Infertility Flashcards
What’s the definition of Infertility?
How many couples are affected?
“Failure to conceive after 12months of unprotected intercourse.
1/4 couples.
How many kids are we expected to have on average in NZ
2.2
___% of women are childless by choice at midpoint of childbearing years
17%
What is done to assess Male Fertility?
Done before woman
A semen Analysis!
Lower Reference Points to Infertility:
- S.Count: <15mill/ml
- Motility: <40% progressive and non-progressive
- Volume <1.5ml
- Total # Sperm <39mill in ejaculate (should be 100-300M)
What is done to Assess female fertility?
- Ovulation: to see she’s ovulating and has a functioning corpus Luteum
- Check E2 day 12
- Check P4 day 21
- FSH day 2-4 <10IU/I
- AMH anti-mullerian hormone (only done last 5-10y via age related graph)
- Timing (not frequency) of Intercourse: Only 16% population and 27% clients know when they are ovulating. Be careful with wording! “do you have it at least 2 times around the women’s fertile period?”
Causes of infertility in %
Unexplained 20%
Male 30%
Female 30%
Both 20%
What are the 6 causes of Female Infertility?
Treatment for each?
- Anovulation
- Weight gain/loss
- Drugs
- PCOS
- metformin, clomiphene citrate or FSH
- IVF
- Tubal disease
- Surgery
- IVF
- Cervical problems
- IUI
- Endometriosis
- IVF
- Ablation or hormone contraceptives
- Premature menopause (rising FSH and decr AMH with age)
- donor egg
- No uterus
- surrogacy
What drugs are used to treat Anovulation?
- GnRH
- Clomiphene citrate: used to be 1st line treatment, now outdated and SERM (non-steroidal) used
- FSH
- Letrazole: Aromatase inhibitor → decreases amount of estrogen. Better for a single not multiple ovulation
What is PCOS
- Multiple cysts/follicles on ovary cortex
- Often infrequent/no period
- Weight gain is common as it’s a metabolic syndrome
First line treatment = WEIGHT LOSS then metformin (insulin sensitiser), CC, FSHn or IVF
What can cause tubal Defects
- Blocked tubes: often by infection or STI; (clamhydia)
- Also Fibroids, cysts/tumours, endometriosis, tubal pregnancy
Describe the Steps involved in IVF
- Ovarian Stimulation
- Stimulation: FSH
- Control: prevent ovulation via GnRH antagonist
- Trigger: stimulate Ovulation via HCG or GnRH agonist (whilst trying to avoid fatal overactive ovaries)
- Luteal support: progesterone (to balance the system)
- Egg Retrival: 36h post stimuli
- Sperm preperation and Fertilisation
- Embryo Culture
- Embryo Transfer: day 3-5
- Embryo Freezing: day 5 is the earliest you can do this!
How does age affect the cumulative pregnancy rate of IVF
(chance of success with every embryo picked from one lot)
<35 is 51%
35-39 is 45%
40+ is 25%
So once in your 40’s it’s a massive failure rate!
IVF cycle tracking
Scans: day 1, 5 and 9
Daily injection of ovarian stimulation drugs: Days 1-10
Daily injections of antagonist: Days 5-10
Egg +sperm implanted Day 12
Blood tests look at Estrogen (~1000m/follile) and progesterone (<6pmol/L)
Fertilised embryo becomes unique embryo when ___
8cell.
What are the pro’s of the recent innovation of ‘Time Lapse Photography and single step media”
- Undisturbed culture from external environ.
- Individual embryo tracking of cell division: can see hidden abnormalities
- Algorithms predict those with best potential
- Provides full info instead of snapshiot selection
The four main causes of Male infertility?
- Oligospermia (decr. sperm conc)
- ICSI
- Donor Sperm (cheaper)
- OATS (oligoasthenoteratospermia; low Sperm conc, and slow, no much you can do!)
- ICSI
- Donor Sperm
- CAVD congenital absence of the Vas Deferens
- ICSI
- Azoospermia (no sperm)
- Treatment dependent on type
What are the differing types and therefore treatments for Azoospermia (NO sperm)
- Kallman’s Syndrome (no GnRH) → FSH/LH replacement
delayed puberty and impaired sense of smell - No spermatogenesis → Donor insemination
- Obstuctive or Vasectomy → reversal, PESA or TESA + ICSI
- Non-Obstuctive → TESE + ICSI
PESA: percutaneous epididymal sperm aspiration
TESA: Testicular sperm aspiration
TESE: testicular sperm extraction
What is ICSI
in vitro fertilization (IVF) procedure in which a single sperm is injected directly into an egg.
Via a big microscope
Steps involved in ICSI in sperm vs egg
Sperm:
- Select motile sperm with normal morphology
- Immobilize sperm
- aspirate sperm tail first
- Position sperm in needle
Egg:
- Position PB at 12o’clock
- suction pipette
- insert needle into egg
- rupture egg membrane by aspirating
- expel the sperm
- culture overnight
What do you do about unexplained infertility?
Mild stimulation with IUI or IVF and hope for the best!
Whats the impact of Age on fertility?
Leading underlying cause of infertility
>40year eggs have more mitochondrial issues and chromosome defects (Pre-implantation Genetic Screening (PGS))
Age of first child is increasing; ~30year in NZ
Due to pressure: social, financial, career and lack of knowledge
Education is key; do the AMH testing
What’s PGS
Pre-implantation Genetic Screening
- Trophoectoderm biopsy day 5/6
- Freeze ALL biopsied embryos
- tube the 8-10 cells
- amplify
- Next generation sequencing
- Analysis results
- Thaw and transfer unaffected euploid embryo
Describe in more depth the day 5/6 trophectoderm biopsy for PGS
Page 54
What’s the pros/cons of EGG FREEZING
- Less succesful then embryo freezing
- Vitrification more successful then slow freezing
- Need ~10 eggs frozen to achieve pregnancy
- Chemo and radiation
- Social egg freezing
What are some final alternative solutions
Surrogacy
Donor embryo
Adoption
Moving on
