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Fertility Flashcards

1
Q

When investigate infertility

A

been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35

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2
Q

Causes of infertility

A

Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)

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3
Q

General lifestyle advice for couples trying for a baby

A

The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse

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4
Q

Ix for infertility

A

Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS)
Chlamydia screening
Semen analysis
Female hormonal testing (see below)
Rubella immunity in the mother
Female hormone testing

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5
Q

What does female hormone testing involve?

A

Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea

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6
Q

High FSH

A

Pcos

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7
Q

Positive that ovulation has occurred

A

Rise in progesterone on day 21 -corpus luteum secreting

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8
Q

High anti-mullerian hormone

A

Food ovarian reserve

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9
Q

Beyond hormonal testing, further Ix for infertility

A

Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram to look at the patency of the fallopian tubes
Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

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10
Q

Hysterosalpingogram what involved and uses

A

Assess shape of uterus and latency of fallopian tubes
Therapeutic benefit
Can also perform tubal cannulation during procedure (must have Sri screening first)

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11
Q

Mx of anovulation

A

Weight loss for overweight patients with PCOS can restore ovulation
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

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12
Q

Mx of tubal issues

A

Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
In vitro fertilisation (IVF)

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13
Q

Mx of uterine issues

A

Surgery may be used to correct polyps, adhesions or structural abnormalities

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14
Q

Mx of sperm production

A

Surgical sperm retrieval - when block along vas deference preventing sperm to reach ejaculated semen. Collected from epididymis
Surgical correction of obstruction- in vas deferent
Intra uterine insemination - involves collecting and separating out high-quality sperm, then injecting them directly into the uterus
Intracytoplasmic sperm injection -involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman
Donor insemination

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15
Q

How provide a semen sample

A

Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery

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16
Q

Fx affected semen analysis and sperm quality/quantitiy

A

Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine

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17
Q

When repeat samples of semen

A

repeat sample is indicated after 3 months in borderline results or earlier (2 – 4 weeks) with very abnormal results.

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18
Q

Normal semen results

A

Semen volume (more than 1.5ml)
Semen pH (greater than 7.2)
Concentration of sperm (more than 15 million per ml)
Total number of sperm (more than 39 million per sample)
Motility of sperm (more than 40% of sperm are mobile)
Vitality of sperm (more than 58% of sperm are active)
Percentage of normal sperm (more than 4%)

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19
Q

Define polyspermia

A

high number of sperm in the semen sample (more than 250 million per ml)

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20
Q

Define normospermia

A

normal characteristics of the sperm in the semen sample

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21
Q

Define oligospermia

A

reduced number of sperm in the semen sample. It is classified as:

Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)

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22
Q

Define cryptozoospermia

A

to very few sperm in the semen sample (less than 1 million / ml).

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23
Q

Azoospermia define

A

absence of sperm in the semen.

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24
Q

Pre testicular causes of poor sperm creating

A

Testosterone required
low LH and FSH resulting in low testosterone), can be due to:

Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome

25
Testicular causes of poor sperm
Testicular damage from: Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer
26
Genetic or congenital disorders resulting in defective or absent sperm production
Klinefelter syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia (absent testes)
27
Post testicular causes of low sperm in semen
Obstruction: Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens (may be associated with cystic fibrosis) Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
28
Ix for male causes of infertility
Semen analysis USS of testes Hormone analysis - LH, FSH, testosterone Genetic testing Transrectal Uss or MRI Vasography Testicular biopsy
29
Mx of male causes of infertility
Surgical sperm retrieval where there is obstruction Surgical correction of an obstruction in the vas deferens Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg Donor insemination involves sperm from a donor
30
Success rate of IVF
25 – 30% success rate at producing a live birth
31
Intrauterine insemination definition
different from IVF. It is a more straightforward process, and involves injecting sperm into the uterus, avoiding intercourse
32
IUI indications
donor sperm for same-sex couples, HIV (avoiding unprotected sex) and practical issues with vaginal sex
33
IVF involves
A cycle of IVF involves a single episode of ovarian stimulation and collection of oocytes (eggs). A single cycle may produce several embryos. Each of these embryos can be transferred separately in multiple attempts at pregnancy, all during one “cycle” of IVF. Embryos that are not used immediately may be frozen to be used at a later date. Frozen embryos can potentially be used years later, even after a successful pregnancy
34
Process of IVF
Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfer
35
How suppress natural menstrual cycle
GnRH agonists or GnRH antagonists
36
How GnRH agonist given
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
37
How gnrh antagonist given?
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.
38
Why suppress menstrual cycle IVF
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.
39
How does ovarian stimulation work
subcutaneous injections of follicle-stimulating hormone (FSH) over 10 to 14 days Then 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”.
40
How Oocyte collection work
Transvaginal USS 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 Sedation
41
Oocyte insemination how work
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
42
Intracytoplasmic sperm injection when use
male factor infertility, where there are a reduced number or quality of sperm
43
How embryo culture works
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).
44
How embryo transfer work
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)
45
When pregnancy test performed
Day 16 after egg collection Could be miscarriage or ectopic if positive
46
Why progesterone used in IVF
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
Main complications of IVF
Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome
48
Risks of egg collection procedure
Pain Bleeding Pelvic infection Damage to the bladder or bowel
49
ovarian hyperstimulation syndrome definition
a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.
50
ovarian hyperstimulation syndrome patho
increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space. This results in oedema, ascites and hypovolaemia.
51
raised renin
indicates OHSS - as activation of renin-angiotensin system if high - high severity
52
risk fx of OHSS
Younger age Lower BMI Raised anti-Müllerian hormone Higher antral follicle count Polycystic ovarian syndrome Raised oestrogen levels during ovarian stimulation
53
how monitor OHSS
Serum oestrogen levels (higher levels indicate a higher risk) Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)
54
ways to reduce risk of OHSS developing
Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol) Lower doses of gonadotrophins Lower dose of the hCG injection Alternatives to the hCG injection (i.e. a GnRH agonist or LH)
55
clinical fx of OHSS
<7 days of hCG injection= early >10 days = late Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)
56
severity of OHSS assessed
based on clinic fx Mild: Abdominal pain and bloating Moderate: Nausea and vomiting with ascites seen on ultrasound Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%) Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)
57
mx of OHSS
SUPPORTIVE Oral fluids Monitoring of urine output Low molecular weight heparin (to prevent thromboembolism) Ascitic fluid removal (paracentesis) if required IV colloids (e.g. human albumin solution) admit if severe and to ICU if critical
58
pt develop raised haematocrit following GnRH injection
DEHYDRATION - OHSS
59

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