Infertility And ART

Question 1

Define infertility
Sterility
Primary and secondary infertility

Answer 1

Sterility implies an intrinstic inability to achieve pregnancy.
Infertility implies a decrease in an ability to conceive.
Primary infertility applies to those who have never conceived.
Secondary infertility applies to those who have conceived at some time in the past regardless of live birth or not.

Infertility — inability of a couple to conceive within one year of unprotected sexual intercourse.

Question 2

What 5 main questions do you ask couples that come to you about infertility?

Answer 2

Q1. Are the couple normal or abnormal? (statistic)

1: abnormal or normal?
•~ 90% of couples conceive within 1 year of unprotected intercourse.
•incidence ranges from 7~28%
•incidence increase with age

Q2. Why can’t they conceive ? (reason or factors of infertility)
Q3. What tests should they take? (evaluation)
Q4. How can we help them? (treatment)
Q5. If they need ART at last, What means ART?

Question 3

State five factors of infertility and causes under each factor(state factors in males and females)

Answer 3

ovulatory dysfunction: ovulatory dysfunction 30-40%
• polycystic ovarian syndrome (PCOS)
• simple anovulation
• decreased ovarian reserve

• tubal disease: tubal and peritoneal factors 30-40%
• tubal injury
• tubal blockage
• paratubal adhesion

• uterine factor: uterine abnormalities
• uterine myoma
• adhesions of uterine cavity(Asherman’s syndrome )
•Endometritis
•Polyp of endometrium

• cervical and immunologic factor:
cervical factor is estimated to be a cause of infertility in no more than 5% of infertile couples.

Endometriosis’s prevalence increases to 30-40% among infertile women.
The reasons of endometriosis induced infertility are multiple.

• unexplained factor

Males:

abnormality of semen
• abnormality of sexual activity
• immune factor

abnormal intercourse
• immune factor
• unexplainded reason

Question 4

Under evaluation what is The Most Important Factor in the Evaluation of the Infertile Couple ?
What are the important things to note in the history of an infertile couple and physical exam of this couple

Answer 4

History

0
history
•menstrual history
•Pelvic pain
•Previous pregnancy outcomes
•PID, IUD, pelvic surgery
•Pituitary, adrenal, thyroid function
•Galactorrhea, hirsutism, weight change

Developmental defects
•Past genital surgery
•Mumps orchitis
•Genital trauma
•Medications
•Occupational exposures
•Sexual history

Family history of •Infertility
•Premature ovarian failure
•Congenital or developmental defects
•Mental retardation

Physical exam:
Height,weight,body habitus
•Hair distribution
•Thyroid gland
•Pelvic examination

Question 5

State three basic investigations done for couples that complain of infertility

Answer 5

Semen analysis

•Confirmation of ovulation

•Documentation of tubal patency

Question 6

When is semen analysis performed?
When is the semen examined?
What are the characteristics of semen analysis in a normal person
What factors are associated with diminished semen quality?

Answer 6

performed after at least 48 hours of abstinence
• examination within 0ne-half to one hour of collection

Characteristics of semen analysis(normal)
• Volume – 1.5-5ml
• concentration - ≥20million/ml
• Motility - >50% with forward movement
• Morphology - >30% normal

Several specimens are necessary to verify an abnormality.
• Caffeine, alcohol, and smoking has been associated with diminished semen quality.

Question 7

What four tests do you do to check for ovarian function ?
What is BBT?
What are the disadvantages of using BBT to determine ovulation ?

Answer 7

Document ovulation:
–BBT
–Luteal phase progesterone
–LH surge
–Ultrasound monitoring
–The only convincing proof of ovulation is pregnancy

Basal body temperature chart
•Temperature be determined before arises, eats, drinks, smoking
•secretion of progesterone causes a temperature increase of about 0.5 ℃

Cheap and easy, but…
–Provides evidence after the fact (retrospectively)
–May delay timely diagnosis and treatment
–the exact time of ovulation is difficult to determine
–Inconsistent results
–Biphasic profiles can also be seen with LUF syndrome

Question 8

What is luteal phase progesterone and when is this test performed
Under LH monitoring,when does ovulation occur after the onset of LH surge and after LH peak?

Answer 8

peak progesterone secretion in the midluteal phase
•Performed 7 days after presumptive ovulation
•>3ng/ml consistent with ovulation

Ovulation occurs 34 to 36 hours after the onset of the LH surge
•about 10 to 12 hours after the LH peak.

Question 9

In ultrasound monitoring,ovulation is characterized by?
State two methods of analyzing ovulation

Answer 9

Ovulation is characterized by a decrease in the size of a monitored ovarian follicle.
•It most often occurs when follicular size reaches about 21 to 23 mm

Methods:
Endometrial biopsy
•Cervical mucus changes

Question 10

State five follow up tests for testing ovulation function

Answer 10

FSH LH PRL T TSH
•Hypothalamic-pituitary disorder
hypothyroidism
PCOS polycystic ovarian syndrome
POF premature ovarian failure

Question 11

Under tubal function,when do you evaluate tubal patency?
What tests are used to evaluate tubal patency?

Explain the procedure of HSG

Answer 11

Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition

•Tests
–HSG(hysterosalpingography)
–Laparoscopy

Procedure
A speculum is inserted into the vagina，
•A catheter is then inserted into the cervix
•Contrast material is injected into
the uterine cavity through the
catheter
•Fluoroscopic images are
then taken

Question 12

State the uses,risks and benefits of HSG

Answer 12

Uses:

used to evaluate infertility or with frequent miscarriages
•Uterine abnormalities
•Congenital uterine anomalies
•Fibroids or tumor masses
•Adhesions

Benefits:

minimally invasive procedure
•Minimal exposure to radiation
•Can detect intrauterine and tubal disorders but not always definitive
•Increase subsequent pregnancy rates

Risk:
Can be uncomfortable
•Pregnancy test is advisable
•Infection
•vasovagal reaction
•allergic response to the contrast dye

Question 13

What four things does laparoscopy allow you to visualize?

Answer 13

Invasive and requires office setting
•offer diagnosis and treatment in one setting
•visualization
–detection of intramural and submucous uterine myoma
–peritubal and periovarian adhesions
–endometriosis
–Tubal patency

Question 14

What tests do you do to check for cervical and immunological factors

Answer 14

Test:
•Postcoital test
•Antisperm antibodies

Question 15

What is the purpose of post coital test
How is the test done
Antisperm antibodies contribute to sub fertility true or false

Answer 15

Purpose:
–determine the number of active sperm in the cervical mucus
–the length of sperm survival after coitus

Scheduled as close to ovulation as possible
–2 days of male abstinence before test
–No lubricants
–Evaluate 8-12h after coitus
–aspirating cervical mucus with a syringe or forceps
•More than 10 motile sperm per high-power field

False
In serum, cervical mucus and semen
•Contribute to subfertility
•The diagnosed function of ASA is limited

Question 16

What are the treatment options for abnormal sperm findings

What are the treatment options for abnormal sperm findings that are related to ART therapy

Answer 16

Abnormal sperm findings
•Urology referral
•Quitting smoking, alcohol
•Avoidance of lubricants
•Medical therapy
•Surgical therapy

Abnormal sperm findings-ART–related therapies
•Intrauterine insemination(sperm injected through cervix)
•IVF or ICSI
•Artifical insemination(donor)

Question 17

Under Ovarian disorders,state the treatment options for Anovulation,hyperprolactinemia,premature ovarian failure

Answer 17

Ovarian disorders
•Anovulation/Oligo-ovulation
–Clomiphene Citrate ± hCG
–hMG
–Induction + IUI (often done but unjustified)

Hyperprolactinemia
–Bromocriptine

POF (premature ovarian failure)
–high-dose hMG (not very effective)

Question 18

What are the treatment options for structural abnormalities in women who are infertile
State four treatment options for unexplained infertility

Answer 18

Structural Abnormalities
•surgical therapy
–Laparoscopic lysis of adhesions
–Laparoscopic endometriosis ablation
–Microsurgical Tuboplasty
–Salpingostomy
•IVF

Unexplained Infertility
•Expectant observation
•Ovulation induction
•IUI
•IVF-ET

Question 19

How is Clomiphene Citrate given?
How does it function to treat anovulation

Answer 19

Clomiphene Citrate
–The first-line intervention for medical induction of ovulation
–Given by mouth, starting on day 5 of menses
–Decreasing the normal ovarian-hypothalamic estrogen feedback loop
–Increases GnRH pulse amplitude
–Lead to increased pituitary secretion of gonadotropins
–promotes ovarian follicular development

HMG(Human menopausal gonadotropin. Menotropin is a hormonally active medication for the treatment of fertility disturbances. Frequently the plural is used as the medication is a mixture of gonadotropins. Menotropins are extracted from the urine of postmenopausal women. Being a combination drug, Menotropins bind to the follicle stimulating hormone receptor (FSH), which results in ovulation in the absence of sufficient endogenous luteinizing hormone (LH). It also binds the LH receptor, thereby stimulating proper hormone release.)
–75IU HMG(75IU FSH+75IU LH)
–Extract from the urine of menopausal women
–Pregnancy rate is higher while the risk of OHSS(Ovarian hyperstimulation syndrome is an exaggerated response to excess hormones. It usually occurs in women taking injectable hormone medications to stimulate the development of eggs in the ovaries. Ovarian hyperstimulation syndrome (OHSS) causes the ovaries to swell and become painful.) and multiple gestation are increased

Question 20

Assisted Reproductive technologies include what methods ?(name four)

Answer 20

Include
–artificial insemination
–in vitro fertilization and embryo transfer IVF-ET
–gamete intrafallopian transfer(GIFT)
–zygote intrafallopian transfer(ZIFT)
•IVF-ET is the most important technics of ART

Question 21

State the types of Artificial Insemination
What are the indications for artificial insemination

Answer 21

AID（Artificial Insemination by Donor）
•AIH（Artificial Insemination with Husband’s sperm）

So the two above ways can be done in these three ways :
Intrauterine insemination
•Intracervical insemination
•Intravaginal insemination

Indication
•Unexplained infertility
•Male factor infertility

Question 22

What is the indication for Artificial insemination by donor
What issues can it raise?
What kind of semen is used?

Answer 22

For men with azoospermia
•Raise medical, emotional, ethical, legal issues for the potential parents and the practitioner
•Only use the frozensemen

Question 23

What are the indications for IVF ET(In Vitro fertilization and embryo transfer)
(State five)
State the five processes involved

Answer 23

Severe tubal disease
•Antisperm antibodied
•Endometriosis
•Oligospermia
•Unexplained infertility

Process:
ovarian stimulation
•egg retrieval
•fertilization
•embryo culture
•transfer of embryos to the uterus

Question 24

What drug therapies can be used for ovarian stimulation done in IVF ET

Answer 24

Controlled ovarian hyperstimulation
1.CC/HMG/HCG
Clomiphene citrate/Human menopausal gonadotropin (hMG)/Combined human chorionic gonadotropin (HCG)
(pulsatile GnRH is not indicated, HCG is used as the source of luteinizing hormone (LH) bioactivity to stimulate testosterone secretion by Leydig cells, whereas HMG is used as the source of FSH to stimulate the Sertoli cells )

2.FSH/HCG

3.FSH+HMG/HCG

4.GnRH-a(gonadotropin releasing hormone (GnRH) agonists)/FSH、HMG/HCG

Question 25

How do you monitor follicle stimulation after giving drugs
What is ICSI
What is used to retrieve eggs for IvF
What media is used for egg culture

Answer 25

ultrasound
•Serum hormon level
•HCG given to mature the oocytes

ICSI process, a tiny needle, called a micropipette, is used to inject a single sperm into the center of the egg.

The key difference between IVF and ICSI is how the sperm fertilises the egg. In IVF, the egg and sperm (of which there are multiple) are left in a petri dish to fertilise on their own. In ICSI, one sperm is directly injected into the egg.

Typically, transvaginal ultrasound aspiration is used to retrieve eggs. During this procedure, an ultrasound probe is inserted into your vagina to identify follicles, and a needle is guided through the vagina and into the follicles.

Another medium specifically designed for human IVF was human tubal fluid

Embryo transfer catheter is used to transfer embryo

Question 26

What two things are used to give luteal support
What two things are used for pregnancy testing

Answer 26

Progestorone
•HCG

Testing:
Serum or Urine HCG level
•Ultrasound

Question 27

Name four IVF related techniques
State and explain four risks of IVF

Answer 27

Preimplantation genetic diagnosis
PGD

•Cryopreservation of Embryos
•Oocyte donation
•Embryo donation
•Gestational surrogacy

Risks
Multiple gestation: the transfer of more than one embryo associated with a high risk of multiple gestation

•Adverse perinatal outcomes:
Perinatal death
•Pretern delivery
•Low or very low birth weight

•Birth defects: ART is associated with an increased risk of birth defects
•Further research
–neurodevelopmental outcomes
–longterm health of children

•Maternal health risks:

Ovarian Hyperstimulation syndrome
–less than 5% of IVF cycles
–Ovarian swelling
–Pelvic pain
–Hemodynamic fluid shifts
•Ectopic and heterotopic pregnancies
•Increased risks of breast and gynecologic cancers

Question 28

Question 2. What are the Assisted Reproductive Techniques practised to help infertile couples? Describe any three techniques.