infertility Flashcards

1
Q

human fertility compared to other mammals

A

inefficient reproductive system

conception per cycle - 20% at peak age, declines with age

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2
Q

natural expectation of pregnancy

A

in a couple with no underlying fertility issues
80% of couples will become pregnant within the first year of trying
over 1/2 of the couples that didn’t get pregnant in the first year will get pregnant in the second year
90% of couples should achieve a pregnancy after 2yrs

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3
Q

why does female fertility decline

A

eggs production stops at birth
over the reproductive life span, the majority of the eggs perish with each cycle
fertility declines as egg numbers decline
eggs also don’t perform as well
begins after 35y/o

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4
Q

can we predict decline in fertility?

A

no

at the moment we can only plan ahead and use fertility tests (can’t determine if a women will get pregnant)

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5
Q

4 stages of conception

A

ovulation
sperm production
fertilisation
implantation

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6
Q

what does normal conception rely on

A
functioning hormonal axis and gonads
ovarian reserve 
regular ovulation
normal sperm production
fertilisation: sperm and egg interaction, patent fallopian tubes
normal uterine cavity for implantation
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7
Q

lifestyle factors affecting conception

A
age 
BMI
smoking 
alcohol 
recreational drug use
stress
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8
Q

clinical definition of infertility

A

inability to conceive over a 12mth period despite exposure to regular, unprotected intercourse

represents a prognosis based approach
provides practical guidance on when to initiate investigations

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9
Q

epidemiological definition of infertility

A

lack of conception after 2yrs in women of reproductive age (15-49) who are at a risk of becoming pregnant (sexually active, not using contraception)

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10
Q

demographic definition of infertility

A

inability to become pregnant with a live birth, within 5yrs of exposure

based upon a consistent union status, lack of contraceptive use, non-lactation and continuation of a desire for a pregnancy

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11
Q

global infertility trends

A

10% of woman affected globally, likely underestimated (based on demographic definition)

1/7 couples in western world, 1/4 couples in developing countries affected

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12
Q

difficulties with estimating prevalence of infertility

A

main challenge in getting true estimates is inconsistency in definition used to calculate prevalence

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13
Q

when to refer

A

no conception after 1yr of regular unprotected intercourse

referral earlier if:

  • age >35
  • known cause for infertility
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14
Q

types of infertility

A

1y - never managed to have pregnancy before/never fathered a child

2y - have had a pregnancy before/fathered a child but cannot manage again

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15
Q

causes of infertility

A
male - 30%
female - 30%
combined - 10%
unexplained - 25%
other - 5%
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16
Q

female infertility factors

A
ovulatory dysfunction 35%
tubal factor 30%
diminishing ovarian reserve 20%
endometriosis - 10%
uterine factor 5%
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17
Q

male infertility factors

A

hormone production
blockage of sperm transport
sperm production problems
erection and ejaculation problems

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18
Q

why may there be blockage of sperm transport

A

infection
prostate related problems
absence of vas deferens
vasectomy

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19
Q

why may there be issues with sperm production

A
genetic
undescended testes
infection
torsion
varicocele
drugs 
radiation damage 
sperm antibodies
heat
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20
Q

why may there be erection and ejaculation problems

A
prostate surgery 
damage to nerves
ejaculation problems 
timing of intercourse
medication
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21
Q

investigating infertility

A

are eggs available
are sperm available
can they meet
any other factor

22
Q

investigating infertility - egg availability

A
age 
ovarian reserve test - bloods and scan
bloods: 
- FSH, D1-D5 of cycle (<10iu/L)
- AMH (5.0-25.0pmol/L)

US - antral follicular count

23
Q

investigating infertility - is ovulation happening

A

used by couples:

  • natural methods - BBT, cervical mucus
  • LH ovulation kits
  • ovulation calender

used to investigate:
- D21 serum progesterone

24
Q

natural ovulation detection - basal body temperature

A

female checks temp
at the time of fertile window
at the time of progesterone rise (post-ovultation) - slightly higher temperatures can be recorded
fertile window is just before this

25
Q

natural ovulation detection - cervical mucus

A

phase and stage, sensation, cervical fluid appearance

pre-ovulatory stage - dry-light moisture; INFERTILE; no observable mucus

fertile - moist/sticky; white/cream in colour, thick to a little stretchy, breaks easily when pulled

highly fertile - slippery, wet, lubricated; thin, watery, transparent, like egg white, increased amount

post-ovulatory - dry/moist/sticky; INFERTILEl thick, opaque white/cream, much decreased amount

26
Q

LH kits

A

measures peak of LH
uses urine to measure
LH surge - fertile

27
Q

ovulation diagnosis

A

progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle

levels >20nmol/L show satisfactory ovulation

28
Q

investigating infertility - sperm availability

A

semen analysis

29
Q

parameters for semen analysis - lower limit normal, 95% confidence

A
volume - 1.5ml, 1.4-1.7ml
total sperm number - 39mln, 33-46mln
concentration - 15mln/ml, 12-16mln/ml
vitality - 58%, 55-63%
progressive motility - 32%, 31-34%
total motility - 40%, 38-42%
normal morphology - 4%, 3-4%
30
Q

investigating infertility - can egg and sperm meet

A

intercourse - any difficulties, female or male

patent fallopian tubes

31
Q

how to check fallopian tube patency

A

if no pelvic infection/gynae problem previously - hysterosalpingogram (HSG)

if any of above - laparoscopic dye test

32
Q

HSG - what is done

A

small catheter inserted through cervix
dye injected
x-ray image taken
observe fallopian tubes

33
Q

other tests for investigating fertilit

A

serum prolactin
TFTs
chlamydia screening
pelvic US for uterine problems

also - rubella immunity, cervical smear up to date

34
Q

managing ovulation disorder

A

optimise body weight, healthy lifestyle, exercise

medication

laparoscopic ovarian drilling

35
Q

medication for ovulation disorders

A

ovulation induction:

  • clomiphene citrate
  • gonadotrophins
36
Q

managing sperm problems - very low count/no sperm

A

medication - gonadotrophins
surgical sperm retrieval - epididymis/testis
donor sperm - intrauterine insemination
ICSI - intracytoplasmic sperm injection

37
Q

what is azoospermia

A

no sperm in the ejaculate

38
Q

management of tubal problems

A

role of surgery is limited to mild tubal disease

IVF

39
Q

management of endometriosis for infertility

A

ablation/resection of spots
adhesiolysis
cystectomy for endometrioma

40
Q

uterine surgery for infertility

A

removal of polyp/fibroid

adhesiolysis for synechiae

41
Q

management of unresolved infertility

A

IVF

42
Q

human fertilisation and embryology authority

A
regulatory authority
licensing 
inspections
forms - registration, treatment, outcome
register
43
Q

what eggs are used in IVF

A

own eggs - gonadotropin induced superovulation

donor eggs

44
Q

when are donor eggs used in IVF

A

used with increased age and poor ovarian reserve - poor quality eggs, ovarian failure, genetic cause

45
Q

what sperm are used in IVF

A

partner

donor

46
Q

partner sperm for IVF

A

fresh sample on day of egg collection

frozen sample (thawed) from surgical retrieval or fertility preservation

47
Q

donor sperm for IVF - when are they used

A
single women 
same sex relationship 
azoospermia 
genetic cause
infection - HIV, hep B/C
48
Q

IVF process - 8 key steps

A
controlled ovarian stimulation
follicular monitoring 
timing ovulation 
egg collection
lab fertilisation - insemination/ICSI
incubation/embryo development 
embryo transfer
progesterone support
49
Q

‘managament’ following embryo transfer

A

progesterone pessaries
normal activity
pregnancy test after 2wks
if +ve - scan at 7wks

50
Q

risks of IVF

A

ovarian hyperstimualtion syndrome (OHSS)
multiple pregnancy
medication side effects
procedure related

51
Q

long term effects of IVF

A

children born - no difference as per short term data
risk of ovarian cancer not confirmed
absolute risk to women and children low

52
Q

IVF expansions

A
donor gametes
fertility preservation - gamete/embryo cryopreservation
ovarian tissue cryopreservation
preimplantation genetic diagnosis 
assisted hatching 
in vitro maturation
surrogacy