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Laura MRCOG Part 2 > 14) Subfertility - Overview & ART > Flashcards

14) Subfertility - Overview & ART Flashcards

1
Q

Definition of subfertility

A

Unwanted delay in conception after 1 year of regular unprotected intercourse (or 6 cycles of IUI)

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2
Q

Incidence of subfertility

A

15%

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3
Q

What are the overall outcomes for subfertile couples?

A

15% subfertile.
50% of these will conceive spontaneously (or with simple advice).
8% remain sub fertile and require more complex treatment (4% primary, 4% secondary).
Only 4% of population remain involuntarily childless.

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4
Q

What is the rate of conception in the first month of trying and what is the monthly conception rate after 1 year?

A

Most likely to conceive in first month - 15-20% conception rate.
After 1 year, 5% per cycle.

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5
Q

In an unselected population, what percentage of couples will have conceived after 6 months, 1 year, 2 years?

A

6 months: 60%
12 months: 85%
24 months: 95%

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6
Q

In a woman aged 19-26 what is her 1 year and 2 year chance of conception, compared to a woman 35-39 years?

A

19-26: 1 year 92%, 2 years 98%.

35-39: 1 year 82%, 2 years 90%.

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7
Q

What proportion of women in their 40s are able to conceive?

A

50%

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8
Q

When during the menstrual cycle is conception most likely to occur?

A

Probability rises from 6d pre-ovulation, peaks 2d pre-ovulation and falls by the day of ovulation.

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9
Q

What are the incidences of the different causes of subfertility?

A 
40% - both male and female component
30% - male factor
25% - ovulation disorders
25% - unexplained
20% - tubal damage
5-10% - endometriosis
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10
Q

How to investigate a sub fertile couple?

A

1) Sperm analysis
2) D21 progesterone
3) Assessment of tubal function

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11
Q

For how long should a man be abstinent prior to sperm sample?

A

2-3 days

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12
Q

What is the normal value for sperm volume?

A

> 1.5mL

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13
Q

What is the normal value for sperm pH?

A

> 7.2

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14
Q

What is the normal value for sperm concentration?

A

> 15million/mL

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15
Q

What is the normal value for sperm number?

A

> 39 million

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16
Q

What is the normal value for sperm motility?

A

> 40% (>32% progressive)

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17
Q

What is the normal value for sperm vitality?

A

> 58%

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18
Q

What is the normal value for sperm morphology?

A

> 4%

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19
Q

What to do if the sperm sample is abnormal?

A

Repeat in 3 months (or if grossly abnormal repeat ASAP)

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20
Q

Options for assessment of tubal function

A

HSG (if not known to have co-morbidities)
HyCoSy (ultrasound) is an alternative to HSG
Lap + dye if thought co-morbidities

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21
Q

When to test thyroid in sub fertility patients?

A

If symptomatic

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22
Q

When to test prolactin in fertility patients?

A

If ovulatory disorder, galactorrhea or pituitary tumour

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23
Q

When to test FSH/LH in fertility patients?

A

Irregular menstrual cycles

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24
Q

What tests are used to predict likely ovarian response to gonadotrophin stimulation in IVF?

A

Total antral follicle count (done on D2-D5 via TVUS)
- low response <4, high response >16.

AMH - low response <5.4, high response >25
FSH (D2-D5 of cycle) - low response >8.9, high response <4

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25
Q

Who are the legal parents of a child born through fertility treatment?

A
  • Heterosexual couple using their own gametes - both parents irrespective of marital status.
  • Sperm donor used - if married/CP then both parents, if not married/CP then need to fill out a form before treatment.
  • Egg donor used - both parents (birth mother is legal mother)
  • Surrogacy - birth mother and her husband/CP are the legal parents. Parental order can only be issued after birth for commissioning couple to assume parental role.
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26
Q

When can a child born via donor games access information about donor?

A

Non-identifying information age 16.

Identifying information age 18.

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27
Q

What is meant by oligo(zoo)spermia?

A

Reduced concentration of sperm

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28
Q

What is meant by astheno(zoo)spermia?

A

Reduced motility of sperm

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29
Q

What is meant by terato(zoo)spermia?

A

Reduced normality of sperm

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30
Q

What is meant by azoospermia?

A

No sperm in ejaculate

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31
Q

What is meant by aspermia?

A

No ejaculate

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32
Q

What is meant by necrozoospermia?

A

Only dead sperm

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33
Q

What is meant by globozoospermia?

A

Acrosome completely absent from sperm

34
Q

What is the most common abnormality on semen analysis?

A

Oligo-terato-asthnospermia (OAT) - unexplained!

35
Q

Management of male subfertility

A

Hypogonadotrophic hypogonadism - gonadotrophin drugs
Obstructive azoospermia - surgical correction
Treatment of ejaculatory failure
Assisted reproductive techniques e.g. ICSI/donor

36
Q

What to do about leucocytes in semen?

A

Nothing unless infection identified

37
Q

What to do about varicocele?

A

Don’t offer surgery - doesn’t improve pregnancy rates

38
Q

How to confirm anovulation?

A

Clinically: If woman is oligomenorrhoeac (cycle 6w –> 6m) or amenorrhoea (no natural period >6m)

If regular cycles - D21 progesterone (>30 confirms ovulation, >15 suggestive)

39
Q

What is type 1 ovulatory disorder and what percentage of ovulatory disorders does it account for?

A

Hypothalamic pituitary failure (hypogonadotrophic hypogonadism) - 10%

40
Q

What is type 2 ovulatory disorder and what percentage of ovulatory disorders does it account for?

A

HPO dysfunction (predominantly PCOS) - 85%

41
Q

What is type 3 ovulatory disorder and what percentage of ovulatory disorders does it account for?

A

Ovarian failure (hypergonadotrophic hypogonadism) - 5%

42
Q

Treatment of type 1 ovulatory disorder

A
  • Increase BMI if <19 and moderate exercise.
  • Pulsatile GnRH (or gonadotrophin with LH activity) will induce ovulation in 95%
  • If due to prolactin, address underlying cause +/- bromocriptine
43
Q

Treatment of type 2 ovulatory disorder

A
  • Weight loss if BMI >30
  • Pharmacological: Clomifene, metformin, Combination of both
  • Second line treatments: Laparoscopic ovarian drilling, combined clomifene/metformin, gonadotrophin (FSH only, unlike patients with Type 1 ovulatory disorder)
44
Q

What monitoring should be done during clomifene treatment?

A

Ultrasound monitoring during first cycle - if >2 mature follicles recruited avoid unprotected intercourse.
Serum progesterone D21 to ensure ovulation and increase dose if not.

45
Q

When should clomifene be given?

A

For 5 days from D2/D3.

Not for more than 6 months.

46
Q

When does ovulation after clomifene occur?

A

7 days after last dose

47
Q

What percentage of patients have uterine factors identified?

A

10-15%

48
Q

What is the gold standard investigation for uterine factors?

A

Hysteroscopy

49
Q

Data on polyps and fertility

A

Limited

50
Q

Data on fibroids and fertility

A

Cause subfertility and pregnancy rates improve after myomectomy

51
Q

What to do with intrauterine adhesions?

A

Offer adhesiolysis

52
Q

Congenital anomalies on subfertility

A

Unclear

53
Q

Sensitivity of HSG for detecting tubal pathology

A

50%

54
Q

When should HSG be done?

A

10 days of LMP (after excluding chlamydia infection)

55
Q

Treatment for women with tubal factors

A

IVF first line for moderate/severe/bilateral tubal disease.
Hydrosalpinges should be offered salpingectomy before IVF (as they reduce the success rate 50%)
Proximal tubal obstruction can be offered tubal catheterisation/hysteroscopic cannulation.
(For women with mild tubal disease, tubal surgery more effective than no treatment)

56
Q

Average cycle fecundity for women with unexplained fertility without treatment

A

1.3-4.1%

57
Q

Treatment for women with unexplained fertility

A

Try to conceive for 2 years –> IVF

Don’t offer ovarian stimulation

58
Q

When can IUI be done?

A

Can be done in natural cycle or stimulated cycle.

59
Q

How is the cycle stimulated for IUI if a stimulated cycle is performed?

A

5 days of clomifene or 7-10d gonadotrophin.
When 1-3 suitably sized follicles with 1 dominant follicle >17mm then injection of hCG is given.
Insemination of sperm 24-36h after hCG.

60
Q

What does NICE say should be offered on NHS for IVF?

A

Age < 40 (not conceived after 2 y of intercourse or 12 cycles insemination) - 3 full cycles (where each cycle is 1 episode of ovarian stimulation and transfer of any resultant embryos).

Age 40-42 - 1 full cycle.

61
Q

What are the two protocols involved in IVF stimulation?

A

“Long” (agonist) protocol:

  • GnRH agonist (buserelin/noferelin) for 2-3w to desensitise pituitary
  • Ovarian stimulation with gonadotrophin (hMG/rFSH) until desired follicular response obtained
  • hCG for final maturation
  • Oocyte collection 34-37h after final hCG

“Short” (antagonist) protocol:

  • No downregulation stage
  • Gonadotrophin (hMG/rFSH) administered in early menstrual phase (D2/D3)
  • GnRH antagonists from D5/6 (prevent premature leutinisation)
  • hCG to induce final maturation
  • Oocyte collection 34-37h after final hCG
62
Q

Which IVF stimulation protocol has higher rates of OHSS and shouldn’t be used in PCSO?

A

Long/agonist protocol.

63
Q

How many embryos should be transferred?

A

For women <37 years:

  • First full cycle - SET
  • 2nd full cycle - SET if >1 top-quality embryos, 2 if no top-quality embryos
  • 3rd full cycle - No more than 2

For women 37-39 years:

  • 1st & 2nd full cycle - SET if >1 top-quality embryos, 2 if no top-quality embryos
  • 3rd full cycle - No more than 2

40-42 years: Consider 2 embryos

64
Q

What is given for luteal phase support?

A

Progesterone until 8 weeks

65
Q

What is the birth rate per embryo transferred?

A

21.4%

66
Q

What percentage of overall births is ART responsible for?

A

2.1%

67
Q

What is the role of kisspeptin + GIH/RFRP?

A

Modulate GnRH release

68
Q

What modulates LH/FSH release?

A

Sex steroids, inhibin, prolactin, activin, follistatin

69
Q

What is the effect of FSH in the ovary and in the testes?

A

IN the ovary it acts on granulose cells to promote aromatisation of androgens to estrogens.
In the testes it acts on sertoli cells to increase sperm production.

70
Q

What is the effect of LH in the ovary and in the testes?

A

In the ovary it acts on the theca cells to produce androgen.

In the testes it acts on the leydig cells to produce testosterone.

71
Q

What is the role of pre-treatment before ART?

A

Doesn’t affect chance of live birth.
Can use in women on antagonist protocol to schedule IVF.

Pretreatment with GnRH analogues for 3-6 months in women with endometriosis associated sub fertility increases odds of clinical pregnancy 4x.

72
Q

What is the difference between agonist and antagonist protocol outcomes?

A

Reduced follicles/oocytes with antagonist protocol but no difference in live birth rate.
Reduced OHSS with antagonist.

73
Q

What is the purpose of the pituitary downregulation (agonist/antagonist)?

A

To suppress endogenous LH/FSH and premature ovulation.

74
Q

What is the purpose of the gonadotrophin phase?

A

To achieve multi follicular development

75
Q

What is the purpose of the final trigger?

A

Achieve follicular maturation

76
Q

What is the first line final trigger substance?

A

Urinary hCG

77
Q

How to obtain sperm samples?

A

Ideally by masturbation after 2-5d abstinence.
If retrograde ejaculation then can do urine samples post-masturbation.
Surgical methods if required.

78
Q

Appropriate surgical sperm retrieval techniques for someone with obstructive azoospermia.

A

Percutaneous or microsurgical epididymal sperm aspiration.

Testicular sperm aspiration.

79
Q

Appropriate surgical sperm retrieval techniques for someone with non-obstructive azoospermia

A

Microscopic testicular sperm extraction or open testicular biopsy.

80
Q

Best predictor of ART success

A

Female age

81
Q

How does obstetric history predict ART success?

A

Spontaneous pregnancy 20% increased success rate.

Prev ART pregnancy 60% increased success rate.

82
Q

Effect of BMI on ART success?

A

None! But obstetric risks increased therefore get BMI <30

Laura MRCOG Part 2 (56 decks)

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