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RDA > 8 - Infertility > Flashcards

8 - Infertility Flashcards

1
Q

Infertility definition?

A

The failure to conceive after 12 months of unprotected intercourse

(isn’t really classified as a disease anymore)

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2
Q

How many couples are affected by infertility and what are the consequences?

A

1/4 couples

In 1st world countries is a largely emotional burden. In 3rd world countries there are more serious consequences (ostracised, poverty, death)

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3
Q

World fertility rate?

A

Declining - good as the current population growth is unsustainable (2.2)

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4
Q

Voluntary childlessness?

A

Increasing - 18% in NZ

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5
Q

Assessment of male infertility includes…

A

Semen analysis

  • Count
  • Motility
  • Volume
  • Total number of sperm
  • Morphology
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6
Q 
Normal:
Count
Motility 
Volume 
Total number of sperm 
Morphology
A 
Count: 15 million/mL
Motility: 40%
Volume: 1.5mL 
Total number of sperm: 39 million in ejaculate  
Morphology: Only 4% normal morphology
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7
Q

Basic assessment of female fertility includes…

A
  1. Ovulation
    - regularity of periods around 28 days
    - E2 - day 12
    - P4 - day 21
    - FSH - day 2-4 (< 10 IU/I)
    - AMH - age-related graph
  2. Timing (not frequency) of intercourse
    - low awareness of when they are ovulating
  3. STIs
    - 70% are a-symptomatic
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8
Q

6 leading causes of infertility in women and main treatments?

A
  1. Anovulation
    > weight gain/loss
    > drugs
2. PCOS
> weight loss
> letrozole 
> metformin (insulin sensitiser)
> IVF
  1. Tubal disease
    > surgery
    > IVF
  2. Cervical problems insemination
    > rare
    > IUI (intrauterine insemination)
  3. Endometriosis
    > Hormonal contraceptives
    > Ablation - surgery/scar
    > IVF
  4. Premature menopause/Premature Ovarian Failure or rising FSH and decreasing AMH with age
    > Donor egg (IVF)
  5. No uterus (rare)
    > surrogacy
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9
Q

3 most common causes of male infertility?

A
  1. Oligospermia
    > ICSI (intra-cytoplasmic sperm injection)
    > donor sperm if really bad
  2. OATS (oligoasthenoteratospermia - low concentration, low motility and abnormal morphology)
    > ICSI
    > donor sperm
  3. Azoospermia
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10
Q

Anovulation and treatment?

A

Often due to under or overweight

> first line of treatment is weight gain/loss
Drugs:
- GnRH
- Clomiphene citrate (selective estrogen receptor modulator&raquo_space; produces more FSH to stimulate production of more oestrogen)
- Letrazole (unlike CC get more of a monofollicular growth - less likely to get twins)
> prevents conversion of androgens to oestrogen so brain produces more FSH
- FSH

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11
Q

Polycystic Ovarian Syndrome and common treatments?

A
  • 10% of women
  • Lots of medium sized follicles on US that don’t seem to complete development
  • Infrequent or no periods
  • Often a metabolic syndrome - overweight
  • often increased androgens

> weight loss
letrozole
metformin (insulin sensitiser - part of metabolic syndrome)
IVF

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12
Q

Letrozole?

A

Aromatase inhibitor - prevents conversion of androgens to oestrogen. Then stimulates release of FSH and so oestrogen production

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13
Q

Tubal disease and common treatments?

A
  • cysts
  • tumors
  • ectopic pregnancies
  • blocked/damaged tubes
  • adhesions (common)
  • endometriosis

> surgery
IVF (bypasses the tubes)

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14
Q

Cervical problems

A
  • aren’t very common

> Intra-uterine insemination (also often used for unexplained fertility problems)

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15
Q

Endometriosis?

A
  • 10% of women affected
  • > 30% of infertile women have some stage of endometriosis

> hormonal contraceptions
ablation - surgery/scaring
IVF

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16
Q

What are the 6 steps of IVF?

A
  1. Egg production is stimulated by hormone therapy
  2. Eggs are retrieved from the ovary
  3. A sperm sample is provided
  4. The eggs and sperm are combined to allow fertilisation
  5. The fertilised eggs are introduced into the uterus
  6. Embryo freezing
17
Q

How are the ovaries stimulated in IVF?

A

a) Stimulation by FSH
b) Give GnRH antagonists to PREVENT ovulation (until follicles have grown to sufficient size/matured)
c) Stimulate ovulation by HCG or GnRH agonist
d) Give progesterone for luteal support (essential)

> essential as the fertility drugs have a negative effect on the endometrium

18
Q

How do you track the IVF cycle?

A
  • Transvaginal US scans (measure size of each follicle)
  • Blood tests:
    > estrogen (1000 units per follicle)
    > progesterone (don’t want to see rise)
19
Q

How does the success rate of IVF change with age?

A

Success rate is measured by the cumulative pregnancy rate from first fresh and subsequent frozen cycles.

Declines with age (50% > 25% by 40)

…

20
Q

Time lapse photography and advantages?

A

Recent innovation - used to get the embryos/eggs out every day and check quality and grade by hand every day.

Photograph of every embryo is taken every 10 minutes

  • not taking out incubator so undisturbed culture
  • individual embryo tracking of cell division
  • able to predict those with the best potential with algorithms
  • provides full information
  • no more single snapshot in time selection
21
Q

Azoospermia causes and treatments?

A

No sperm

  • Kallman’s Syndorme (no GnRH - FSH/LH)
  • no spermatogenesis
  • obstructive or vasectomy
  • congenital absence of the VD (common in cystic fibrosis)

> donor insemination
TESA - testicular sperm aspiration/extraction + ICSI

22
Q

Testicular sperm aspiration?

A

Number of methods

  • aspirate fluid out of the epididymis (hope there’s sperm)
  • testicular aspiration
  • chunk of testis
23
Q

ICSI

A

Intra-cytoplasmic sperm injection

  • 2 needles; one to hold egg in place and one to hold and inject the sperm
  • ‘chop’ the sperm tail to stop it moving and to de-stabilize the membrane
24
Q

Unexplained fertility?

A

May be due to an unknown aetiology, fertilisation issue (at level of sperm and egg) or most commonly due to age

> mild ovarian stimulation with IUI (first line - cheaper)
IVF (10,000)

25
Q

Impact of age on fertility?

A

One of the leading causes of infertility
Average age of first child is 30 years (increasing)
Pressures - social, financial, career, lack of knowledge
Haven’t been able to alter the reproductive life of women

Implantation rates decrease with age while aneuploidy and mitochondrial defect rates increase - both contribute to infertility (less than 5% IVF success rate over 40 years)

RDA (2 decks)

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