2: Fertility and Sub-Fertility: Causes, IVF Flashcards
1
Q
Define sub fertility
A
Failure to conceive despite one-year of unprotected sex, in absence of known cause infertility.
2
Q
What is infertility
A
No possibility of conceiving
3
Q
What is primary sub-fertility
A
When women has not conceived previously
4
Q
What is secondary sub-fertility
A
Women has conceived previously
5
Q
What % of couples can conceive in one-year
A
80
6
Q
What is mnemonic to remember causes of infertility
A
UMATE
7
Q
What are the causes of infertility
A
Unexplained (28%) Male (25%) Anovulation (21%) Tubal (20%) Endometriosis (8%)
8
Q
In males, how can causes of infertility be divided
A
- Sperm
- Azoospermia
- Inflammation
- Coitus
9
Q
What is the most-common cause of infertility in males
A
Semen abnormality
10
Q
What proportion of infertility is due to semen abnormality
A
85%
11
Q
What is oligospermia
A
Decrease number of sperm in ejaculate
12
Q
What are 4 causes of oligospermia
A
- Testicular cancer
- Varicocele
- Alcohol
- Idiopathic
- Rec drugs
13
Q
What proportion of male infertility is due to azoospermia
A
5%
14
Q
Define azoospermia
A
Complete absence of sperm in ejaculate
15
Q
How can causes of azoospermia be classified
A
Pre-testicular, Obstructive, Non-Obstructive
16
Q
What are 3 pre-testicular causes of azoospermia
A
- Hypogonadotorphic hypogonadism
- Kallman’s
- Anabolic steroids
17
Q
What are 4 causes of obstructive azoospermia
A
- Congenital absence vas deferens (CF)
- Vasectomy
- Gonorrhoea
- Chlamydia
18
Q
What can cause a congenital absence of the vas deferens
A
Cystic fibrosis
19
Q
What are 3 non-obstructive causes of azoospermia
A
Klinfelter’s (XXY)
Chemotherapy
Cryptochidism
Orchitis
20
Q
What are 3 inflammatory causes of male infertility
A
- Antibodies = reversal vasectomy
- Infective
- idiopathic
21
Q
What are coitus causes of male infertility
A
Erectile dysfunction
22
Q
What two medications can cause erectile dysfunction
A
B-blockers
SSRIs
23
Q
What are the 3 cause of female infertility
A
- Anovulation
- Tubal
- Endometriosis
24
Q
What are two types of anovulation
A
Primary and Secondary
25
What is primary anovulation
Anovulation due to pathology in the ovary
26
What are 4 causes or primary anovulation
1. PCOS
2. Tuners (45XO)
3. Premature ovarian failure
4. Iatrogenic: chemoradiotherapy
27
what is secondary anovulation
Anovulation due to problems with pituitary or hypothalamus
28
what are 5 causes of secondary anovulation
Kalmann's
PCOS
Anorexia
Hyperprolactinaemia
29
What are 2 -tubal causes of female infertility
1. PID
| 2. Previous surgery
30
Explain endometriosis as cause of infertility
Endometriosis causes inflammation, which can lead to scarring which can cause tubal occlusion.
31
In male 'work-up' for infertility what two things need to be established in history
- Alcohol and Smoking = both can cause subferility
| - Medications = some can lead to ED
32
On examination, what 3 aspects may be focused on
1. Secondary sexual characteristics (absence of)
2. BMI
3. Testicular volume
33
What can obesity cause
Subfertility
34
What can absence of secondary sexual characteristics be caused by
Klinfelter's
35
After history and examination, what should be tested in male infertility
Semen analysis
36
In semen analysis what do WHO define as normal progressive motility
32%
37
In semen analysis what do WHO define as normal total motility
40%
38
In semen analysis what do WHO define as normal morphology
>4%
39
Why may FSH be tested for male infertility
Will be raised in testicular failure
40
Why may LH be tested in male infertility
Low in androgen deficiency
41
What karyotyping may be ordered for male infertility
- Klinefelters (XXY)
| - Cystic fibrosis - congenital absence VD
42
In history for female infertility what should be focused on
Alcohol and Smoking - Decrease fertility
| Previous STI or pelvic surgery - tubal occlusion
43
What should be looked for on examination in female infertility
```
BMI
Hirsuitism - PCOS
Absence secondary characteristics
Visual field defect - prolactinoma
Pelvic mass
```
44
What test is ordered to determine ovarian reserve
FSH
45
When should FSH be measured
Day 2-4 of cycle
46
What is normal for FSH
>10
47
What is used to determine if individual is ovulating
Mid-luteal progesterone
48
When should progesterone be performed
7d prior to first-day menses
49
In a 28-day cycle, when should mid-luteal progesterone be performed
day 21
50
What level of mid-luteal progesterone indicates a women is ovulating
>30
51
if a women has a mid-luteal progesterone of 16-30 what is done
Repeat test
52
If a women has a mid-luteal progesterone of less than 16 what is done
Refer
53
What is done for following mid-luteal progesterones
a. > 30
b. 16-30
c. <16
a. Nothing = normal
b. repeat test
c. refer
54
What is gold-standard test to examine tubal latency
Laparoscopy and methylene blue dye
55
Explain laparoscopy and dye
Dye is injected into cervix and laparoscopy used to examine tubal patency
56
What is hysteroscopesalpingogram
Contrast dye injected. X-rays used to visualise
57
What is hysteria-salpingo contrast sonography (HyCoSy)
Contrast injected, Trans-vaginal US used to examine tube patency
58
What are 4 lifestyle factors in males that can improve fertility
- Smoking cessation
- Reduce alcohol
- Medication review (If ED)
- Weight loss if BMI over-30
59
What is second-line for male infertility
Multivitamin
60
What does the multi-vitamin given for male subfertiltiy contain
Zinc
Selenium
Vitamin C
61
What is follow up after giving tablet containing zinc, selenium and vitamin C
3-months to check semen
62
What is third-line for managing infertility
Intracytoplasmic sperm insemination (ICSI)
63
What are 4 female lifestyle factors used to treat sub fertility
- Smoking cessation
- Weight loss
- Folic acid
- Regular sexual intercourse
64
How often should a couple trying to conceive have sex
2-days
65
What causes 80% of anovulation in females
PCOS
66
What is first-line for managing PCOS
Weight Loss
67
What is second-line to manage sub-fertility in PCOS
Clomiphene citrate
68
Explain how clomiphene is given
Day 2-6 of the cycle
69
How does clomiphene work
It is anti-oestrogen, so works to increase FSH
70
What is required in PCOS after giving clomiphene
US - to check for ovarian hyper stimulation
71
What is third-line for managing sub-fertility in PCOS
Laparoscopic ovarian drilling
72
What is laparoscopic ovarian drilling
Diathermy used to drill holes in ovary
73
What is used for clomiphene-resistant PCOS
Gonadotrophins
74
What are two indications for donor insemination
- Same-sex couple (Female)
| - Male has azoospermia, with abnormal semen analysis and failure of ICSI
75
What is intracytoplasmic sperm injection
Sperm is taken from ejaculate or surgically from testes. Then injected into ova
76
When is intracytoplasmic sperm injection (ICSI) used
IVF Failed
| Abnormal sperm parameters
77
What is intrauterine insemination
Sperm is taken form ejaculate. Or, surgically from testes and injected into uterus.
78
What may intrauterine insemination be combined with
ovarian stimulation
79
What are indications for intrauterine insemination (IUI)
- Mild azoospermia
80
What is in-vitro maturation
Immature eggs taken from ovaries and ICSI
81
What is ooplasmic transfer (OT) or nuclear transfer (NT)
Baby has two mothers one donates ova and other cytoplasm.
82
What does ooplasmic transfer count as
Human genetic modification
83
What are 5 indications for IVF
- Tubal occlusion
- Maternal age impact fertility
- Unexplained sub-fertility for 2-years
- Endometriosis
- Infertility not responding to clomiphene
84
What should couples before IVF be screened for
HIV
Hep B
Hep C
85
What are the 5 steps of IVF
1. Ovarian Stimulation
2. Oocyte retrieval
3. Fertilisation
4. Embryo transfer
5. Luteal support
86
What is the first-stage of IVF
Ovarian stimulation
87
What is given in ovarian stimulation.
GnRH analogue or agonist
88
What is the role of GnRH agonist
Down-regulates women HPA axis
89
when is GnRH agonist given
Day 21 (mid-luteal) until day 10
90
what is then given
FSH
91
what is the role of FSH
Stimulate follicle development
92
what is given after FSH and why
hCG - matures follicles
93
what is the second-stage of IVF
Oocyte retrieval
94
how long after hCG given are oocytes retrieved
36-hours
95
what is used to retrieve follicles
trans-vaginal needle aspiration
96
what is stage 3 of IVF
fertilisation
97
what is culture of sperm and oocyte referred to as
'day 0'
98
what days are embryos transferred into women uterus
2-3 or day 5 (blastocyst)
99
what is the embryo at day-5
Blastocyst
100
what is the maximum number of embryos transferred
2
101
what is stage-5 of IVF
Luteal support
102
what is given in stage-5
Progesterone
103
What factors improve success of IVF
Younger Age
Previous pregnancy
Shorter duration sub-fertility
104
What factors reduce success of IVF
Obese
Smoking
Low AMH
105
What is role of COCP in IVF
Given 1-2W prior to stimulation to suppress cycle
106
What is the role of gonadotrophin analogue in IVF
Suppresses cycles
107
What is role of FSH in IVF
Increases follicle development
108
What is role of bHCG
Acts a luteinising hormone surge - causing oocyte to separate from follicle
109
What are both men and women given in IVF and why
Doxycycline - prevents infection that may impact implantation
110
When should men take doxycycline
7d prior to retrieval
111
When should women take doxycycline
4d prior to retrieval
112
What is ovarian hyperstimulation syndrome
Complication of stimulation in fertilisation treatment
113
What are 4 RF for ovarian hyperstimulation syndrome
- Young
- Low BMI
- Previous OHSS
- PCOS
114
When do individuals with OHSS present with symptoms
5-7 after-induction
| Or, 12-15d after pregnancy
115
What are mild symptoms of OHSS
Abdominal pain
| Abdominal bloating
116
What are moderate symptoms of OHSS
Abdominal pain
Abdominal bloating
N+V
US evidence ascites
117
What are severe symptoms of OHSS
```
Abdominal pain
Abdominal bloating
N+V
Clinical evidence ascites
Oliguria
High haematocrit
Hypoproteinaemia
```
118
What are severe symptoms of oHSS
```
Abdominal pain
Abdominal bloating
N+V
Clinical evidence ascites
Anuria
ARDS
VTE
```
119
Explain pathophysiology of OHSS
When stimulated there can be multiple lutenised corpus luteum cysts which release oestrogen, progesterone and VEGF. VEGF causes increases in membrane permeability - accumulation fluid in pleural and peritoneal space.
120
What are two features of OHSS
Ovarian enlargement
| Fluid shift - pleural or peritoneal spaces
121
What is criteria for offering IVF in women under-40
Offer 3-cycles of IVF if: 2-years unprotected intercourse trying to conceive with 12 cycles of artificial insemination (or 6 IUI)
122
What is criteria for offering IVF in women 40-42
Offer 1-cycle if: 2-years unprotected intercourse or 12-cycles artificial insemination (6 IUI) and
- No previous IVF
- No evidence low ovarian reserve
- Understands risk of pregnancy in this age
123
What is the NHS criteria for funding IVF
- No children
- BMI <30
- Non-smoker
- <42
124
What act regulates IVF
Human Fertilisation and embryology act
125
Explain HFEA criteria for gamete donors
- No medical or psychiatric conditions
- Known or anonymous
- Can only be used in up-to 10 families
- Full infection screen
- <35
- Counselled
126
Can children know about their donors
Once 18, children can contact HFEA to find-out information about their donors
