Infertility Flashcards by Katie Robertson

Chances of natural conception decline with increasing what?

Female age

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What are the chances of conception per cycle?

20% at peak

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What is there a predetermined number of in women?

Pre determined number of eggs-no new egg production following egg numbers which the female is born with

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What happens as the ovarian reserve is exhausted?

Cycle irregularity begins to start by age 45 & then over the next 5-7 years menopause is reached

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What is associated with the decline in egg number?

Decline in the quality of the eggs where the capacity of the egg to perform well in terms of nuclear and genetic material division also declines (important feature required to achieve a conception)

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Can a decline in fertility be predicted?

NO, to date there is no fertility test that can tell whether a woman can get pregnant and have a baby

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What are 4 key important factors for conception?

Ovulation=egg production cyclically

Sperm production=Good & swimming well to fertilise egg

Fertilisation=Sperm & egg to meet-happens in fallopian tube (patent & functioning well), no ejaculatory or projectile problems (sexual dysfunction) to allow adequate sperm into the female repro tract

Implantation=Uterus has to be normal

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What parts are crucial for ovulation to happen?

Functioning of the hypothalamus & pituitary gland & ovaries along with the hormones has to be normal for ovulation to happen

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What is the diagnostic test for ovulation?

Measure progesterone to show whether ovulation did happen in that cycle or not

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What happens to the hormone levels in ovulation?

LH surge mid cycle and after ovulation progesterone goes up

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What cycles are coordinated in a cyclical fashion?

Ovarian & menstrual cycles

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What uterine changes occur each month?

Generate an endometrium each month which is capable of having an implantation & pregnancy

Endometrial development under the effect of ovarian hormones

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Fertilisation-oestrogen plays a role and also along with progesterone plays a role in tubal transport and implantation. How does the embryo get into the uterine cavity?

Once the egg is fertilised it starts dividing into embryo

Muscular spasms drive the embryo into the uterine cavity where it implants

Endometrium is prepared under influence of hormones in order to receive the embryo & drive the process of implantation

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What 6 things does natural conception rely on?

Functioning hormonal axis and gonads

Ovarian reserve

Regular ovulation

Normal sperm production

Fertilization- egg and sperm interaction patent fallopian tubes

Normal uterine cavity for implantation

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What lifestyle factors can affect fertility?

Age
BMI
Smoking-can accelerate the decline in ovarian reserve
Alcohol
Recreational drug use
Stress

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What is the WHO clinical definition of infertility?

Inability to conceive over a 12 month period despite exposure to regular , unprotected intercourse. Represents a prognosis based approach and provides practical guidance on when to initiate investigations.

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Why are global infertility trends often unreliable?

Many different definitions (WHO (clinical), epidemiological, demographic definitions)-used inconsistently when calculating prevalence

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When should people be referred for fertility issues?

No conception after one year of regular unprotected intercourse

Referral earlier if-
- Age>35 years
- Known cause for infertility

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What is the difference between primary and secondary infertility?

Primary=never manage to have a pregnancy before or the man has never fathered a child

Secondary=couple have had a pregnancy before in this or in a previous relation but then have not managed to get pregnant

What are some causes of female infertility?

Ovulatory dysfunction
Diminishing ovarian reserve
Endometriosis
Uterine factor
Tubal factor

What may cause male infertility?

Problems in producing hormones for sperm production
Blockage of sperm transport
Erection & ejaculation problems
Sperm production problems

How is it checked that there are eggs available?

Age
Ovarian reserve test- blood test and scan

Blood test- FSH, D1-D5 of cycle (<10 iu/L)
AMH (5.0-25.0pmol/L)
USS- Antral follicular count

AMH=Anti-mullerian hormone – can be measured at any time in the cycle to give an indication of whether the ovarian reserve is satisfactory

What investigations are used to check that ovulation is happening?

Used by couples-
natural methods(BBT, cervical mucus)
LH ovulation kits (measures peak that happens mid cycle)
ovulation calendar

Used to investigate-
D21 serum progesterone

D21-test done on day 21 of the cycle when it is expected that the hormone level will have reached a peak-any levels over 20 are suggestive of ovulatory cycles

What are the natural methods used for ovulation detection?

Progesterone rise that happens post ovulation-slightly higher temps can be recorded

Cervical mucus discharge-maximum around the time of ovulation (looks quite thin & watery)

How is ovulation diagnosed?

Progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle Levels > 20nmol/l show satisfactory ovulation

What can be used to see if there is sperm available?

Semen analysis If these parameters are below that it does not mean total infertility but it means reduced infertility

What needs to be the case in order for the egg and sperm to meet

Intercourse - with no sexual difficulties (e.g. pain or discomfort that prevents regular intercourse or that the man doesn't have any erection or ejaculation problems) Patent fallopian tubes

How is the patency of fallopian tubes checked?

If no pelvic infection or gynaecological problem in past- Hysterosalpingogram(HSG) If any of above- Laparoscopic dye test

How is a HSG taken?

Catheter, dye and a radiograph

How is laparoscopy carried out?

Laparoscope to inspect pelvic organs then put in methylene blue dye & see the flow of that out of the tubes Any additional minor procedures can be carried out at the same time as necessary

What other tests could be carried out?

Serum prolactin Thyroid function test Chlamydia screening Pelvic Ultrasound for uterine problems Also check- Rubella immunity Cervical smear up to date

What are the potential broad category causes of infertility?

Female, male, combined or unexplained

How are ovulation disorders managed?

Optimise body weight, Healthy life style, Exercise Medication (ovulation induction) - Clomiphene citrate-6 cycles oral tablets - Gonadotrophins Laparoscopic ovarian drilling

What are the options if there is a very low count or no sperm (azoospermia)?

Medical treatments- gonadotrophins Surgical sperm retrieval- epididymis/testis Donor sperm- intrauterine insemination ICSI (intracytoplasmic sperm injection)

What can be done in the cases of tubal problems?

Role of surgery is limited to mild tubal disease IVF (blocked tubes removed to make IVF suitable for them)

What are other treatments for 1) Endometriosis & 2) Uterine surgery?

Endometriosis-Ablation or resection of spots, adhesiolysis, cystectomy for endometrioma Uterine surgery- removal polyp/fibroid, adhesiolysis for synechiae

What is an option for unresolved infertility?

IVF (In vitro fertilisation)- egg (oocyte) + sperm=embryo

What is the role of Human Fertilisation & Embryology Authority (HFEA)?

Regulatory authority Licensing Inspections Forms - registration, treatment, outcome Register

What eggs can be used for IVF?

Own eggs-gonadotrophin induced superovulation Donor eggs - age (poor ovarian reserve) poor quality ovarian failure genetic cause

How is sperm got for IVF?

Partner- Fresh sample on day of egg collection Frozen sample (thawed)from surgical retrieval or fertility preservation Donor sperm- Single women Same sex relationship Azoospermia(no sperm) Genetic cause Infection (HIV, HepB,HepC)

What are the key steps for the IVF process?

Controlled ovarian stimulation Follicular monitoring Timing ovulation Egg collection Lab fertilization-Insemination/ICSI Incubation/ embryo development Embryo transfer-done under US guidance Progesterone support Final injection of hCG hormone to trigger ovulation & then 36 hrs=egg retrieval (via transvaginal US) Support is given in the form of vaginal pessaries to maintain the endometrium for pregnancy

How are embryos frozen and stored for IVF?

Technique of freezing=vitrification (straws frozen in liquid nitrogen)- can be kept in the freezing for ~10 yrs – can use it when ready for subsequent cycles Each embryo stored in labelled/colour coded ‘straw'

In IVF what is done post embryo transfer?

Progesterone pessaries Normal activity Pregnancy test after 2 weeks If positive- scan at 7 weeks

What are the risks of IVF?

Ovarian hyperstimulation syndrome (OHSS) Multiple pregnancy Medication side effects Procedure related - Over response of the ovaries-can get production of multiple follicles which can give rise to symptoms - Egg recovery-risk of bleeding or infection

Are there any negative long term affects of IVF?

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