I need ART now what? Flashcards
Who needs to access ART
- Medically infertile individuals
- Socially infertile individuals
What is the process for a medically infertile individual to access ART and are they covered by medicare?
Medically infertile: 12 months of regular unprotected sex and no pregnancy (if over 36 only 6 months)
need to see GP and get a referral to a fertility specialists
treatment costs are reimbursed by medicare
What is the process for a socially infertile individual to access ART and are they covered by medicare?
socially infertile: ART required to provide gametes, uterus, genetic testing etc
- single women/men
- same sex couples
- transgender couples
See a GP for a specialists referral
No access to medicare need to pay full out of pocket cost
What are the factors that patients will consider when choosing a fertility clinic?
location
recommendations
specialist preference (male, female etc)
specialist expertise (endo, PCOS etc)
continued care (specialist still practices OB)
Cost (private or bulk billing)
Online presence
A spike in which hormone causes ovulation?
LH
What hormone spikes after ovulation due to the presence of corpus luteum?
progesterone
What are the steps involved in stimulation of follicles to prepare the oocytes?
- stimulate follicles
- prevent LH surge (spontaneous ovulation)
- Trigger
How is the hormonal pathways involved in ovulation manipulated to stimulate follicle growth?
Injectable FSH is given to stimulate follicle growth
(e.g. Gonal-F)
How is an LH surge prevented during follicle stimulation and why do we need to avoid this?
LH surge is prevented through two different medications:
- GnRH antagonist (binds and blocks GnRH receptor so GnRH cannot bind = no production of LH and FSH)
- GnRH agonist (activates GnRH receptor which at first causes a surge of LH but then receptors are oversaturated leading to down regulation)
Avoiding spontaneous ovulation allows for control of follicular growth so we can extract the oocytes at the right time and not lose them to the reproductive tract (we cannot collect once in tract)
Once the patients follicles are ready for pick up how do we trigger the LH surge?
giving LH injections are too expensive so we use:
- hCG (same active subunit as LH so mimics the LH surge)
- GnRH agonist (causes an increase in the production of FSH and LH causing a LH surge)
Post oocyte pick up progesterone is given to the patient. Why is this given?
As oocytes are aspirated from the follicle no corpus luteum forms = no progesterone
For the patient to have an embryo transfer the endometrium needs to be receptive which is usually progesterones role so instead progesterone medication is given.
What are the two types of cycles for stimulation and which is the most common?
- antagonist cycle (most common)
- agonist cycle
What is an antagonist cycle?
- Day 3 of menstruation start FSH
- Day 5 GnRH antagonist is taken to block LH production
- Day 12 trigger taken
- can be hCG or GnRH - 36 hours after trigger OPU
- After OPU progesterone treatment begins
Explain the steps in the agonist cycle
- GnRH agonist begins well before day 1 of menstrual cycle (this will cause an LH surge then down regulate the production of LH and FSH due to over saturation of receptors)
- FSH begins day 3 of cycle
- Day 12: trigger taken (only hCG can be taken in this cycle as an agonist has already been taken)
- 36 hours after trigger OPU
- Progesterone begins after OPU
Why are antagonist cycles more commonly used?
- patient friendly
- less injections
- shortened stimulation time (can get more round per year if required) - Effective
- probability of live birth does not differ between the two cycle options - Safe
- option of GnRH agonist trigger reduced OHSS risk
What is Ovarian hyper-stimulation syndrome (OHSS)?
OHSS is caused by the result of stimulation medications causing ovarian blood vessels to leak
(it can not be predicted and is poorly understood)
Can be very serious with a spectrum of symptoms:
- bloating
- nausea
- high BP
- pressure on lungs and brain
- increases risk of stroke
- death if left untreated
The antagonistic cycles are more popular due to their option of having a GnRH agonist trigger over a hCG trigger. Why is this important to have these two trigger options rather than just hCG (seen in the agonist cycle)?
hCG is known to exacerbate OHSS but GnRH agonists are safe to use.
The antagonistic cycles allows for a back up option if the patient is showing OHSS symptoms
For OHSS patients other than avoiding hCG triggers during the stimulation process what else should be avoided when doing embryo transfer?
avoiding fresh embryo transfer in the same cycle they get OHSS symptoms.
Freeze the oocytes retrieved and once OHSS goes away them perform transfer.
How does the clinician know when to administer the trigger in the stimulation process?
Scans
- ultrasound to check size and number of follicles
Blood test
- check estradiol levels
Other than to cause ovulation why else is a trigger needed during stimulation?
oocyte maturation
FSH only stimulates the follicle but the oocyte remains:
- arrested @ prophase 1 of meiosis
- Immature (diploid DNA compliment)
- closely associated with follicle wall
LH surge causes oocyte to resume meiosis and release a polar body (arrested at metaphase 2 of meiosis)
Once the trigger is taken what are the different morphological stages of oocyte maturation?
- germinal vesicle (GV)
- fried egg
- 2N arrested
- no capacity to be fertilised
- 2 hours after trigger - Metaphase 1 (MI)
- no PB/ no GV
- 2N arrested
- cant be fertilised
- 12 hours after trigger - Metaphase 2 (MII)
- 1 polar body
can be fertilised
- about 30 hours after trigger
What would happen if patient forgot to take trigger?
Oocyte would be collected at prophase 1 of meiosis
What would happen if patient was to take trigger significantly earlier than instructed?
Ovulation would occur before OPU and no eggs would be retrieved
What would happen if a patient takes the trigger significantly later than instructed?
May only get immature oocytes and the GV or MI stage which do not have the capacity for fertilisation
