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Addressing Fertility Problems at Your Routine Visit ###
Stuart Russell BVSc DBR MRCVS
Define:Ag ### IVC Evidensia Academy
17th Nov 2021 --- layout: true .footnote[The _Future_ of Dairy.] <style type="text/css"> iframe { width: 40rem; height: 24rem; } .remark-code-line { font-size: 1.1rem; } </style> --- layout: true class: top, inverse background-image: url('./images/iStock_000010110567_Full.jpg') background-size: cover ## Plan .footnote[The _Future_ of Dairy.] --- The Dairy Cow Problem Environment Population At Risk Reproductive Disease Strategy Monitoring --- layout: true class: top, inverse background-image: url('./images/iStock_000010110567_Full.jpg') background-size: cover --- layout: false class: bottom, inverse background-image: url('./images/iStock_000009626499Large.jpg') background-size: 100% ## The Dairy Cow Problem .footnote[The _Future_ of Dairy.] --- layout: true ## The Dairy Cow Problem .footnote[The _Future_ of Dairy.] --- background-image: url('./images/liver.png') background-size: 30% background-position: 80% 60% ### Liver Metabolism - ↑ **Dry matter intake** - ↑ Portal vein blood flow - ↑ **Progesterone & oestrogen clearance** - Large, highly-active ovarian structures - ↓ **oestrus expression** - ↑ **double ovulations** .reference[Sangsritavong, S & Others (2002), _Journal of Dairy Science_] --- background-image: url('./images/ingvartsen1.png') background-size: 45% background-position: 100% 70% ### Disease .left[ <img src="./images/ingvartsen2.png" width="50%" height="60%"> ] .reference[Ingvartsen, K L & Others (2003), _Livestock Production Science_] --- background-image: url('./images/milk_x_intensity.png') background-size: 50% background-position: 50% 70% ### Effects --- background-image: url('./images/wiltbank_multiple_ovulations.png') background-size: 45% background-position: 100% 70% ### Effects (cont.) .left[ <img src="./images/wiltbank_duration.png" width="47%" height="75%"> ] .reference[Wiltbank, M & Others (2006), _Journal of Dairy Science_] --- layout: false class: bottom, center, inverse background-image: url('./images/iStock_000013567165_Full.jpg') background-size: cover ## Environment .footnote.left.white[The _Future_ of Dairy.] -- Time Budgets & Comfort -- Heat Stress --- layout: false background-image: url('./images/parlour_throughput.png') background-size: 53% background-position: 100% 55% ### Time Budgets .footnote[The _Future_ of Dairy.] <br> <br> .pull-left[ <table class="table table-striped table-hover" style="font-size: 20px; "> <thead> <tr> <th style="text-align:left;"> Activity </th> <th style="text-align:right;"> hr/day </th> <th style="text-align:left;"> IQR (hr/d) </th> </tr> </thead> <tbody> <tr> <td style="text-align:left;"> Lying </td> <td style="text-align:right;"> 12.1 </td> <td style="text-align:left;"> 10.6-13.5 </td> </tr> <tr> <td style="text-align:left;"> Standing in Stall </td> <td style="text-align:right;"> 2.0 </td> <td style="text-align:left;"> 1.2-3.6 </td> </tr> <tr> <td style="text-align:left;"> Feeding </td> <td style="text-align:right;"> 4.3 </td> <td style="text-align:left;"> 3.5-5.0 </td> </tr> <tr> <td style="text-align:left;"> Travelling, Socialising, & Drinking </td> <td style="text-align:right;"> 2.1 </td> <td style="text-align:left;"> 1.5-3.1 </td> </tr> <tr> <td style="text-align:left;"> Milking </td> <td style="text-align:right;"> 2.5 </td> <td style="text-align:left;"> 1.8-3.5 </td> </tr> </tbody> </table> ] .reference[Cook, J & Gomez, A (2010), _Journal of Dairy Science_] --- layout: true ### Heat Stress .footnote[The _Future_ of Dairy.] --- background-image: url('./graphs/temp_timeline.png') background-size: 70% background-position: 50% 60% #### vs Rumination --- background-image: url('./images/heat_stress_vs_cr.png') background-size: 47% background-position: 100% 64% #### vs Fertility .left[ <img src="./images/heat_stress_vs_pr.png" width="45%" height="60%"> ] --- background-image: url('./images/define_nutrition_effect.png') background-size: 45% background-position: 100% 60% #### vs Production?? .left[ <img src="./graphs/temp_effect.png" width="54%" height="60%"> ] --- layout: false class: bottom, right, inverse background-image: url('./images/iStock_000037132704_XXXLarge.jpg') background-size: cover ## Population At Risk .footnote.left.white[The _Future_ of Dairy.] --- layout: true ## Population At Risk .footnote[The _Future_ of Dairy.] --- background-image: url('./images/herd_mix_pr_300_25stack.png') background-size: 45% background-position: 100% 47.5% <span style="position:absolute;left:55%;top:80%;"> _**75% High Fertility:**_ 32% 21-d PR<br> _**25% Low Fertility:**_ 10% 21-d PR<br> </span> -- .left[ <img src="./images/herd_mix_pr_300_50stack.png" width="50%"> ] <span style="position:absolute;top:80%;"> _**50% High Fertility:**_ 32% 21-d PR<br> _**50% Low Fertility:**_ 10% 21-d PR<br> </span> --- background-image: url('./images/herd_mix_pr_300_25.png') background-size: 45% background-position: 100% 47.5% <span style="position:absolute;left:55%;top:80%;"> _**75% High Fertility:**_ 32% 21-d PR<br> _**25% Low Fertility:**_ 10% 21-d PR<br> </span> .left[ <img src="./images/herd_mix_pr_300_5050.png" width="50%"> ] <span style="position:absolute;top:80%;"> _**50% High Fertility:**_ 32% 21-d PR<br> _**50% Low Fertility:**_ 10% 21-d PR<br> </span> --- background-image: url('./images/herd_mix_pr_50-75dim.png') background-size: 55% background-position: 100% 60% ### Relevance - Cows presented at fertility visits - Timing of interventions - Accuracy of diagnosis - 'Success' of treatments - **Prior probability** -- <br> .comment[ _Are we setting up for success?_ ] --- background-image: url('./images/bisinotto_meta_by_detection_of_estrus.png') background-size: 50% background-position: 100% 60% ### Examples .reference[Bisinotto, R S & Others (2015), _Journal of Dairy Science_] - Sync CR % (+/- Heat detection) -- - 'Dirty' checks -- - Cyst/'Anoestrus' diagnosis -- - Grazer vs High-yielding treatment success -- - PD+ at presentation -- - Sexed Semen CR% --- background-image: url('./images/cr_uniform_heatvssexed.png') background-size: 40% background-position: 100% 55% ### Troubleshooting #### Cow-side Problem <span style="position:absolute;left:65%;top:20%;"> Conception Risk % by Month of AI </span> - Transition, Nutrition, Lameness, Disease - Heat Stress - Stocking Rate - Stage of lactation (semi-seasonal) --- background-image: url('./images/cr_uniform_heatvssexed.png') background-size: 40% background-position: 100% 55% ### Troubleshooting #### Bull-side Problem <span style="position:absolute;left:65%;top:20%;"> Conception Risk % by Month of AI </span> - Inseminator Skill & Diligence - Semen Storage - Specific Sires - Less specific Oestrus detection - good/bad - Sexed Semen Use --- layout: true class: top, inverse background-image: url('./images/iStock_000010110567_Full.jpg') background-size: cover ## Plan .footnote[The _Future_ of Dairy.] --- The Dairy Cow Problem Environment Population At Risk Reproductive Disease Strategy Monitoring --- The Dairy Cow Problem Environment Population At Risk > Reproductive Disease Strategy Monitoring --- layout: false class: inverse background-image: url('./images/iStock_000010172391_Large.jpg') background-size: 100% background-position: 20% 0% # Reproductive Diseases .footnote.white[The _Future_ of Dairy.] --- layout: true # Reproductive Disease .footnote[The _Future_ of Dairy.] --- .center[ <img src="./images/plos_screenshot.jpg" width="75%" height="75%"> ] .reference[Ioannidis, J P A (2005), _PLOS Medicine_] --- background-image: url('./images/pr_graph_dim_metritis.png') background-size: 45% background-position: 100% 54% ### Metritis <span style="position:absolute;left:55%;top:75%;"> _**Lact 3+ Metritis**_<br> _21-d IR: 61%_<br> _21-d PR: 15%_ </span> -- .left[ <img src="./images/pr_graph_dim_nometritis.png" width="49%" height="65%"> ] <span style="position:absolute;top:75%;"> _**Lact 3+ NO Metritis**_ <br> _21-d IR: 67%_<br> _21-d PR: 24%_ </span> --- background-image: url('./images/endometritis.png') background-size: 50% background-position: 100% 60% ### Uterine Pathology .reference[LeBlanc, S J (2012), _Reproduction in Domestic Animals_] **35-50% of Cows** - Endometritis _(10-30%)_ - Cervicitis _(15-40%)_ - Purulent Vaginal Discharge _(5-15%)_ - Considerable Overlap --- background-image: url('./images/sheldon_graph.png') background-size: 50% background-position: 100% 60% ### Uterine Pathology - Bounce back vs crash & burn? .reference[Sheldon, I M & others (2009), _Biology of Reproduction_] --- ### Uterine Pathology - Diagnosis <table class="table table-striped table-hover" style="font-size: 20px; margin-left: auto; margin-right: auto;"> <thead> <tr> <th style="text-align:left;"> Finding </th> <th style="text-align:left;"> 20-26 Dim </th> <th style="text-align:left;"> 27-33 Dim </th> </tr> </thead> <tbody> <tr> <td style="text-align:left;"> External Pus </td> <td style="text-align:left;"> 8.5% </td> <td style="text-align:left;"> 4.6% </td> </tr> <tr> <td style="text-align:left;"> Vaginoscopic Pus </td> <td style="text-align:left;"> 29.6% </td> <td style="text-align:left;"> 17.1% </td> </tr> <tr> <td style="text-align:left;"> Grade 0 </td> <td style="text-align:left;"> 61.8% </td> <td style="text-align:left;"> 78.3% </td> </tr> <tr> <td style="text-align:left;"> Grade 1 </td> <td style="text-align:left;"> 12.1% </td> <td style="text-align:left;"> 7.9% </td> </tr> <tr> <td style="text-align:left;"> Grade 2 </td> <td style="text-align:left;"> 15.7% </td> <td style="text-align:left;"> 8.5% </td> </tr> <tr> <td style="text-align:left;"> Grade 3 </td> <td style="text-align:left;"> 10.4% </td> <td style="text-align:left;"> 5.4% </td> </tr> </tbody> </table> .reference[LeBlanc, S J & Others (2002), _Journal of Dairy Science_] --- background-image: url('./images/nejm_screening_header.png') background-size: 40% background-position: 100% 65% ### Uterine Pathology - Diagnosis .reference[Bleyer, A & Welch, H G (2012), _The New England Journal of Medicine_] .comment.right[ _"We estimated that in 2008, **breast cancer was overdiagnosed in more than 70,000 women**; this accounted for **31% of all breast cancers** diagnosed"_ ] -- - Be aware of the downsides of screening strategies. -- - Cost -- - Antibiotics -- - Randomisation of Sync -- - **Semen deficiency?** --- background-image: url('./images/denis-robichaud_dubuc_1metricure_effect.jpg') background-size: 50% background-position: 100% 50% ### Uterine Pathology #### Treatments - Antibiotics (Metricure) - Study: predicting 1st TAI success - Exam at 35 (+/- 7) DIM. 100% TAI ~ 70 DIM - Randomised Metricure for _all_ - Normal CR: 31-35% - Score 1 (flecks) CR: ~22% - Score 2 (mucopurulent) CR: ~22% - Score 3 (purulent) CR: ~15% <span style="position:absolute;left:50%;top:80%;"> Response to treatment by Diagnostic Criteria _Purulent Vaginal Discharge_ = Score 3 (purulent) </span> .reference[Denis-Robichaud, J & Dubuc, J (2015), _Journal of Dairy Science_] --- background-image: url('./images/dubuc_2metricure_effect.jpg') background-size: 60% background-position: 100% 60% ### Uterine Pathology #### Treatments - Antibiotics (Metricure) - 36 (+/-7) DIM, +/- 14d later - 100% TAI ~ 70 DIM - PVD: Score 2 (Mucopurulent) - ROI vs 1 more AI? .reference[Dubuc, J & Others (2021), _Journal of Dairy Science_] --- background-image: url('./images/heimerl_meta_header.png') background-size: 55% background-position: 100% 25% ### Uterine Pathology #### Treatments - PGF<sub>2α</sub> .reference[Haimerl, P & Heuwieser, W (2013), _Journal of Dairy Science_] .center[_"Our meta-analysis **did not reveal an improvement** of [CFSI or CCI] of cows with endometritis after treatment with PGF<sub>2α</sub>"_] -- .center[_"Additional **confirmatory trials are necessary** to shed more light on the **contradictory results published.**"_] -- .center[_"...may reveal important aspects concerning **study quality** and **applicability** of the results..."_] --- background-image: url('./images/lima_doublepg_endometritis.png') background-size: 50% background-position: 100% 60% ### Uterine Pathology #### Treatments - PGF<sub>2α</sub> .reference[Lima, F S & Others (2013), _Journal of Dairy Science_] - Study: PGF<sub>2α</sub> before Double Ovsynch - Allows 1 more AI? -- <br><br> .pull-left[ _**You need a strategy that guarantees a reasonable CR% 1st AI before 90 days in milk.**_ ] --- ### Cysts .center[ <img src="./images/plos_screenshot.jpg" width="60%" height="60%"> ] .center[ _A gentle reminder..._<br> _**What about diagnoses?**_ ] .reference[Ioannidis, J P A (2005), _PLOS Medicine_] --- ### Cysts #### Ultrasonographic - Follicular, luteal -- #### Histological - Follicular, Partially-luteinized follicular, Atypical corpus luteum -- #### Hormonal - Oestrogen, progesterone, inhibin, mixed, inactive --- ### Follicular Cysts - Diagnosis #### Size - **20mm+ diameter** ( or 17, or 25mm?) **wall <3mm** -- #### Persistent - **>7-10 days** (or 'dynamic cyst'...) -- #### Dominant - **No other follicles 4-9mm & no _corpus luteum_** --- ### 'Luteal' Cysts - Diagnosis #### Size - **20mm+ diameter** ( or 17, or 25mm?) **wall 3mm+** #### Persistent - **>7-10 days** #### Dominant -- .center[_"How is this different from an atypical Corpus Luteum?"_] --- #### **Cysts - Treatment** - **PGF<sub>2α</sub>** (partially-luteinised, 'luteal', 'atypical CL', 'persistent CL') ##### Any - **Exogenous Progesterone** - **TAI protocol + Progesterone** (e.g. CIDR+Ovsynch-56) - **Ovsynch-56** (+ restart in 1wk if no luteal tissue => GGPG) - **Ovsynch-56 with 2PG** (+ restart in 1wk if no luteal tissue => GGPPG) - **No treatment?/Squeeze** (hormonally inactive => misdiagnosed 'cysts', or if refractory?) --- ### Anoestrus #### Need Progesterone - **Exogenous** e.g. CIDR, CIDR+Ovsynch-56 - **Endogenous** e.g. hCG, GGPG, G6G, Double Ovsynch -- #### Diagnosis? --- layout: false class: inverse, bottom, right background-image: url('./images/iStock_000020656607_Full.jpg') background-size: 100% ## Strategy .footnote.white.left[The _Future_ of Dairy.] --- layout: true ## Strategy .footnote[The _Future_ of Dairy.] --- background-image: url('./images/Cow&Calf - individual pen or signs of calving.jpg') background-size: 50% background-position: 100% 55% - Minimise negative energy balance. -- - Optimise immune function. -- - Maximise Oestrus Expression -- - Help 'problem cows' (if poss.) -- - Early 'Do not breed' decisions. -- - Abolish semen deficiency. -- - **Monitor** success --- background-image: url('./images/iStock_000049322144_XXXLarge.jpg') background-size: 40% background-position: 100% 55% ### My Typical Approach - Excellent transition (esp precalving stocking & DMI) -- - Fresh checks (<7 DIM) - Farm Staff -- - Typically no prebreeding check (AYR herds) -- - Targeted Presynch-Ovsynch-56 (problem cows) -- - Excellent Oestrus Detection -- - Back Door Ovsynch-56 (+ day 8 PGF<sub>2α</sub>) - 63-70 DIM --- background-image: url('./images/iStock_000049322144_XXXLarge.jpg') background-size: 40% background-position: 100% 55% ### My Typical Approach (cont.) -- - Pregnancy Diagnosis - 32-39d -- - Negatives => Ovsynch-56 (+ day 8 PGF<sub>2α</sub>) -- - Recheck _all_ synchs on day 7 & restart if necessary. -- #### Adjustments - ↑ CIDR/GGPG use if more truly anoestrus cows -- - ↑ washouts, ↑ CIDR use on Seasonal Dairies --- layout: false class: inverse background-image: url('./images/iStock_000009626499Large.jpg') background-size: 100% ## Monitoring .footnote[The _Future_ of Dairy.] .pull-left[ <br><br><br><br><br><br><br><br><br><br> _Is there value in knowing what happened last month if it doesn't reliably predict what will happen next week?_ ] --- layout: true ## Monitoring .footnote[The _Future_ of Dairy.] --- background-image: url('./images/heat_stress_vs_pr.png') background-size: 50% background-position: 10% 64% <table class="table table-striped table-hover" style="font-size: 20px; margin-right: 0; margin-left: auto"> <thead> <tr> <th style="text-align:left;"> Metric </th> <th style="text-align:left;"> Herd 1 </th> <th style="text-align:left;"> Herd 2 </th> <th style="text-align:left;"> Herd 3 </th> </tr> </thead> <tbody> <tr> <td style="text-align:left;"> 100d ICR </td> <td style="text-align:left;"> 62% </td> <td style="text-align:left;"> 65% </td> <td style="text-align:left;"> 60% </td> </tr> <tr> <td style="text-align:left;"> 200d NICR </td> <td style="text-align:left;"> 9% </td> <td style="text-align:left;"> 6% </td> <td style="text-align:left;"> 9% </td> </tr> <tr> <td style="text-align:left;"> 21-d PR </td> <td style="text-align:left;"> 26% </td> <td style="text-align:left;"> 30% </td> <td style="text-align:left;"> 25% </td> </tr> <tr> <td style="text-align:left;"> 21-d IR </td> <td style="text-align:left;"> 67% </td> <td style="text-align:left;"> 74% </td> <td style="text-align:left;"> 64% </td> </tr> <tr> <td style="text-align:left;"> CR - Lact 1 </td> <td style="text-align:left;"> 43% </td> <td style="text-align:left;"> 44% </td> <td style="text-align:left;"> 50% </td> </tr> <tr> <td style="text-align:left;"> CR - Lact 2 </td> <td style="text-align:left;"> 35% </td> <td style="text-align:left;"> 38% </td> <td style="text-align:left;"> 39% </td> </tr> <tr> <td style="text-align:left;"> CR - Lact 3+ </td> <td style="text-align:left;"> 34% </td> <td style="text-align:left;"> 34% </td> <td style="text-align:left;"> 33% </td> </tr> <tr> <td style="text-align:left;"> % AI to Synch </td> <td style="text-align:left;"> 16% </td> <td style="text-align:left;"> 16% </td> <td style="text-align:left;"> 17% </td> </tr> <tr> <td style="text-align:left;"> 4-17d ISI </td> <td style="text-align:left;"> 10% </td> <td style="text-align:left;"> 19% </td> <td style="text-align:left;"> 14% </td> </tr> <tr> <td style="text-align:left;"> 4-17d ISI CR </td> <td style="text-align:left;"> 25% </td> <td style="text-align:left;"> 22% </td> <td style="text-align:left;"> 23% </td> </tr> <tr> <td style="text-align:left;"> Replacement Rate </td> <td style="text-align:left;"> 28% </td> <td style="text-align:left;"> 46% </td> <td style="text-align:left;"> 21% </td> </tr> </tbody> </table> .reference[10-13,000kg 305d yield herds. 600-2200 milkers] --- layout: true class: top, inverse background-image: url('./images/iStock_000010110567_Full.jpg') background-size: cover ## Plan .footnote[The _Future_ of Dairy.] --- The Dairy Cow Problem Environment Population At Risk Reproductive Disease Strategy Monitoring