Assisted Conception

Question 1

what are the indications for assisted reproduction

Answer 1

· Endometriosis
· Male factor
· Tubal disease
· Multiple male and
female factors
· Unexplained
· Ovulatory disorder
· Multiple female factors
· Other
○ Fertility preservation in cancer and transgender patients
○ Treatment to avoid transmission of blood born viruses between patients
○ Pre-implantation diagnosis of inherited disorders
○ Treatment of single parents or same sex couples
○ Treatment with surrogacy when absent/abnormal uterus

Question 2

what must the patient do before treatment

Answer 2

· Alcohol intake limited to 4 units per week

Weight between BMI 19-29 for both male and female

No smoking

Taking folic acid

0.4mg/day preconception

Rubella vaccination for female

Cervical smears

Occupational factors - avoid exposure to hazards

Drugs

Screen for blood born viruses

Asses ovarian reserve

Counselling

Question 3

what treatments are available for assisted reproduction

Answer 3

Donor insemination

Intra-uterine insemination

In vitro fertilisation

Intra-cytoplasmic sperm injection

Fertility preservation

Surrogacy

Question 4

when would you use intra-uterine insemination (IUI)

Answer 4

sexual problems
same sex relationships
discordant BBV
abandoned IVF

Question 5

how is intra-uterine insemination done (IUI)

Answer 5

prepared semen inserted into uterine cavity around time of ovulation

Question 6

when would you use IVF

Answer 6

unexplained infertility (>2 years)

pelvic disease (endometriosis, tubal disease, fibroids)

anovulatory infertility (after failed ovulation induction)

failed intra-uterine insemination (after 6 cycles)

Question 7

how many eggs are usually needed to get one successful embryo

Answer 7

8-12

Question 8

IVF step one

Answer 8

Down regulation

• synthetic gonadotrophin releasing hormone analogue or agonist
• reduces cancellation from ovulation improves success rates
• allows precise timing of oocyte recover by using gonadotrophin trigger given artificially (LH/FSH)

Question 9

IVF step 2

Answer 9

Ovarian stimulation

-gonadotrophin hormone containing either synthetic or urinary gonadotrophin (FSH +/- LH)

can be self administered injection

causes follicular development

Question 10

how is the semen taken for IVF

Answer 10

Abstinence for 72 hours before hand

produced in ‘men’s room’ in the ward or at home (within 1 hour)

asses for:

• volume
• density
• motility
• progression

Question 11

step 3 - how are the oocytes collected

Answer 11

collect follicular fluid and there should be oocytes in there

risks:
- bleeding
- pelvic infection
- failure to obtain oocytes

embryologist searches through follicular fluid to identify eggs and surrounding mass of cells

collects them into cell culture medium

incubates at 37 degrees C

Question 12

step 4 IVF

Answer 12

Fertilisation

• two pronuclei
• male and female genetic information
• approximately 60% of eggs fertilise normally

Question 13

how many days after fertilisation is the usual day of transfer and cryopreservation

Answer 13

day 5

deposit embryos in middle of the endometrium

Question 14

how are embryos transferred into the endometrium

Answer 14

transfer 1 embryo

give luteal support progesterone suppository for 2 weeks

pregnancy test 16 days after oocyte recovery

Question 15

indications for Intracytoplasmic sperm injection

Answer 15

for severe male factor infertility

previous failed fertilisation with IVF

Preimplantation genetic diagnosis

Question 16

how is surgical sperm aspiration done for ICSI

Answer 16

extracted from epididymis (if obstructive) or testicular tissue (if non obstructive)

Question 17

method for ICSI

Answer 17

each egg stripped

sperm mobilised

single sperm injected

insulate at 37 degrees overnight

Question 18

complications of ICSI

Answer 18

Small chance of genetic abnormality

ovarian hyper-stimulation syndrome

Question 19

how do you prevent ovarian hyper-stimulation syndrome

Answer 19

low dose protocols

use of antagonist for suppression

Question 20

how do you treat ovarian hyper-stimulation syndrome

Answer 20

freeze the embryo

then single embryo transfer once better

Question 21

how do you treat ovarian hyper-stimulation syndrome after embryo transfer

Answer 21

Monitoring with scans and bloods

Reduce risk of thrombosis

Analgesia

Hospital admission if required, IV fluids/more intensive monitoring/paracentesis

Question 22

other complications of ART

Answer 22

multiple pregnancy

ectopic pregnancy

Question 23

what other problems can you get in IVF

Answer 23

no eggs retrieved

surgical risk of oocyte retrieval

surgical risks of surgical sperm aspiration

failed fertilisation

problems in early pregnancy - increased miscarriage and ectopic pregnancy

increase risk in on-going pregnancy

psychological problems

failed treatment

Question 24

chance of getting pregnancy via ART at age of 35

Answer 24

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