Infertility and Assisted Conception

Question 1

What is assisted conception treatment?

Answer 1

Any treatment which involves gametes outside the body

Question 2

What are some common indications for ART?

Answer 2

Endometriosis
Male factor
Tubal disease
Multiple M/F factors
Unexplained
Ovulatory disorders
Multiple female factors

Question 3

What are some less common indications for ART?

Answer 3

Fertility preservation in cancer patients
Treatment to avoid transmission of BBVs between patients
Pre-implantation diagnosis of inherited disorders
Treatment of single parents/same sex couples
Cryopreservation of gametes
Tx when absent/abnormal uterus

Question 4

What must be done prior to ART?

Answer 4

Alcohol-limit 4 units/week
Weight-between 19-29 optimal both M/F
Smoking- advise to stop
Folic acid- 0.4mg/day preconception -12 weeks gestation
Rubella-immunise
Smear- check up to date
Occupation- hazard check
Drugs- check prescribed, OTC and recreational
Screen for BBVs- hep B/C, HIV
Assess ovarian reserve: antral follicle count or AMH

Question 5

What are the range of ART’s available?

Answer 5

Donor insemination
Intra-Uterine Insemination (IUI)
In Vitro Fertilisation (IVF)
Intra-Cytoplasmic Sperm Injection (ICSI)
Fertility Preservation
Surrogacy

Question 6

When is Intra Uterine Insemination (IUI) indicated?

Answer 6

Unexplained infertility
Mild or moderate endometriosis
Mild male factor infertility

Question 7

How is IUI carried out?

Answer 7

Can be in natural/stimulated cycle

Prepared semen inserted into uterine cavity around time of ovulation

Question 8

When is In Vitro Fertilisation (IVF) indicated?

Answer 8

Unexplained (>2y)
Pelvic disease (endometriosis, tubal disease, fibroids)
Anovulatory infertility
Male factor infertility ( if >1x10^6 motile sperm)
Others (pre-implantation genetic diagnosis)

Question 9

What is the first step in IVF?

Answer 9

Down regulation

Question 10

How is down regulation carried out?

Answer 10

Synthetic GnRH analogue or agonist is administered as spray or injection
Reduces cancellation from ovulation improving success rates
Allows precise timing of oocyte recover by using HCG trigger

Question 11

What are some S/Es of down regulation?

Answer 11

Hot flushes and mood swings
Nasal irritation
Headaches

Question 12

How is ovarian stimulation carried out?

Answer 12

GnH containing either synthetic or urinary gonadotrophins (FSH+-LH)
Can be self-administered sc injection
Causes follicular development

Question 13

What are the side effects of ovarian stimulation?

Answer 13

Mild allergic reactions

Ovarian hyper stimulation syndrome (OHSS)

Question 14

What happens if the action scan shows a slow response (40-50%)?

Answer 14

Repeat scan 72hrs later

Question 15

What happens if the action scan indicates a poor response to FSH?

Answer 15

Abandon treatment/increased dose of FSH (8% are abandoned)

Question 16

What should be done at the action scan?

Answer 16

Assess for risk of OHSS

Plan date/timing of HCG injection

Question 17

What does the HCG injection in IVF do?

Answer 17

Mimics LH causing resumption of meiosis in oocyte, 36hrs before oocyte recovery

Question 18

How long should men be abstinent prior to giving a sperm sample for IVF?

Answer 18

72hrs

Question 19

What criteria are used in assessment of sperm?

Answer 19

Volume
Density-numbers of sperm
Motility- what proportion are moving
Progression- how well they move

Question 20

What are some risks in oocyte collection?

Answer 20

Bleeding
Pelvic infection
Failure to obtain oocytes

Question 21

What does an embryologist do to the oocyte sample?

Answer 21

Search through follicular fluid
Identify eggs and surrounding mass of cells
Collect them into cell culture medium
Incubate at 37’C

Question 22

What occurs at the embryo transfer stage of IVF?

Answer 22

Normally transfer 1 embryo (max 3 in exceptional cases)

Luteal support: progesterone suppositories for 2 weeks, then pregnancy test

Question 23

When is Intra Cytoplasmic Sperm Injection (ICSI) indicated?

Answer 23

Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis

Question 24

If the male is azoospermic, what is required in ART?

Answer 24

Surgical sperm aspiration

Question 25

How can surgical sperm aspiration be carried out?

Answer 25

From epididymis (if obstructive) 
From testicular tissue (if non-obstructive)

Question 26

What happens during ICSI at the lab stage?

Answer 26

Each egg is stripped
Sperm immobilised
Incubate at 37’C overnight

Question 27

What is OHSS?

Answer 27

Enlarged ovaries, excess follicles

Question 28

What are the symptoms of OHSS?

Answer 28

Abdominal pain/bloating
Nausea/diarrhoea
Breathless

Question 29

What is the treatment for OHSS before embryo transfer?

Answer 29

Coasting
Elective freeze
Single embryo transfer

Question 30

What is the treatment for OHSS after embryo transfer?

Answer 30

Monitoring with scans and bloods
Antithrombotic: Fluids, TED stockings and fragmin
Analgesia
Hospital admission if required IV fluids/more intensive monitoring/paracentesis

Question 31

What are some complications of ART?

Answer 31

OHSS
No  eggs  retrieved (very uncommon: 0.2%)
Surgical risks of oocyte retrieval 
Surgical risks of surgical sperm aspiration
Failed  fertilisation (approx. 4%)
Ectopic pregnancy
Non-continuing  pregnancy
Increase risk in on-going pregnancy
Psychological problems

Question 32

What is the current success rate for IVF?

Answer 32

35%