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Complex Care 2 > Infertility > Flashcards

Infertility Flashcards

1
Q

What is the WHO definition of infertility?

A

Failure to achieve clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

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2
Q

What is the definition of primary infertility?

A

When a woman is unable to ever bare a child either due to inability to become pregnant or the inability to carry a pregnancy to a live birth.

Either failure to achieve a pregnancy, or pregnancy that ends in spontaneous miscarriage or stillbirth.

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3
Q

What is the definition of secondary infertility?

A

Inability to become pregnant or achieve a live birth after previous successful pregnancy.

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4
Q

List some factors that affect fertility.

A 
Maternal age
Obesity / Underweight
Substance use
Medical/surgical conditions (ie PCOS)
Environmental issues
Socioeconomic issues
Cultural issues
Religious issues
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5
Q

At what age does fertility begin a sharp decline for women?

A

35 - the number and quality of eggs declines and there is an increase in the rate of chromosomal abnormality and miscarriage.

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6
Q

What are the categories of causes of infertility?

A 
Ovulation disorders
Tubal infertility
Endometriosis
Uterine or cervical causes
Unknown causes

What about drug affects such as chemotherapy? - Early menopause?

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7
Q

What are the types of ovulation disorders?

A

Polycystic ovarian syndrome
Hypothalmic dysfunction
Hyperprolactinaemia
Premature ovarian insufficiency

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8
Q

What is Polycystic Ovarian Syndrome?

A

It is a hormonal imbalance resulting in higher levels of male sex hormones (androgen) and lower levels of oestrogen. This results in interference with ovulation and causes the follicles to enlarge creating cysts.

It also causes excess hair growth and acne, insulin resistance (Too much insulin = production of androgens = PCOS), pelvic pain, acanthosis nigricans (patches of thick dark velvety skin), obesity (from increased appetite).

Causes are thought to be genetic and environmental.

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9
Q

What percentage of women are affected by PCOS?

A

10%

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10
Q

How is PCOS diagnosed and treated?

A

Diagnosed by haematology and ultrasound.

Treated by dietary changes to decrease insulin, hormone treatment such as the oral contraception pill and metformin to improve insulin sensitivity.

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11
Q

What causes tubal infertility?

A 
Pelvic inflammatory disease (could be from chlamydia/gonnohrea);
Surgical complications (ie surgery for ectopic);
Pelvic tuberculosis (more common in developing world)
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12
Q

What is endometriosis?

A

Where endometrial tissue grows outside the uterus

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13
Q

How does endometriosis result in infertility?

A

Scarring may interfere with release of an egg, or the ability of the sperm to travel along the fallopian tube to meet the egg.

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14
Q

What are some uterine / cervical causes of infertility?

A

Polyps or tumours (can block ovulation or disrupt implantation);
congenital abnormalities;
cervical stenosis (abnormal narrowing of a passage in the body) - inherited malformation or damage to the Cx;
incompatible cervical mucous.

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15
Q

What is the incidence of male infertility and some causes?

A

20% incidence rates:
Sperm production - the most common cause: low numbers or poor motility
Blockage of sperm in vas deferens (20% of male infertility) from infection, prostate problems or after vasectomy.
Sperm antibodies -
Sexual problems such as erectile dysfunction
Hormonal problems - steroid use?

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16
Q

What lifestyle changes or treatments may be considered for infertility?

A

Weight loss;
Enhanced nutrition;
Traditional chinese medicine;
Antioxidants

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17
Q

What act regulates assisted reproductive technology in Australia?

A

ART Act 2007 - prevents anonymous donation of gametes with information being contained in a central register.

Altruistic donation only allowed - no commercial payments, only to cover costs.

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18
Q

What is fecundability?

A

A couple-specific probability of conceiving a recognised pregnancy per menstrual cycle given no contraception.

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19
Q

What is considered very advanced maternal age?

A

Over 45 years

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20
Q

What is the definition of miscarriage?

A

Spontaneous pregnancy loss before 20 weeks gestation.

21
Q

What is the miscarriage rate in the over 45 years age group?

A

As high as 90%. (This is from lecture slides)

Pairman states over 50% by age 42.

22
Q

Hypertensive disorders in pregnancy are twice as likely in women over 40 than younger women. True or False?

A

True

23
Q

What conditions increase in incidence with advanced maternal age?

A 
Hypertensive disorders;
Placenta praevia;
LBW or preterm;
Ectopic;
Miscarriage;
Chromosomal abnormalities;
Diabetes.
24
Q

The rate of teenage pregnancy in Australia and New Zealand has _________ in recent years. Why?

A

Declined. - Thought to be due to increased access to sex education, contraception and abortion.

25
Q

What is the leading cause of pelvic inflammatory disease in western industrialised countries?

A

Chlamydia infection - results in damage to fallopian tubes, increasing rates of ectopic pregnancy.

26
Q

Chlamydia is most prevalent in which age group in Australia?

A

Young women aged 16 - 24 years.

27
Q

ART increases the risk of what outcomes?

A 
Maternal thromboembolic disease;
abnormal placentation;
miscarriage;
gestational diabetes;
hypertensive disorders;
low birth weight;
congenital malformations;
growth disorders.
28
Q

What are some first-line investigations where infertility occurs?

A 
For women:
Cervical smear test;
Urinalysis for chlamydia;
Blood test for progesterone levels;
Test for rubella;
Blood test at time of menstruation for FSH, LH, and oestradiol;
Tests for onset of menopause.

For men:
Sperm test for count and abnormalities
Urine test for chlamydia.

29
Q

The transfer of fresh or frozen embryos reduces the risk of LBW or preterm birth from ART?

A

Frozen embryos reduce the risk.

30
Q

What are the four basic steps of IVF?

A
  1. Ovarian stimulation;
  2. Egg recovery;
  3. Insemination;
  4. Embryo replacement.
31
Q

What type of drugs are used to stimulate the ovaries for IVF?

A

Gonadotrophins.

32
Q

What is the key risk of ovarian stimulation during ART?

A

Ovarian hyperstimulation syndrome.

33
Q

How is the response of the ovaries to stimulation monitored?

A

Daily oestrogen measurements and ultrasound to see the number and size of follicles and to determine appropriate timing of egg recovery.

34
Q

What is done approx 36 hours before egg collection?

A

Injection of hCG given to initiate the final process of egg maturation.

35
Q

How is egg collection performed?

A

The woman is under sedation or GA, and the needle is guided by a vaginal ultrasound probe. The needle enters the ovary from the top of the vagina and aspirates each follicle using a suction device.

36
Q

What happens during insemination and fertilisation?

A

Eggs are placed in a medium in the lab and placed in an incubator. Sperm are extracted from a sample and used to inseminate the eggs several hours later. After 2 - 3 days the embryos will reach the 6 cell stage and be ready for implantation.

37
Q

Are any further drugs required after embryo transfer?

A

hCG injections or progesterone pessaries/injections may be recommended.

38
Q

What is the incidence rate of Ovarian Hyperstimulation Syndrome, and what are the symptoms?

A

2-3% of cases.

Severe nausea and vomiting, rapid weight gain, abdominal swelling, shortness of breath.

39
Q

What occurs in severe ovarian hyperstimulation syndrome?

A

Haemoconcentration;
Thrombosis;
Oliguria;
Respiratory distress;

Criteria:
Haematocrit >45%
WBC > 15000
Oliguria
Creatinine 1 - 1.5mg/dl
Liver dysfunction
40
Q

What worsens overian hyperstimulation syndrome?

A

Conception or menstruation.

41
Q

What is the management of OHSS?

A

Monitor electrolytes and blood counts, ultrasound to monitor the ovarian follicles.

42
Q

What is gamete intrafallopian transfer (GIFT)?

A

Where collected oocytes and sperm are injected back into the fallopian tube.

Process up to egg collection is same as for IVF, but both gametes injected to fallopian tube, rather than a transfer of embryo.

43
Q

What are the average pregnancy rates of IVF and GIFT?

A

IVF - 15 - 30%; GIFT - 25-30% (more successful but requires laparoscopy.

44
Q

What is ICSI?

A

Intracytoplasmic sperm injection - a single sperm is injected directly into an egg. The embryo is then transferred into uterus as for IVF.

45
Q

How is the egg prepared for the ICSI insemination?

A

The egg is treated with hyaluronisdase, a natural enzyme produced by sperm which digests the cumulus cells surrounding the egg. Further cell layers around the egg are then mechanically removed by gentle suction making it accessible to the sperm.

46
Q

How is the sperm prepared for ICSI?

A

It is immobilised by placing in a viscous solution to slow it’s motility, and then tail is immobilised completely and it is aspirated into a microinjection needle which is carefully pushed through the zone pellucida and into the egg’s cytoplasm. A small amount of cytoplasm is aspirated into the needle and then they are injected into the egg.

47
Q

What are some risks associated with ART?

A

Minor and major birth anomalies;
Increased risks of preeclampsia, APH;
Increased risk of caesarean (possibly due to risk averse approach to such pregnancies);
Increased risks of preterm birth and LBW.

48
Q

What investigations are done for potential infertility?

A

Cervical smear test;
Urine test for chlamydia;
Blood test for progesterone levels 7 days before menstruation;
Test for rubella;
Blood test at menstruation to check FSH, LH and oestradiol levels;
Test for onset of menopause.

For Men:
Test sperm for number and abnormalities
Urine test for chlamydia

49
Q

What is the most prevalent cause of maternal mortality in Australia?

A

Non-obstetric haemorrhage and cardiovascular causes, then thromboembolism followed by obstetric haemorrhage, suicide and sepis.

(From Maternal deaths in Australia report 2012-2014)

Complex Care 2 (15 decks)

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