncomfortable reading a perk to female employees.

Portland delivers The idea of egg freezing in a bid to guarantee postnatal care.

However, it if will never Hoare,* a 37-year-old whothat, works in speculate we can that one is get around the fact either. “You hope that around 2,000 babies eggs frozen as an insura that asthen you getborn older, at youThe havePortland fewer eggs. medicine, who had her eggs frozen when going to freezeCrystal eggs, it’s better or the unfamiliar, egg Natasha was future pregnancy is becoming increasingly popular, each year. go on to meet the right In aaddition, you get older, a large she was 33. “I froze my eggs to because do so Ibefore woman as is 35, freezing – or “fertility there in 2013.

“I’ve the eggs,” she says. “If yo number of your eggs will have always chromosomal wanted to pursue my career and and had I wastwins ideally before she is 30.” preservation” as it is with some companies even offering the procedure about wanting a baby abnormalities – for example aged 41, 45 a lot of social pressure to get married The quality of a woman’s eggs heard Mum talk about the wonderful ORGET ABOUT sometimes known – is Its ethos is to put womenunder in charge of this is a wake-up call.” per cent Mowbray of our eggs are abnormal.

So even and have children,” she tells asks me. “It made as a corporate perk.

But, Nicole , is depends almost entirely on her a medical procedure Cashing in an ovari if you areWhen ovulatingmy regularly, those eggs me astressed, I was making allexperience the wrong she had. gynaecologist their own pregnancy within supportive HE PRICE TAGS age, genetics and, to a minor in which patients in your forties is not w are not going to fertilise and implant.” decisions when it cameto to put men, sotheir I it wise for women to try fertility on ice? suggested she deliver my babies there, I said environment.

There's team of experienced extent, her environment – for inject themselves with it doesn’t pay out? As a Bickerstaff identifies a tipping point of decided to postpone my fertility, focus on at does a private birth cost a history of orheavy hormones to stimulate at the London Wome “aroundI couldn’t 34 35” have as thehad age aatmore which my career and, if it happens inexample, the future, Photograph by Jenny van Sommers ‘yes’ immediately. midwives, consultant obstetricians and London? As you’d expect smoking willwomen further reduce their ovaries into Bridge Centre, it is Tra still have enough eggs of good then great. positive experience.” anaesthetists and a dedicated Emergency to help women in this quality – but still need to meet a partner “Freezing my eggs has chances taken the ofbirth success. a greater number of one of theproducing world's most

The Portland

f

S o - c a l l e d “e g g - f r e e z i n g p a r t i e s”, h e l d i n u p m a r k e t hotels and clubs in New Yo r k , w e r e a t t e n d e d b y pressure off,” she continues. “I see many single women in about h u n d r e d s o f p r“I’m o f not e any s worried smore. i o nIt’s aonel myof their late thirties and early forties,” Mr Nikolaou explains.flanked “Almostbyallher mother and he labourfertility ward on the seventh hospital wheelchair, the best things I’ve ever of them have been slightly ofsLondon’s Strthe Thomas’s aChelsea friend. The guttural sounds emanating and low Westminster Hospital’s staff, The Kensington done.

When time comes, w o m e nfloor l a t y e a misinformed, because while HospitalI offers will trybreathtaking to have children from between her gritted teeth belie her

t

about wo having c “but quit mention donor e happen and equipment, if itdoneeds to. A full range fertility-unit websites always Once frozen, the eggs remain at TETRICIAN £3,500-£8,000 views ofnaturally Big Ben, thefresh composed exterior, since the woman – not far feel shock firstacross with my state that success rates are relatively low, for any woman considering the procedure the age they were at extraction, which isat the of blood tests –and arestages offered as well Chelsea and – and de eggs,oily-black but if I’m waters 40 by the out fast-flowing of her teens is inscans the first of labour. theymy rarely get around to telling women – regardless of age. key, as the quality of ovarian eggs declinesWestminster NS, BLOOD TESTS £500 Hospital are limit time I try, I will defrost The idea of egg freezing inof a bidthe to guarantee as an antenatal, birth and postnatal package.

River Thames.

As In her perfect world, Jessica Hughes,* a future pregnancy becoming increasingly popular, Between 1991 and 2012,eggs justand 21use babies as a woman ages. sense of w those.” exactly how low the rates are. They don’t sees more isthan with some companies even offering the procedure the clock chimes 8pm on a 38-year-old City worker, will end up on a ITIONAL BLOODWhen TESTS UP TOdecides £2,000 Facilities aresuccess contemporary say, ‘Do realise the rates are 10and luxurious and born Britain a Hoare result of 253 the patient the time is5,000 thought o says she is aware of you as awere corporate perk. in But,being asks Nicole as Mowbray , is babies for women to try tousing put theirfrozen fertility oneggs. ice? “There balmy autumn the similar ward, when time is right for permay cent?’

If youlabour ask most clinics, theythe will fertility cycles right for a baby, the egg is thawed slowly it wise Most the risks evening, that the eggs Photographevery

by Jenny van Sommers the team encourages mums to choose their delivered year.

PITAL FEE (normal a feels busy year, Hughes majority o not up fertilise, but notthat haveher. hadThis one live birth from a froze frozen her eggs at a haven’t been verystaff many gear babies born,for both before beingdelivery) fertilised with a partner’s or a themselve had themegg… frozenItLondon birthing positionclinic. (birth balls, floor he labour ward on the seventh hospital wheelchair, flanked bybecause herClipboard-wielding mother and [fertility preservation] is a service in the UK or internationally, as she a result donor’s sperm via ICSI IVF – a procedure night. fertility She is beanbags, certain she 600 TO £5,900 floor of London’s St Thomas’s a friend. The low guttural sounds emanating offers breathtaking from between her gritted relatively teeth belie her egg freez young, those risks to be priced upto and sold.” aHospital freezing says in which sperm is injected into the egg –TheofKensington viewswoman of Big Ben, across the composed exterior,her since the own woman – not eggs,” far in obstetricians burgundy wants be a mother, but the right relationship mats, birthing stools and pools are available) Wing offers midwife-led fast-flowing oily-black waters out of her teens – is in the first stages of labour. in their are “They areThe an HFEA, which licenses fertility of the River Thames.

In her perfect world, Jessica Hughes,*low. a ITIONAL SCANS UP TO £1,000 Nikolaou.

“AtAs least 20,000 eggs have been and implanted back into the womb. It’s not the clock chimes 8pm on a 38-year-old City worker, will end up oninto a scrubs sweep the room of eludes her.

“I know I want to have children,” balmy autumn evening, the similar labour ward, when theinsurance time is right for found the policy,” she says. and and pain relief options.

They also encourage carefrozen for straightforward pregnancies and staff gearin up for a busy her. This year, Hugheshave froze her eggs at a clinics issues guidelines for good the UK. There been around cheap, carries risks and is not available on a fertility woman who haseggs recently night.

Clipboard-wielding London clinic. She is certain she WIFE-LED CARE (excluding Dr Wa “I relationship have 18 frozen, so she tells me, “but I’d rather not do it on my obstetricians in burgundy wants to be a mother, but the right practice, does not regulate cost.

Hannah 600 to 700 embryos created from thawed the NHS unless it’s for medical reasons (forbirth scrubs sweep into the room of eludes her.

“I know I want to have children,” the so useI’m ofwaiting complementary and can callshe tellsdelivered onme, “butthe expertise until I findtherapies. the right man.” a woman who has recently I’d rather I not do ita on my healthy in private believe I of willthe bebaby able to own delivered a healthy baby own so frozen I’m waiting until Ieggs find the rightare man.” fertilised sultant) £8,550 Verdin, head of regulatory policy at the eggs [this is where example, if a patient needs cancer treatment girl. The newborn baby – Hughes is one of the growing number of Centre fo haveforchildren.

There always girl.

The babyisHFEA, – Hughes is one of the growing number of just minutes old – nuzzles British women freezing their eggs newborn sosilentlyeither against her mother’s called “social reasons”sperm – the blanket termor given that of a says part of the clinic’s duty is to with a partner’s which could damage her fertility). The Genetic chance that none of the British breast. She’s yet to settle on a by the media to a variety ofthe factors, such as minutes – nuzzles women freezing their eggs for soname, she explains, beaming not just having a partner, not being ready for old appropriate information, Private including sperm far there have been but give egg-harvesting procedure typically costs maternity care.v2.indd 51 with pridedonor], at her doll-like and children, orso wanting to prioritise your career. which eggs will survive, at least new arrival.

According to the body that regulates the silently her mother’s called the blanket term given Consultant 150 obstetrician in this country,against Human the chances of“social success,reasons” a costed–treatment around toindustry 200 embryo transfers – between £3,000 and £5,000 per round in patients a I thehave Helen Bickerstaff, fresh from Fertilisation and Embryology Authoritytried.” an emergency caesarean in (HFEA), 2012 saw 580 women freeze their toBickerstaff, settle onplan awho media to a variety of factors, such as andbyanthe explanation of any side effects. istheatre,when abreast. clinic puts ayetfertilised Britain, storage costs are about £200 a year, me. “I lovewhich the operating grins at eggs – more than double She’s the number in 2009. egg free Helen my job,” she says, before breaking It’s a trend that shows no signs of slowing darlings with her team a patient nearby down; in fact, the opposite. name, explains, beaming not having a partner, ready for She admits, however, that it www.littledarlingsmagazine.com is not hard being to embryo womb.

But the then attempting to fertilise the eggs via offwhotoisdiscuss believes is when anthe honorary consultant having difficulties withback her delivery. inside The desire to the become she a mother Seconds later, the double doors of the unit ability or circumstance eludes you is a uniquely swing open and in glidesstatistics a young woman in a desperate feeling.

Few things in life around will do f gynaecologist obstetrician comparechildren, clinics asor–wanting unlike with IVF – your career. latest show only 20 IVF costs between £5,000 and £8,000. withthat pride at> her and doll-like to prioritise what the at King’s there are no statistics to available on which babies have been born women whoCollege have London, As it is the age of the eggs that determines new to arrival.

According the body that regulates the did for spent the first 15 yearsare of her theindustry most successful unitscountry, “because the Human frozen their own eggs.

The average livefertility potential, rather than the age of Consultant obstetrician in this generatio working IVF andhaven’t been enough cycles of egg there birth rate of this Helen process Bickerstaff, iscareer around 10fresh perin from the mother, it’s no wonder egg freezing Fertilisation and Embryology Authority e.v2.indd 51 08/04/2014 11:30 will give freezing to collate statistics”. The HFEA cent per embryo transfer.” IVF research. She believes has become an attractive procedure for an emergency caesarean in (HFEA), 2012 saw 580 women freeze their freedom,” that the recent advances in was also unable to provide any data on the While Mr Nikolaou admits it is financially secure women in their mid- to seeing more women soon double if they the wish to conceive. It’s an egg freezing havegrins meantatthat the procedure the women operating theatre, than success eggs rates – ofmore the procedure by age. number in 2009. options”, he 22 late thirties who feel the desire to be important to “offer relationship, women w uncomfortable nowbefore a more breaking viable one thanIt’s previously, me. “I love my job,” she issays, a trend that shows notruth. signs of slowing ready to have a child…

“Older motherhood is not ideal,” she especially for young eggs, but there are 164 off to discuss with her team a patient nearby down; in fact, the opposite. will change how people t says. “I would really hate to think women still drawbacks.

eggs. These are extracted from the

MMA TICKLE. DIGITAL ARTWORK: Y. *NAMES HAVE BEEN CHANGED

SET DESIGN: GEMMA TICKLE. DIGITAL ARTWORK: HEMPSTEAD MAY. *NAMES HAVE BEEN CHANGED

pensive capitals, ovaries using it a finedoesn’t needle, before liquiddo nitrogen me cheap – being but“preserved” what in you a maximum of 10 years (the t for your for money is worth it. limit imposed by the HFEA).

pregnant

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t

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01-15welleggsVO49340-002.pgs 17.11.2014 14:50

Breaking News: Heard about PGD and three-parent embryos?

Three-parent embryos What is meant by ‘three-parent babies’?

Three-parent babies are embryos that are created through a special technique of in-vitro fertilization, which involves cytoplasmic transfer so that the mitochondria of the egg of the future baby come from a donor. More than 99% of the DNA of the future baby comes from its mother and less than 1% is mitochondrial DNA that comes from the donor.

An example of PGS results illustrating a chromosome abnormality.

PGD What is PGD? Pre-implantation genetic diagnosis (PGD) refers to genetic profiling of embryos prior to implantation. It is a way of ensuring that the baby will not carry a specific gene or chromosomal abnormality.

One form of PGD is the pre-implantation genetic screening or PGS. This is not looking for a known genetic or chromosomal abnormality but aims at identifying embryos at risk.

Because of the potential association with eugenics, PGD is a controversial technique and there are restrictions in its use in various countries. In the UK, PGD is not allowed for sex selection for family balancing, although it is allowed for sexselection in order to avoid a sex-linked disorder.

Uses • Genetic abnormality screening for an ever-growing list of disorders as part of IVF (pre-embryo implantation).

Screening covers both single-gene disorders be that autosomal recessive, dominant or sex-linked, as well as chromosomal aberrations such as chromosomal translocations.

• Identifying embryos at risk and so increases the chance of conception and live-birth

• Selecting embryos that match the HLA type of a sibling in order to create a donor • Selecting embryos that have lower chance to be predisposed to cancer and also for sex selection (UK not allowed in UK for family balancing, only sex selection to avoid a sex-linked disorder) Benefits • Any genetic abnormalities are detected before the embryo is transferred into the uterus preventing the need for termination of pregnancy unlike amniocentesis or chorionic villus sampling • Possible long-term benefits to the wider health economy of proactivity screening for certain health conditions Successes Data from randomised studies and meta-analyses do not show clinical effectiveness in using PGD for older women. Using PGS to reduce the chances of miscarriage, increase the chance of pregnancy or deal with recurrent implantation failure is controversial.

PGS will shortly be offered as part of pre-conception testing at Chelsea and Westminster.

The process involves removing the nucleus of the egg of the mother and transferring it in an egg of the donor of which the nucleus has been removed.

Thus the resulting cell has the nucleus of the mother but the cytoplasm of the donor, including the mitochondrial DNA. Uses • Avoid the genetic transmission of mitochondrial diseases such as diabetes and deafness and some heart and liver conditions.

• A potential use of this technique is to create an egg with younger mitochondria, by using a young donor Benefits • Prevent a selection of genetically transmitted mitochondrial diseases • Increase the chance of a live-birth for older women, for whom the only effective treatment at present is eggdonation Success The procedure is regarded ethically controversial, as it interferes with the germ-line, and it has only just been legalised in the United Kingdom. For the technique to be effective in avoiding the genetic transmission of disease, the donor must not be a maternal relative.

There are no plans to introduce the mitochondrial DNA technique at Chelsea and Westminster at the current time until a stronger evidence base for this technique is available.

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A cut above the rest: Optimising recovery for caesarean section patients

Miss Gubby Ayida, Consultant Obstetrician and Gynaecologist and Women’s and Children Divisional Medical Director provides a unique insight into the unusual mixture of normality, joy, family expansion, combined with a time of recovery from a major surgical intervention and all this entails: One in three women in major London maternity units are now delivered by the abdominal route. Indications range from permissive maternal requests though to conditions where vaginal delivery is prohibited such as placenta preavia.

Excluding the 20 percent of low risk women delivering in midwifery led units or at home, modern postnatal wards are akin to surgical wards. The difference being the sound of crying babies and rampant hormones. We need to become better at understanding some of the subtle needs of new mums.

For example, in women delivering vaginally, the first labour is often the toughest with benefit of subsequent easier deliveries. The converse is true for caesarean, where the first operation is often the easiest to recover from, with subsequent caesarean sections having more prolonged recovery along with a newborn and other young children at home.

Optimisation of care at every stage is therefore important to allow enhanced recovery, appropriate length of stay and timely return to full family life following childbirth.

24

Antenatal preparation

Haemoglobin Avoidance of anaemia and optimisation of Haemoglobin in anticipation of the increased blood loss at Caesarean section is key. Women with good pre-operative Hb levels can weather blood loss of up to 2 litres without need for a transfusion Placenta site location This is important particularly with previous caesarean section, as there is a propensity for placentas to implant around site of scars, accreta must be excluded in all anterior located placentas especially if low.

It is becoming increasingly accepted that detection of future accreta pregnancies can be seen in early first trimester scans by location of the gestation sac low in the uterus. The surgical risks with placenta accreta / percreta are so serious that the option of early termination of pregnancy is now offered.

Timing of elective caesarean section The risk of transient tachynpnoea of the newborn (TTN )is a risk of elective operative delivery before 39 weeks. It is no longer considered best practice to deliver women before 39 weeks unless

by risk assessment delay till 39 weeks is the lesser clinical risk for example, a growth restricted baby. The unnecessary admission of a term baby to the SCBU at e.g. 38 weeks because of elective delivery should be avoided.

Surgical environment Birth as a special occasion can be reproduced even under the sterile, bright lights and high tech operating theatre environment. With over 95% of operations performed under regional anaesthesia, dedicated obstetric theatre staff have mastered the skill of trying to normalise a clearly surreal setting for parents. The option of women bringing in their personalised play list to listen to on the iPod deck seems to sit comfortably alongside an airline style surgical (WHO) check list that demands the full attention of all the staff before ‘knife to skin’. The lowering of the separating drapes at time of delivery is a true ‘Kodak’ moment and one that the theatre staff never tire of cooing over. The ability to have skin to skin with baby minutes after birth even whilst the uterus is being closed can be magical. If this is not possible with mum then dad can have a go. Mothers never

leave the operating theatre without baby tucked in under the gown â&#x20AC;&#x2DC;Koala styleâ&#x20AC;&#x2122; for the short journey to the recovery unit.

Post Operatively

There are two priorities for new mums with caesarean sections:

1 Effective, generous, pre-emptive analgesia to enable women to be able to care for and feed their babies whilst recovering from significant surgery. This aids early mobilisation and enhanced recovery.

2 Venous

thromboprophylaxis, is critical in this at risk group and at minimum all women have TED socks and low molecular weight heparin whilst inpatients and if any additional risk factors, go home with 7 days total injections. Often overlooked is the fact that women with a parity of 3 or more automatically have this as an additional independent risk factor.

At home

Earlier discharge of women from hospital some of the early post-operative symptoms may now be an issue at home.

These include the following:

1 Shoulder tip pain resulting from some residual blood in the abdomen irritating the peritoneum.

2 Wind that can be so severe that

women can be in marked discomfort and fear something serious is going on. Telltale signs including abdomen being quite tympanic, no history of flatus or burping, being day 2-3 post op and normal observations. This can often be aggravated by codeine analgesia and relieved by peppermint tea or water.

of the excess fluid is from night sweats in the first couple of weeks or diuresis.

Finally, it is unlikely that the caesarean section rate in London with its demographics (older women, multiple pregnancy, assisted conception, ethnic mix) is going to lower. Whilst we are familiar with routine post-operative management, it is the combination of new mother, looking after baby, recovering from surgery, reversal of physiological adaptation of pregnancy that makes this a complex time.

Patients wishing to find out more can be referred on 0203 733 0003 or kensington@chelswest.nhs.uk

3 Another source of concern to women is postop swollen legs. This is usually related to position in bed and their fair share of crystalloids IV infusions. Reassuring features are normotension, no proteinuria and otherwise well. Reassurance that this can take a few days to resolve is often required and continuing use of TEDs helpful. Most likely route of getting rid

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Borne: Saving lives

Mr Shane Duffy, Dr Enitan Ogundipe, Professor Mark Johnson, Miss Gubby Ayida and Ms Vivien Bell

Chelsea and Westminster Hospital clinicians have a long history of increasing the safety of childbirth.

From Dr El-Refaey’s pioneering treatments minimising the complications of childbirth being adopted by the World Health’s Organisation to our current collaboration between CW+ (our hospital charity) and the maternity team who have together founded Borne.

the risk of preterm labour. Our animal models have shown a powerful relationship between a high fat maternal diet and increased susceptibility to hypoxia (lack of oxygen to the brain).

3 Managing women with heart disease during their

Borne is led by Professor Mark Johnson, Consultant Obstetrician and Gynaecologist, and CW+’s Chief Executive, Mark Norbury. It is a charitable organisation with two major ambitions:

pregnancy and delivery: we have started an ongoing study of women with heart disease and their pregnancy outcomes, which includes two randomised studies to define the best management of the 2nd and 3rd stages of labour.

1 To make childbirth safer by devising treatments to reduce

4 Metabolic Health: we have established a clinic to study the

the risk of death and disability that all too often accompany pregnancy and childbirth.

impact of bariatric surgery on pregnancy outcomes.

Professor Mark Johnson had this to say: ‘Childbirth, although

2 To promote lifelong health by developing ways to protect natural, is still not without risk even in the 21st Century. Borne is here the unborn baby and help children enjoy longer lives.

Since December 2013, Borne has raised more than £3 million (mostly given by grateful private patients from Chelsea and Westminster Hospital) to fund research and education.

Borne’s current focus is to reduce the risk of pre-term labour. If clinical trials replicate laboratory findings, Borne will reduce high risk cases from 35% to a 10% risk.

Other clinical trial priorities include: 1 Reducing the risk of premature birth and cerebral palsy: we are looking to understand the action of cyclic adenosine monophosphate (or cAMP) to prevent pre-term birth and also the benefit of combining it with progesterone.

2

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Improving brain development through early life nutrition: we are examining the interaction between maternal diet and

to change that and significantly improve outcomes for mothers and babies. Seeing first-hand the personalised, high-quality maternity care we provide here at Chelsea and Westminster Hospital as well as the benefits of support from private maternity for Borne research makes me incredibly proud to recommend Chelsea and Westminster Hospital’s Maternity Care for your patients.’

If you would like to find out more about Borne, see www.borne. org.uk or contact Mark Norbury at E: mark.norbury@chelwest.nhs.uk If you wish to refer a patient to Professor Johnson or his colleagues at Chelsea and Westminster’s Kensington Wing, please contact 0203 733 0003 or email: kensington@chelwest.nhs.uk

Breastfeeding Masterclass: What to do when it doesn’t go to plan

Chelsea and Westminster Hospital has recently been reaccredited for the highest standard of the UNICEF UK Baby Friendly Initiative.

This means that all our maternity staff, including our community midwives, have been trained to give a high standard of breastfeeding support.

The Kensington Wing midwives share their top tips on breastfeeding: Tip 1 Preparation, preparation, preparation: We offer free 2 hour Antenatal Breastfeeding Workshops and the Kensington Wing antenatal class includes a 45-60 minute session on Infant Feeding.

These classes cover technique, feeding principles and troubleshooting.

Additionally there are a number of recommended resources for mothers on the web: . From Bump to Breastfeeding video . Off to the Best Start leaflet . Building a happy baby leaflet . Caring for your baby at night leaflet www.bestbeginnings.org.uk/watchfbtb

Tip 2 Nose to nipple:

Tip 3 Seek specialist support:

Small adjustments in positioning and attachment can make a big difference.

Any infant feeding problems under 28 days can be referred to the community midwife or InfantFeedingTeam@chelwest.nhs.uk Tel: 0203 315 3017. We support mothers according to their individual needs: exploring her feelings and providing information as needed. We also support women to assess the effectiveness of the milk transfer, to determine that the baby is getting enough milk and offering support with positioning and attachment.

Is baby’s head and body on a straight line?

Is baby able to tilt head back?

Is baby being held close to mum?

Is baby’s nose aligned with mum’s nipple?

Bonding and breastfeeding has been shown to calm mother and baby, regulate breathing and heartbeat and encourages high levels of oxytocin and low levels of stress hormones encouraging optimal brain development.

Effective attachment is important to ensure an adequate milk transfer, to prevent sore nipples, engorgement, blocked ducts, mastitis.

Parents can also access support 9.30am – 9.30pm seven days a week on the National Breastfeeding Helpline 0300 100 0212.

GPs interested in learning more about breastfeeding can undertake a specially designed GP online training programme: http://bit.ly/gpbreastfeeding 27

The Newborn Baby ‘First Day’ Check The NICE recommendations are that 95% of newborn examinations are done within 72 hours of birth and preferably after 24 hours except if clinically indicated otherwise. A newborn check is mainly an external check and cannot guarantee that a baby will not develop a problem.

At Chelsea & Westminster the ‘first day’ newborn check is performed within 48 hours of giving birth. On the Kensington Wing the newborn check is completed by a team of Neonatal Consultants and all babies on the Kensington Wing have the full neonatal team support should your baby require it during your stay. The key check involves:

1 Ensuring that baby has the normal parts of the body externally which includes size, head shape, limbs, mouth, eyes, anus and genitalia. The eye check is for a ‘red reflex’ which is not an indicator of how well your baby can see.

2 Ensuring that baby’s breathing is normal.

3 Checking for signs of an abnormality of the heart. Some

signs may be present in the early days of life but it is important to note that sometimes if a baby is checked early (<24hours), we may pick up transient signs e.g. a heart murmur that is only temporary whilst baby adapts to being born. Also, some signs do not become evident until later on e.g. 6 weeks of life.

4 Checking for signs or risk of congenital hip dislocation. If there are any concerns, the consultant will arrange for a hip ultrasound to be done when baby is 6 weeks old. In addition, some babies may need other interventions e.g. physiotherapy before the hip scan.

5 Checking for problems that may arise from known risk factors

In addition to this examination, all babies in the UK have a routine newborn hearing screen test done by the hospital’s national hearing screening team. This will sometimes be performed during your stay on the Kensington Wing but if baby is discharged before the screen, the midwives will inform baby’s health visitor who would arrange for the hearing screen to be done at home.

Once discharged, remember that if baby seems unwell, parents must seek help early e.g. by contacting the Health visitor or GP if non urgent or hospital A&E/Ambulance service, if urgent.

Neonatal Consultants unfortunately do not undertake routine reviews of babies. If you would like to have a private paediatrician to see your baby we can arrange that on your behalf, please speak to one of the Patient Liaison Officers to arrange.

Any babies found to require surgery will typically then be seen under the NHS and will be taken next-door to the Neonatal Intensive Care Unit. Having an on-site Neonatal ICU and a team specialising in Paediatric surgery is a rarity in London and we accept cases from all over London and South East England.

In 2016, we are planning to expand and redevelop our special care baby unit to include a private neonatal option for those families who would prefer to be seen privately.

The team of seven neo-natal consultants, led by Mr Gary Hartnoll undertake baby checks for 1000 babies on the Kensington Wing a year and have a wealth of experience you can tap into.

Ask a neonatologist: Do you have a neo-natal question that you’d like to ask the team?

Well here’s your chance: Email gpqueries.chelwest@ nhs.net with ‘Ask a NICU expert’ in the subject line. A selection of questions and answers will be featured in CW: the Journal later this year.

Warts and all: The HPV Vaccination There are more than 100 types of human papilloma virus (HPV) that cause infection in humans. Conditions arising from HPV infection include common warts, verrucae, genital warts and certain cancers.

50% of sexually active people will acquire HPV infection at some point in their lives. Most ano-genital warts are caused by HPV strains 6 and 11. HPV strains 16 and 18 are found in the up to 80% of ano-genital cancers.

Gardasil® is a quadrivalent HPV vaccine for the prevention of acquisition of HPV strains 6, 11, 16 and 18. This vaccine can be used for the prevention of premalignant genital lesions (cervical, vulvar and vaginal), premalignant anal lesions, cervical and anal cancers and also conditions related to certain oncogenic HPV types such as cancer of the head and neck. In addition Gardasil can prevent anogenital warts caused by strains 6 and 11.

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The NHS is currently offering Gardasil® to all young girls aged between 12 to 13 years of age. However it has a much wider UK licence which is for use in men and women over 9 years of age.

Three doses of the vaccine are generally required over a 6 month period. Gardasil® is sometimes used outside of its licenced indication, for example in individuals with HPV related disease as an adjunctive treatment. Research is ongoing into the use of HPV vaccination as a therapeutic treatment.

A new HPV vaccine will be licenced for use later in 2015. Gardasil 9® will offer increased coverage against 9 different HPV strains.

Patients can visit the Chelsea Vaccine Clinic at Chelsea and Westminster hospital to discuss HPV vaccination and Gardasil® in further detail. The Chelsea Vaccine Clinic is also a registered Yellow Fever vaccine centre and a full range of travel vaccines are available.

Appointments can be made via telephone on 0203 733 0003.

CHELSEA AND WESTMINSTER HOSPITAL

The Kensington Wing Private Maternity Unit At the Kensington Wing you will be in the hands of experienced obstetricians and midwives, all dedicated to ensuring you receive the best possible care.

You will enjoy the privacy and comfort of our facilities and can be reassured that our broad clinical expertise and support is there when you need it.

To find out more about our services, call

020 3315 8616/18 Š Merino Kids 2015

Think outside the uterus!

Differential Diagnosis of Chronic Pelvic Pain Mr Amer Raza, Consultant Obstetrician and Gynaecologist has a specialist interest in Chronic Pelvic Pain and laparoscopic surgery.

The diagnosis of CPP is challenging and multifactorial therefore it is important to ‘think outside the uterus’.

Chronic Pelvic Pain (CPP) is defined as pain of the apparent pelvic origin that has been present most of the time over a six month duration and affects 15-20% of women of reproductive age. Obtaining a full and complete history is the most important key to formulating a patient history.

Here’s Mr Raza’s personal recommended patient history checklist:

Gastrointestinal • Regularity of bowel movements?

• Diarrhea / constipation / flatus?

• Relief with defecation?

• History of hemorrhoids / fissures / polyps?

• Blood in stools, melena, mucous?

• Nausea, emesis or change in appetite?

• Abdominal bloating?

• Weight loss?

Gynaecological • Associated with menses?

• Association with sexual activity? (Be specific) • New sexual partner and / or practices?

• Symptoms of vaginal dryness or atrophy?

• Other changes with menses?

• Use of contraception?

• Detailed childbirth history?

• History of pelvic infections?

• History of gynecological surgeries or other problems?

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Psychological • History of verbal, physical or sexual abuse?

• Diagnosis of psychiatric disease?

• Onset associated with life stressors?

• Exacerbation associated with life stressors?

• Familial or spousal support?

Urological • Pain with urination?

• History of frequent or recurrent urinary tract infxn?

• Hematuria?

• Symptoms of urgency or urinary incontinence?

• Difficulty voiding?

• History of nephrolithiasis?

Musculoskeletal • History of trauma?

• Association with back pain?

• Other chronic pain problems?

• Association with position or activity?

Once you have a complete and detailed history, a physical exam evaluating each area in turn is key. A bimanual exam alone is NOT sufficient for evaluation.

Areas for evaluation include:

Abdomen, Anterior abdominal wall, Pelvic Floor Muscles, Vulva, Vagina, Urethra, Cervix, Viscera – uterus, adnexa, bladder, Rectum, Rectovaginal septum, Coccyx, Lower Back/Spine, Posture and gait

It is also worth considering the following tests: Routine

Pap Smear, Gonorrhea and Chlamydia, Wet Mount, Urinalysis, Urine Culture, Pregnancy Test, CBC with Differential, ESR, Pelvic Ultrasound

Specialised

MRI or CT Scan, Endometrial Biopsy, Laparoscopy, Cystoscopy, Urodynamic Testing, Urine Cytology, Colonoscopy, Electrophysiologic studies

Diagnosis, evaluation and treatment plans for Chronic Pelvic Pain should align with pertinent positives and negatives from the history and physical and will often require an interdisciplinary approach. Whilst 45% of women who undergo a laparoscopy for any indication are diagnosed with endometriosis, there are a number of cyclical and non-cyclical gynaecological conditions to be mindful of, namely: Cyclical

• • • • • •

Non-Cyclical

Endometriosis Adenomyosis Primary Dysmenorrhea Ovulation Pain/ Mittleschmertz Cervical Stenosis Ovarian Remnant Syndrome

• • • • • • • •

Pelvic Masses Adhesive Disease Pelvic Inflammatory Disease Tuberculosis Salpingitis Pelvic Congestion Syndrome Symptomatic Pelvic Organ Prolapse Vaginismus Pelvic Floor Pain Syndrome

To be continued in next edition: Part 2 of Think outside the Uterus will take a closer look at the medical and surgical treatment for endometriosis.

Fertility and Gynaecology GP education session You are cordially invited to attend a special GP education update on fertility and gynaecology on Tuesday 24 March 2015, 6.30pm – 8.30pm Venue: Gleeson Lecture Theatre, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, SW10 9NH This session is free to attend and the programme will cover: • Introduction to fertility – Mr Julian Norman-Taylor • Management of Endometriosis in women with infertility – Mr Dimitrios Nikolaou • What patients need to know about menopause – Miss Claudine Domoney • Fibroid management – Mr Amer Raza To reserve a space at this training session, please email justine.currie@chelwest.nhs.uk or contact T: 0203 315 6603

Image courtesy by Boggio Studio.

In the next edition • • • •

Modern Management of Obesity: Fighting an epidemic Ground breaking sleep apnoea surgery MDT reconstruction: Trauma case study Meeting the Demands of Medical Tourism

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Who’s who: Chelsea and Westminster Obstetricians Chelsea and Westminster Hospital prides itself on providing highly individualised and high quality Maternity Care.

Mum (and Dad’s) choice of Obstetrician is a very important decision.

We are always on hand to help advise which consultant or midwife would be the best fit for patients but here’s a handy summary guide to our Obstetricians:

Gubby Ayida MA FRCOG DM (Oxon) Gubby is dedicated to helping women achieve their expectations of labour.

020 7751 4489 lucy@womenswellnesscentre.com

Keith Duncan MD MRCOG Keith’s major interests are in high risk obstetrics, ultrasound and multiple pregnancies. He is experienced in normal, assisted and caesarean delivery.

020 7349 5204 / 07849 757 283 laura@chelseabirthclinic.co.uk

Shane Duffy DTM&H DObst Msc MRCOG Shane provides a continuum of care for uncomplicated pregnancies and pregnancies that develop complications in early pregnancy or labour.

07903 469 038 obstetrics@chelseagynaecology.co.uk

Hazem El-Refaey MD MRCOG Hazem has more than 25 years of experience and pioneered several treatments to minimise the complications of childbirth.

Hazem has changed the face of the field he works in by pioneering several treatments to minimise the complications of childbirth. These innovations are now a part of the World Health Organisation’s (WHO) protocols for the management of labour, its complications and pregnancy loss. Hazem is a graduate of Cairo university and speaks fluent Arabic.

020 7362 5600 (Mo) herhealth@me.co

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Mark Johnson PhD MRCP MRCOG Mark is a Consultant Obstetrician and a Consultant in General Medicine, Endocrinology and Diabetes, applying this to his special interest in medical disorders of pregnancy.

020 8846 7892 mark.johnson@imperial.ac.uk

Natasha Singh MBBS MRCOG BSCCP Natasha is passionate about empowering women during pregnancy and the birth process. Natasha is equally comfortable caring for women who desire a low intervention active birth to those who have complex medical needs.

07810 708 851 enquiries@londonbirthclinic.co.uk

Roshni Patel MSc PhD MRCOG Ms Patel has national and international experience of normal and high risk pregnancy, pre-pregnancy counselling and managing medical problems in pregnancy.

07503 003 366 roshni.patel@chelwest.nhs.uk

Vasso Terzidou MD MRCOG PhD Ms Terzidou is a member of the High Risk Pregnancy team and heads a specialised prematurity clinic which not only provides emotional support but also skilled obstetric monitoring for women at risk to deliver preterm.

07794 422 141 gaynor@chelseawomenshealth.co.uk

Amer Raza BSc MRCOG DFFP Amer has extensive experience in dealing with normal and complex pregnancies. He focuses his efforts to give mothers a positive birth experience and safe outcome.

07929 860 461 or 07980 948 075 drameraza@gmail.com

Guy Thorpe-Beeston MA MD FRCOG Guy is a member of the High Risk Pregnancy Team. His particular fields of interest include fetal ultrasound scanning, prenatal diagnosis, multiple pregnancy and miscarriage.

020 7224 4460 info@guyThorpeBeeston.com

Makrina Savvidou MD, MRCOG Dr Savvidou is a specialist in fetal medicine (obstetric ultrasound) and prenatal diagnosis.

07590 928 974 enquiries@obstetric-care.com

Nick Wales MRCOG BSc Nick is a member of the High Risk Pregnancy team and clinical lead of the Kensington Wing. Nick offers acupuncture for symptom relief in pregnancy. His special interests are in infectious diseases and cervical incompetence in pregnancy, in particular the use of abdominal and cervical sutures.

07748 808 806 or 01689 603 126 nick.wales@chelwest.nhs.uk 33

CW Private Patient Services We are proud to cater for private patients’ every possible health care requirement in a bespoke private patient environment with a dedicated clinical and administrative team who pride themselves in offering a personalised ‘nothing is too much trouble’ care for patients.

Private Patient Services available at Chelsea and Westminster include: Adult Medical and Therapies Services

Adult Surgical

• • • • • • • • • • • • • • • • • • • • •

• • • • • • • • • • •

Burns Cardiology Dermatology including ‘See and Treat’ clinic Diabetes Dietetics specialising in Bariatric and SMARTloss Endocrinology Gastroenterology General and Elderly Medicine Vaccine Clinic, including HPV and Yellow Fever Haematology HIV and Sexual Health Lipid disorders Neurology Oncology Ophthalmology Pain control Psychiatry Physiotherapy Respiratory medicine Rheumatology Tropical medicine

Family • Fertility –The Assisted Conception Unit are a specialist centre in early ovarian aging, fertility in women over 40, fibroid management and infertility in couples with blood borne viral infections: HIV or Hepatitis B and C • Gynaecology • Obstetrics – The Kensington Wing is the second largest private maternity hospital in the UK providing 24/7 on call consultant obstetricians, 1:1 midwifery care in labour, 24/7 resident consultant anaesthetic cover, baby check by consultant neonatologist, specialist breastfeeding support and postnatal physiotherapy 34

Ear, Nose and Throat General Surgery Gynaecology Hand Surgery Orthopaedics Ophthalmology Plastic Surgery Urology Vascular surgery Weight loss surgery Dental Surgery

Chelsea Children’s Hospital 4 state of the art dedicated paediatric operating theatres one which houses Pluto (Da Vinci Robot), dedicated paediatric and adolescent inpatient ensuite rooms, Neonatal ITU and Special Care Baby Unit and onsite Hospital School and Paediatric Medicinema.

Specialities offered: • Allergy service • Burns • Cranio-maxillofacial and dentistry • Dermatology • Endocrinology and gastroenterology • General surgery • General Medicine • Neonatology • Neurology • Ophthalmology • Orthopaedics • Respiratory medicine • Perinatal medicine • Plastic surgery • Urology

CHELSEA AND WESTMINSTER HOSPITAL

Private Patient Care

Chelsea and Westminster Hospital is one of the safest hospitals in the UK* and provides private patient services through The Chelsea Wing, their dedicated private patient ward.

Services available include:

Cosmetic Surgery Fertility General Medicine Women's Health Services Maternity Cancer Care Sports Medicine Ophthalmology

* Dr Foster Hospital Guide 2011 and 2012.

For more information please contact us:

020 3315 5377 E:

chelseawing@chelwest.nhs.uk

W: www.chelwest.nhs.uk Chelsea and Westminster Hospital 369 Fulham Road London SW10 9NH