Assisted Conception Flashcards
what is assisted conception treatment
any treatment which involves the gametes outside the body
how may couples need ACT
50% of the 1 in 6 couples that have infertility assessments
why is the demand in ACT rising
increasing parental age increasing chlamydia male factor infertility increasing range of ACT options improved success rate
how long should patients be waiting for IVF
less than 12 months
what are the indications for ART (aka ACT)
endometriosis male factor infertility tubal disease multiple male and female factors unexplained ovulatory disorder multiple female factors same sex/ single couples transgender referrals fertility preservation (cancer, transgender, social reasons) avoiding transmission of BBVs pre-implantation diagnosis of inherited disorders treatment with surrogacy when absent/ abnormal uterus
what is ICSI
intra cytoplasmic sperm injection
what is IVF
in vitro fertilisation
what must the patients do before starting ART
limit alcohol to 4 units per week
BMI 19-29
advise to stop smoking
folic acid 0.4mg/day preconception- 12 weeks gestation (5mg if increased risk of NTD/ obese)
rubella screen + immunisation
cervical smears
avoid exposure to hazards
drugs (prescribes, OTC, recreation) review
screen for BBV (hep b/c and HIV)
assess ovarian reserve (antral follicle count or AMH)
counselling
why is it important to assess ovarian reserve
predicts ovaries response to the treatment, helps prevent overstimulation
what are the types of ARTreatments available
donor insertion intra uterine insemination intra-cytoplasmic sperm injection fertility preservation surrogacy
what are the indications for an intra uterine insemination (IUI)
sexual problems (cant achieve penetrative intercourse) same sex relationships discordant BBV/ abandoned IVF
what is the method of IUI
can be in natural or stimulated cycle (inject gonadotrophins to stimulate cycle)
prepared semen inserted into uterine cavity around time of ovulation
what are the indications for in vitro fertilisation (IVF)
unexplained (>2 years) infertility pelvic disease (endometriosis, tubal disease, fibroids) anovulatory infertility (after failed ovulation induction) failed intra uterine insemination (after 6 cycles)
what causes the dominant follicle to be released
LH surge
what is the tonic phase of follicular development
primary and secondary follicles develop into antral follicles
what is the growth phase of follicular development
antral follicles 35 mm to pre ovulatory follicle
this stage is dependent on gonadotrophins
what do gonadotrophins cause in early follicular phase
synchronised growth of all follicles
what is down regulation in IVF
when a synthetic GnRH analogue/ agonist is given
reduces LF and FSH secreted from pituitary - switches off ovaries
this ensures eggs are not released from the follicles before they are collected
allows precises timing of oocyte recovery using HCG trigger
what SEs can down regulation cause
hot flushes and mood swings
nasal irritation
headaches
what does a down regulation (baseline) scan look for in IVF
hopefully no follicle development, no cysts and thin endometrium
what is the first stage in IVF
down regulation injections- allows better control of follicle development
what step follows the baseline (down regulation scan) in IVF
ovarian stimulation via gonadotrophins self administered (injections) causes follicular development
what do the post stimulation scan do in IVF
measures follicle size and thickness of endometrium
allows planning/ timing of HCG injection
what does the hCG injection do in IVF
mimic LH causing meiosis to begin again in the oocyte
when is the hCG injection given in IVF
36 hours before oocyte recovery
what are the prerequisites for semen collection
abstinence for 72 hours beforehand
needs to be analysed within 1 hour
what is assessed in sperm analysis
volume
density - numbers of sperm
motility - what proportion are moving
progression - how well they move
how is sperm prepared in IVF
remove seminal plasma and concentrate
what are the risks of oocyte collection
bleeding
pelvic infection
failure to obtain oocytes
injury to bowel/bladder
what is formed immediately after fertilisation
two pronuclei
at what stage is the embryo transferred/ cryopreserved (IVF)
blastocyst stage
how many embryos are tranferred into patient (IVF)
normally 1 (up to three but in exceptional circumstances)
what is done after embryo transfer (IVF)
luteal support progesterone suppositories for 2 weeks
pregnancy test 16 days after oocyte recovery
what are the indications for intra cytoplasmic sperm injection
severe male factor infertility
previous failed fertilisation with IVF
preimplantation genetic diagnosis
what is required if there is azoospermia
surgical sperm aspiration (extracted from epididymis if obstructive or testicular tissue if non obstructive)
how many sperm are injected to egg in ICSI
one
what temp are embryos incubated at
37 degrees
what syndrome is a possible complication of ART
ovarian hyperstimulation syndrome:
what causes clots and ascites in ovarian hyperstimulation syndrome
LH causes fluid shift
how do you prevent ovarian hyper stimulation syndrome
low dose protocols
use of antagonist
what is the treatment of ovarian hyper stimulation syndrome
before embryo transfer:
- elective freeze
- single embryo transfer
treatment after embryo transfer:
- monitoring with scans and bloods
- reduce risk of thrombosis (fluids, TED stockings, fragmin)
- analgesia
- hospital admission if requiring IV fluids/ more intensive monitoring/ paracentesis
how many ARTs result in multiple pregnancies
10%
which ART has highest risk of ectopic pregnancy
IVF
what are the surgical risk of sperm retrieval
haematoma
infection
what risks during pregnancy are increased in ART
miscarriage
prematurity
growth retardation
congenital abnormalities
what is the overall IVF success rate
35%
