Infertility And ART Flashcards
Define infertility
Sterility
Primary and secondary infertility
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.
What 5 main questions do you ask couples that come to you about infertility?
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?
State five factors of infertility and causes under each factor(state factors in males and females)
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
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
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
State three basic investigations done for couples that complain of infertility
Semen analysis
•Confirmation of ovulation
•Documentation of tubal patency
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?
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.
What four tests do you do to check for ovarian function ?
What is BBT?
What are the disadvantages of using BBT to determine ovulation ?
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
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?
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.
In ultrasound monitoring,ovulation is characterized by?
State two methods of analyzing ovulation
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
State five follow up tests for testing ovulation function
FSH LH PRL T TSH
•Hypothalamic-pituitary disorder
hypothyroidism
PCOS polycystic ovarian syndrome
POF premature ovarian failure
Under tubal function,when do you evaluate tubal patency?
What tests are used to evaluate tubal patency?
Explain the procedure of HSG
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
State the uses,risks and benefits of HSG
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
What four things does laparoscopy allow you to visualize?
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
What tests do you do to check for cervical and immunological factors
Test:
•Postcoital test
•Antisperm antibodies
What is the purpose of post coital test
How is the test done
Antisperm antibodies contribute to sub fertility true or false
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
What are the treatment options for abnormal sperm findings
What are the treatment options for abnormal sperm findings that are related to ART therapy
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)
Under Ovarian disorders,state the treatment options for Anovulation,hyperprolactinemia,premature ovarian failure
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)
What are the treatment options for structural abnormalities in women who are infertile
State four treatment options for unexplained infertility
Structural Abnormalities
•surgical therapy
–Laparoscopic lysis of adhesions
–Laparoscopic endometriosis ablation
–Microsurgical Tuboplasty
–Salpingostomy
•IVF
Unexplained Infertility
•Expectant observation
•Ovulation induction
•IUI
•IVF-ET
How is Clomiphene Citrate given?
How does it function to treat anovulation
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
Assisted Reproductive technologies include what methods ?(name four)
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
State the types of Artificial Insemination
What are the indications for artificial insemination
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
What is the indication for Artificial insemination by donor
What issues can it raise?
What kind of semen is used?
For men with azoospermia
•Raise medical, emotional, ethical, legal issues for the potential parents and the practitioner
•Only use the frozensemen
What are the indications for IVF ET(In Vitro fertilization and embryo transfer)
(State five)
State the five processes involved
Severe tubal disease
•Antisperm antibodied
•Endometriosis
•Oligospermia
•Unexplained infertility
Process:
ovarian stimulation
•egg retrieval
•fertilization
•embryo culture
•transfer of embryos to the uterus
What drug therapies can be used for ovarian stimulation done in IVF ET
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
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
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
What two things are used to give luteal support
What two things are used for pregnancy testing
Progestorone
•HCG
Testing:
Serum or Urine HCG level
•Ultrasound
Name four IVF related techniques
State and explain four risks of IVF
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 2. What are the Assisted Reproductive Techniques practised to help infertile couples? Describe any three techniques.
