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Reproductive Health (Y4) > 5- Infertility (disorders and IVF) > Flashcards

5- Infertility (disorders and IVF) Flashcards

1
Q

hypogonadotropic hypogonadism.

A

due to problems with either the

  • hypothalamus- deficiency in release of GnRH
  • pituitary gland - deficinecy in release of LH and FSH
    Affecting the hypothalamic-pituitary-gonadal axis (HPG axis).

The release of gonadotropins, LH and FSH, act on the gonads for the development and maintenance of proper adult reproductive physiology.

  • LH acts on Leydig cells in the male testes and theca cells in the female.
  • FSH acts on Sertoli cells in the male and follicular cells in the female.

Combined this causes the secretion of gonadal sex steroids and the initiation of folliculogenesis and spermatogenesis.

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2
Q

Hyperprolactinaemia and infertility

A

High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH.

This causes hypogonadotropic hypogonadism.

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3
Q

causes of hyperprolactinaemia

A

pituitary adenoma secreting prolactin

  • Where there are high prolactin levels, a CT or MRI scan of the brain is used to assess for a pituitary tumour.
  • Often there is a microadenoma that will not appear on the initial scan, and follow up scans are required to identify tumours that may develop later.
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4
Q

presentation of prolactinoma

A
  • Irregular menstrual periods or no menstrual periods.
  • Milky discharge from the breasts when not pregnant or breastfeeding.
  • Painful intercourse due to vaginal dryness.
  • Acne and excessive body and facial hair growth.
  • Only 30% of women with a high prolactin level will have galactorrhea (breast milk production and secretion).
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5
Q

management of prolactinoma

A

Often no treatment is required for hyperprolactinaemia. Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production.

These medications treat hyperprolactinaemia, Parkinson’s disease and acromegaly.

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6
Q

hypothalamic ammenorhea

A

hypothalamic hypogonadism is a condition whereby a woman does not get her menses due to an abnormality of the pulsatile release of the gonadotropin-releasing hormone (GnRH). This abnormality is attributed to poor diet, chronic stress, or too much exercise.

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7
Q

PCOS

A

Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women. There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.

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8
Q

essential definitions for PCOS

A
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9
Q

criteria for PCOS

A

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:

  • Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
  • Hyperandrogenism, characterised by hirsutism and acne
  • Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
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10
Q

presentation of PCOS

A
  • Oligomenorrhoea or amenorrhoea
  • Infertility
  • Obesity (in about 70% of patients with PCOS)
  • Hirsutism
  • Acne
  • Hair loss in a male pattern

other feartures
* Insulin resistance and diabetes
* Acanthosis nigricans
* Cardiovascular disease
* Hypercholesterolaemia
* Endometrial hyperplasia and cancer
* Obstructive sleep apnoea
* Depression and anxiety
* Sexual problems

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11
Q

acanthosis nigricans

A

describes thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.

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12
Q

investigations

A

Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone

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13
Q

PCOS blood tests typically show

A
  • Raised luteinising hormone
  • Raised LH to FSH ratio (high LH compared with FSH)
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
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14
Q

PCOS and pelvic ultrasounds

A

transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either:

  • 12 or more developing follicles in one ovary
  • Ovarian volume of more than 10cm3
  • Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS.
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15
Q

general management of PCOS

A

It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease. These risks can be reduced by:

  • Weight loss
  • Low glycaemic index, calorie-controlled diet
  • Exercise
  • Smoking cessation
  • Antihypertensive medications where required
  • Statins where indicated (QRISK >10%)
    *
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16
Q

significant part of management of PCOS

A

weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30.

Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.

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17
Q

managing infertility with PCOS

A
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18
Q

Premature ovarian insufficiency is defined as

A

menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age.

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19
Q

presentation of premature ovarian insufficiency

It presents with early onset of the typical symptoms of the menopause.

A

It presents with early onset of the typical symptoms of the menopause.
- irrefular menstrual periods
- lack of menstrual periods (secondary amenorrhea)
- low oestrogen levels
- hot flushes
- night sweat
- vaginal dryness

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20
Q

premature ovarian insufficiency is charactersited by

A

hypergonadotropic hypogonadism (not hypo)

Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show:

  • Raised LH and FSH levels (gonadotropins)
  • Low oestradiol levels
21
Q

causes of premature ovarian insufficiency

A
  • Idiopathic (the cause is unknown in more than 50% of cases)
  • Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
  • Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
  • Genetic, with a positive family history or conditions such as Turner’s syndrome
  • Infections such as mumps, tuberculosis or cytomegalovirus
22
Q

diagnosis of POI

A

women younger than 40 years with typical menopausal symptoms plus elevated FSH (more than 25 IU/l) on 2 consecutive samples separated by more than 4 weeks

23
Q

Women with premature ovarian failure are at higher risk of multiple conditions relating to the lack of oestrogen, including:

A

Cardiovascular disease
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism

24
Q

management of POI

A

HRT untill the age at which women typically go through menopause

2 options
- traditional hormone replacement therapy
- combined oral contraceptive pill

25
Q

traditional HRT vs the COCP

A

Traditional hormone replacement therapy is associated with a lower blood pressure compared with the combined oral contraceptive pill. The combined pill may be more socially acceptable (less stigma for younger women) and additionally acts as contraception.

26
Q

may be an increased risk of ….. with HRT in women <50

A

VTE

  • risk reduced by using transdermal methods e.g. patches
27
Q

Turners syndrome

A

a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing

28
Q

Turners presentation

A
  • wide neck
  • low set ears
  • cardiac defectd
  • low hairline
  • short fingers and toes
  • smaller
  • no growth spurt at puberty
  • failure to develop secondary charactersitcs
  • infertility
29
Q

in vitro fertilisation refer to

A

fertilising an egg with sperm in a lab and then injecting hte resulting embryo into the uterus

30
Q

success rate of IVF

A

roughly 25 – 30% success rate at producing a live birth.

31
Q

Intrauterine insemination (IUI)

A

is different from IVF. It is a more straightforward process, and involves injecting sperm into the uterus, avoiding intercourse. IUI is used in cases such as donor sperm for same-sex couples, HIV (avoiding unprotected sex) and practical issues with vaginal sex.

32
Q

Intrauterine insemination (IUI)

A

is different from IVF. It is a more straightforward process, and involves injecting sperm into the uterus, avoiding intercourse. IUI is used in cases such as donor sperm for same-sex couples, HIV (avoiding unprotected sex) and practical issues with vaginal sex.

33
Q

criteria for IVF funding

A
34
Q

NICE recommendations for who can access IVF on the NHS

A

Women under 40

According to NICE, women aged under 40 should be offered 3 cycles of IVF treatment on the NHS if:

  • they’ve been trying to get pregnant through regular unprotected sex for 2 years
  • they’ve not been able to get pregnant after 12 cycles of artificial insemination, with at least 6 of the cycles using a method called intrauterine insemination (IUI)
  • If you turn 40 during treatment, the current cycle will be completed, but further cycles shouldn’t be offered.

If tests show IVF is the only treatment likely to help you get pregnant, you should be referred straight away.

Women aged 40 to 42

The NICE guidelines also say women aged 40 to 42 should be offered 1 cycle of IVF on the NHS if all of the following criteria are met:

  • they’ve been trying to get pregnant through regular unprotected sex for 2 years. Or they haven’t been able to get pregnant after 12 cycles of artificial insemination, with at least 6 of the cycles using a method called intrauterine insemination (IUI)
  • they’ve never had IVF treatment before
  • they show no evidence of low ovarian reserve (where eggs in your ovaries are low in number or quality)
  • they’ve been informed of the additional implications of IVF and pregnancy at this age

Again, if tests show IVF is the only treatment likely to help you get pregnant, you should be referred straight away.

35
Q

additional criteria you need to meet before you can have IVF on the NHS, such as:

A
  • not having any children already, from both your current and any previous relationships
  • being a healthy weight
  • not smoking
  • falling into a certain age range (for example, some ICBs only fund treatment for women under 35)
36
Q

There are a number of steps involved in the process of IVF:

A
    1. Suppressing the natural menstrual cycle
    1. Ovarian stimulation
    1. Oocyte collection
    1. Insemination / intracytoplasmic sperm injection (ICSI)
    1. Embryo culture
    1. Embryo transfer
37
Q

Suppression of the Natural Menstrual Cycle

A

There are two protocols for the suppression of the natural menstrual cycle, preventing ovulation and ensuring the ovaries respond correctly to the gonadotropins (i.e. FSH). Suppression of the natural cycle involves either the use of GnRH agonists or GnRH antagonists. The choice between the GnRH agonist and GnRH antagonist protocol depends on individual factors.

1) For the GnRH agonist protocol, an injection of a GnRH agonist (e.g. goserelin) is given in the luteal phase of the menstrual cycle, around 7 days before the expected onset of the menstrual period (usually day 21 of the cycle). This initially stimulates the pituitary gland to secrete a large amount of FSH and LH. However, after this initial surge in FSH and LH, there is negative feedback to the hypothalamus, and the natural production of GnRH is suppressed. This causes suppression of the menstrual cycle.

2) For the GnRH antagonist protocol, daily subcutaneous injections of a GnRH antagonist (e.g. cetrorelix) are given, starting from day 5 – 6 of ovarian stimulation. This suppresses the body releasing LH and causing ovulation to occur.

Without suppression of the natural gonadotropins (LH and FSH) using one of the above protocols, ovulation would occur and the follicles that are developing would be released before it is possible to collect them.

38
Q

Ovarian Stimulation

A

Ovarian stimulation involves using medications to promote the development of multiple follicles in the ovaries. This starts at the beginning of the menstrual cycle (usually day 2), with subcutaneous injections of follicle-stimulating hormone (FSH) over 10 to 14 days. The FSH stimulates the development of follicles, and this is closely monitored with regular transvaginal ultrasound scans.

When enough follicles have developed to an adequate size (usually around 18 millimetres), the FSH is stopped, and an injection of human chorionic gonadotropin (hCG) is given. This injection of HCG is given 36 hours before collection of the eggs. The hCG works similarly to LH does naturally, and stimulates the final maturation of the follicles, ready for collection. This is referred to as a “trigger injection”.

39
Q

Oocyte Collection

A

The oocytes (eggs) are collected from the ovaries under the guidance of a transvaginal ultrasound scan. A needle is inserted through the vaginal wall into each ovary to aspirate the fluid from each follicle. This fluid contains the mature oocytes from the follicles. The procedure is usually performed under sedation (not a general anaesthetic). The fluid from the follicles is examined under the microscope for oocytes

40
Q

Oocyte Insemination

A

The male produces a semen sample around the time of oocyte collection. Frozen sperm from earlier samples may be used. The sperm and egg are mixed in a culture medium. Thousands of sperm need to be combined with each oocyte to produce enough enzymes (e.g. hyaluronic acid) for one sperm to penetrate the **corona radiata and zona pellucida **and fertilise the egg.

41
Q

Intracytoplasmic Sperm Injection

A

Intracytoplasmic sperm injection (ICSI) is a treatment used mainly for male factor infertility, where there are a reduced number or quality of sperm. It is an addition to the IVF process. After the eggs are harvested, and a semen sample is produced, the highest quality sperm are isolated and injected directly into the cytoplasm of the egg.

42
Q

Embryo Culture

A

Dishes containing the fertilised eggs are left in an incubator and observed over 2 – 5 days to see which will develop and grow. They are monitored until they reach the blastocyst stage of development (around day 5).

43
Q

Embryo Transfer

A

After 2 – 5 days, the highest quality embryos are selected for transfer. A catheter is inserted under ultrasound guidance through the cervix into the uterus. A single embryo is injected through the catheter into the uterus, and the catheter is removed. Generally, only a single embryo is transferred. Two embryos may be transferred in older women (i.e. over 35 years). Any remaining embryos can be frozen for future attempts at transfer.

44
Q

when is a pregnancy test performed

A

around day 16 after egg collection. When this is positive, implantation has occurred. Even after a positive test, there is still the possibility of miscarriage or ectopic pregnancy.

45
Q

When the pregnancy test is negative…

A

implantation has failed. At this point, hormonal treatment is stopped. The woman will go on to have a menstrual period. The bleeding may be more substantial than usual given the additional hormones used during ovarian stimulation.

46
Q

what is given to a newly pregnant women who has used IVF

A

Progesterone is used from the time of oocyte collection until 8 – 10 weeks gestation, usually in the form of vaginal suppositories. This is to mimic the progesterone that would be released by the corpus luteum during a typical pregnancy. From 8 – 10 weeks the placenta takes over production of progesterone, and the suppositories are stopped.

47
Q

when is US used in IVF pregnancy

A

performed early in the pregnancy (around 7 weeks) to check for a fetal heartbeat, and rule out miscarriage or ectopic pregnancy. When the ultrasound scan confirms a health pregnancy, the remainder of the pregnancy can proceed with standard care, as with any other pregnancy.

48
Q

Complications of IVF

A

The main complications relating to the overall process are:

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome

49
Q

way LGBTQ couples may have children

A

Possible ways to become a parent include:

donor insemination
IUI (intrauterine insemination)
surrogacy
adoption or fostering
co-parenting

Reproductive Health (Y4) (34 decks)

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