Infertility Flashcards

Question

What is surgical sperm retrieval?

Answer 1

When there is a **blockage somewhere along the vas deferens** preventing sperm from reaching the ejaculated semen a **needle and syringe** is used to **collect sperm** from the **epididymis** through the scrotum

Answer 2

Collecting and separating out **high quality sperm** then **injecting** them **directly** into the **uterus of the woman** (unclear if this is any better than normal intercourse)

Answer 3

**Injecting sperm** directly **into the cytoplasm of an egg** – **fertilised eggs become embryos** and are **injected into the uterus of a woman** – useful when there are significant motility issues and a very low sperm count along with other issues

Answer 4

Using **sperm from a donor** is another option for male factor infertility

Answer 5

Used to **examine the quantity and quality of the semen** and sperm – assesses for male factor infertility

Answer 6

**Abstain from ejaculation** for **at least 3 days** and at most 7 days **Avoid hot baths, sauna and tight underwear f**or 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

Answer 7

Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 8

**After 3 months** in borderline results or 2-4 weeks with very abnormal results

Answer 9

**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%**)

Answer 10

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

Answer 11

Refers to **normal characteristics of the sperm** in the semen sample

Answer 12

**Reduced number of sperm in the semen sample**, classified as: **Mild** oligospermia (10 to 15 million / ml) **Moderate** oligospermia (5 to 10 million / ml) **Severe** oligospermia (less than 5 million / ml)

Answer 13

**Very few sperm** in the semen sample (less than 1 million / ml)

Answer 14

Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 15

**Pathology of the pituitary gland / hypothalamus** **Suppression due to stress, chronic conditions or hyperprolactinaemia** **Kallman syndrome** **Causing hypogonadotrophic hypogonadism** (low LH and FSH resulting in low testosterone – necessary for sperm production)

Answer 16

**Mumps** **Undescended testes** **Trauma** **Radiotherapy** **Chemotherapy** **Cancer**

Answer 17

**Klinefelter** syndrome **Y** chromosome **deletions** **Sertoli cell-only syndrome** Anorchia **(absent testes)**

Answer 18

**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)

Answer 19

**History** **Examination** **Repeat sample** **Ultrasound of testes**

Answer 20

**Hormonal analysis** with LH, FSH and testosterone levels **Genetic testing** **Further imaging**, such as transrectal ultrasound or MRI **Vasography**, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction **Testicular biopsy**

Answer 21

Depends on the **underlying cause:** **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

Answer 22

**Fertilising an egg** with a sperm in a lab and then **injecting** the resulting **embryo** into the uterus – **funding criteria are strict** and vary between areas – couples are limited to a set number of cycles funded by the NHS

Answer 23

25-30% success rate at producing a live birth

Answer 24

**More straightforward process** and involves injecting sperm directly into the uterus avoiding intercourse – used in cases such as donor sperm for same-sex couples, HIV (avoiding unprotected intercourse) and practical issues with vaginal sex

Answer 25

**Cycle of IVF** involves a single episode of ovarian stimulation and collection of oocytes (eggs) – single cycle may produce **several embryos** Embryos can be **transferred separatley** in **multiple attempts at pregnancy** during one "cycle" of IVF - embryos that are not used immediately can be frozen to be **used at later date** - frozen embryos can potentially be used **years later**

Answer 26

**Suppressing the natural menstrual cycle** **Ovarian stimulation** **Oocyte collection** **Insemination** / intracytoplasmic sperm injection (ICSI) **Embryo culture** **Embryo transfer**

Answer 27

GnRH agonist or GnRH antagonist

Answer 28

Injection of GnRH agonist (e.g. goserelin) is given in the **luteal phase** of the menstural cycle (around 7 days before expected onset of menstrual period) usually **day 21 of the cycle** Stilulates the **pituitary gland** to **secrete a large amount of FSH and LH** after this initial surge there is **negative feedback** to the hypothalamus and the natural production of **GnRH** is **suppressed** - causing **suppression of menstrual cycle**

Answer 29

Daily **subcutaneous** injections of a **GnRH antagonist** (e.g. cetrorelix) are given starting from day 5-6 of ovarian stimulation - supresses the body releasing LH and causing ovulation to occur

Answer 30

**Follicles** which are developing would be **released** before it is possible to collect them

Answer 31

Using medications to **promote** the development of **multiple follicles** in the ovary - starting at **beginning of the menstrual cycle** (usually day 2) with **subcutaneous** injections of **FSH** over 10 to 14 days - FSH **stimulates** the development of follicles and this is **closely monitored** with **regular transvaginal ultrasound scans**

Answer 32

When enough follicles have developed to an adequate size (usually around 18 millimetres), the FSH is stopped, and 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”.

Answer 33

Under **guidance** of a **transvaginal ultrasound scan** **Needle** is **inserted** through the **vaginal wall into each ovary** to **aspirate** the fluid from **each follicle** Fluid **contains the mature oocyte** from the follicles Procedure is usually performed under **sedation** (not general anaesthetic) - fluid from the follicles is **examined under the microscope for oocytes**

Answer 34

Male produces a **semen sample** around the time of **oocyte collection** - **frozen sperm** from **earlier** samples may be used - sperm and egg are mixed in a culture medium - **thousands of sperm** need to be **combined** with each oocyte **to produce enough enzyme**s (e.g. **hyaluronic acid**) for one sperm to penetrate the **corona radiata** and **zona pellucida** and **fertilise the egg**

Answer 35

**Male factor infertility**

Answer 36

In **addition to the IVF process** - after the eggs are harvested a semen sample is produced **the highest quality sperm are isolated** and **injected** directly into the **cytoplasm of the egg**

Answer 37

**2 - days** left in an incubator to see which grow into a **blastocyst** stage of development

Answer 38

After 2-5 days the **highest quality embryos** are **selected** for transfer - **catheter is inserted** under **ultrasound guidance** through the cervix and **into the uterus** - a **single** embryo is injected through the catheter - generally a single embryo is transferred but **2 may be transferred in older women** (i.e. over 35 years) any **remaining embryos** can be **frozen** for future attempts

Answer 39

**16 days** after egg collection - when this is **positive** implantation has occured There is the **possibility** of **miscarriage** or **ectopic pregnancy**

Answer 40

**Hormonal treatment is stopped** - woman will go on to have a menstrual period - **bleeding may be more substantial** than usual **given the additional hormones** used during ovarian stimuation

Answer 41

From oocyte collection until 8-10 weeks gestation usually in the form of **vaginal suppositories** in order to **mimic** the progesterone that would be released by the **corpus luteum** during a typical pregnancy (after which the **placenta** takes over the production of progesterone)

Answer 42

Around **7 weeks** (also to rule out miscarriage or ectopic pregnancy) - if this is healthy then the remainder of the pregnancy can proceed with **standard care**

Answer 43

**Failure** **Multiple pregnancy** **Ectopic** pregnancy **Ovarian hyperstimulation syndrome**

Answer 44

**Pain** **Bleeding** Pelvic **infection** **Damage to the bladder** or bowel

Answer 45

Complication of ovarian stimulation during IVF infertility treatment - associated with the use of **human chorionic gonadotrophin** to mature the follicles during the final steps of ovarian stimulation

Answer 46

Increase in **vascular endothelial growth factor** (VEGF) released by the **granulosa cells** of the **follicles** - this **increases vascular permeability** cauing **oedema**, **ascites** and **hypovolaemia** The use of **gonadotrophins** (LH and FSH) during ovarian stimulation results in the **development of multiple follicles**. OHSS is provoked by the "**trigger injection**" of hCG 36 hours before oocyte collection (this **stimulates** the **release of VEGF** from the follicles) There is also **activation of the RAAS** system - notable finding in patients with OHSS is a **raised renin level** which correlates with the severity of the condition

Answer 47

**Younger age** **Lower BMI** **Raised anti-Müllerian** hormone **Higher antral follicle count** **Polycystic ovarian syndrome** **Raised oestrogen levels** during ovarian stimulation

Answer 48

During stimulation with gonadotrophinc they are monitored with: **Serum oestrogen levels** (higher levels indicate a higher risk) **Ultrasound monitor of the follicles** (higher number and larger size indicate a higher risk)

Answer 49

**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)

Answer 50

Within 7 days of the hCG injection (early OHSS) Later than 10 days (late OHSS)

Answer 51

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)

Answer 52

Abdominal pain and bloating

Answer 53

**Nausea and vomiting** with ascites seen on ultrasound

Answer 54

Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (\>45%)

Answer 55

**Tense ascites**, **no urine output** (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

Answer 56

Supportive with treatment of any complications, involving:

Answer 57

**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)

Answer 58

Patients with **mild to moderate OHSS** are often managed as an **outpatient**. **Severe cases require admission**, and critical cases may require admission to the intensive care unit **(ICU).**

Answer 59

**Raised** **haematocrit** can indicate dehydration - this is the **concentration of RBCs in the blood** If its raised this indicated **less fluid in the intravascular space** as the blood is becomming more concentrated