Infertility and assisted conception

Question 1

What changes should be advised before treatment for infertility begins?

Answer 1

Alcohol: females limit to 4 units per week

Weight: BMI between 19-29

Stop smoking

Folic acid: 0.4mg/day preconception-12 weeks gestation

Check rubella immunisation

Check cervical smears

Drugs: prescribed, over-the-counter and recreational

Screen for blood born viruses

Question 2

What is the method for intrauterine insemination?

Answer 2

Prepared semen inserted into uterine cavity around time of ovulation

Question 3

In which cases would intrauterine insemination be used?

Answer 3

Mild male infertility

Mild endometriosis

Unexplained infertility

Question 4

What are the indications for IVF?

Answer 4

Unexplained infertility > 2 years duration

Pelvic disease (endometriosis, tubal disease, fibriods)

Anovulatory infertility

Male factor infertility (if > 1 X 106 motile sperm)

Question 5

What is buserelin and when is it administered?

Answer 5

Synthetic GnRH, which causes ‘downregulation’ and suppresses pituitary release of FSH and LH

Given 21 days after menstrual bleed

Question 6

What are the side effects of buserelin?

Answer 6

Hot flushes

Nasal irritation

Headaches

Mood swings

Question 7

After downregulation by buserelin has been going on for 2-3 weeks, what is the next step in IVF treatment?

Answer 7

Ovarian stimulation by gonadotrophin hormone, causing follicular development

Question 8

What is the risk associated with ovarian stimulation?

Answer 8

Ovarian hyperstimulation syndrome

Question 9

What is the next step in IVF treatment after ovarian stimualtion?

Answer 9

HCG injection, mimicking the LH surge that occurs prior to ovulation

Question 10

How many embryos may be transferred into the uterus?

Answer 10

Patients under the age of 40 - no more than 2 embryos to be transferred

Patients aged 40 and over - 3 may be transferred in exceptional circumstances only

Question 11

Why are so few embyos transferred?

Answer 11

To reduce risk of mulitple pregnancy

Question 12

What are the indications for intracytoplasmic sperm injection?

Answer 12

Severe male factor infertility

Previous failed fertilisation with IVF

Question 13

What is intracytoplasmic sperm injection (ICSI)?

Answer 13

An in vitro fertilization procedure in which a single sperm is injected directly into an egg

Question 14

How are sperm retrieved for ICSI?

Answer 14

Surgical aspiration

Question 15

What are the symptoms of ovarian hyperstimulation syndrome?

Answer 15

Abdominal pain / bloating

Nausea / Diarrhoea

Breathless

Question 16

How does the Y chromosome cause development of the male genital tract?

Answer 16

Y chromosome has the region that codes for testes

Fetal testes release testosterone and mullerian inhibiting factors

The Wolffian ducts then begin to develop the male genital tract as the Mullerian ducts recede

Question 17

Which becomes the female genital tract: Mullerian or Wolffian ducts?

Answer 17

Mullerian

Wolffian ducts degenerate in the absence of testosterone

Question 18

What is androgen insensitivity disorder?

Answer 18

An X-linked recessive disorder in which male chromosomes have been inherited and so the testes develop, but do not respond to testosterone

As a result, testes never descend and Wolffian tracts never develop

Patients often think they are female, and present at puberty with a short vagina, no pubic hair and amenorrheoic

Question 19

What is cryptorchidism?

Answer 19

Undescended testes

Question 20

Why should orchidectomy be considered in an adult whos testes have not descended?

Answer 20

Risk of germ cell cancer 6x

Question 21

What are the implication on fertility if testes undescended?

Answer 21

Sperm count reduced

Usually fertile if unilateral

Question 22

What do Leydig cells do?

Answer 22

Secrete testosterone

Question 23

What do sertoli cells do?

Answer 23

Protects the sperm from antibody attack

Provide nutrients for the developing cells

Phagocytosis

Secrete seminiferous tubule fluid

Produces hormone that binds testosterone so concentration remains high in lumen

Secretes inhibins and activins that regulate FSH

Question 24

Where are sertoli cells located?

Answer 24

The semniferous tubules

Question 25

Which hormone activates Sertoli cells?

Answer 25

FSH

Question 26

What hormone do Sertoli cells secrete early in fetal life?

Answer 26

Anti-Mullerian hormone

Question 27

Which protein in the hypothalamic-pituitary axis is a decapeptide?

Answer 27

GnRH

Question 29

Which area of the oocyte is sperm attracted to/binds to?

Answer 29

Zona pallucida

Question 30

Where are sperm concentrated, stored and matured?

Answer 30

Epidydimis and vas deferens

Question 31

What is secreted by the seminal vesicles?

Answer 31

Semen

Fructose

Prostaglandins

Fibrinogen

Question 32

What is the function of the prostate gland?

Answer 32

Produces alkaline fluid (neutralizes vaginal acidity), produces clotting enzymes to clot semen within female

Question 33

What route does sperm take during ejaculation?

Answer 33

Testes –> epididymis –> vas deferens –> ejaculatory duct –> urethra

Question 34

What is the definition of male infertility?

Answer 34

Infertility resulting from failure of the sperm to normally fertilise the egg

Question 35

What might cause obstruction of the vas deferens?

Answer 35

congenital absence (cystic fibrosis)

infection

vasectomy

Question 36

At what stage is embryo transfer most successful?

Answer 36

Blastocyst