Infertility and Assisted Conception Flashcards
What is assisted conception treatment?
Any treatment which involves gametes outside the body
What are some common indications for ART?
Endometriosis Male factor Tubal disease Multiple M/F factors Unexplained Ovulatory disorders Multiple female factors
What are some less common indications for ART?
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
What must be done prior to ART?
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
What are the range of ART’s available?
Donor insemination Intra-Uterine Insemination (IUI) In Vitro Fertilisation (IVF) Intra-Cytoplasmic Sperm Injection (ICSI) Fertility Preservation Surrogacy
When is Intra Uterine Insemination (IUI) indicated?
Unexplained infertility
Mild or moderate endometriosis
Mild male factor infertility
How is IUI carried out?
Can be in natural/stimulated cycle
Prepared semen inserted into uterine cavity around time of ovulation
When is In Vitro Fertilisation (IVF) indicated?
Unexplained (>2y)
Pelvic disease (endometriosis, tubal disease, fibroids)
Anovulatory infertility
Male factor infertility ( if >1x10^6 motile sperm)
Others (pre-implantation genetic diagnosis)
What is the first step in IVF?
Down regulation
How is down regulation carried out?
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
What are some S/Es of down regulation?
Hot flushes and mood swings
Nasal irritation
Headaches
How is ovarian stimulation carried out?
GnH containing either synthetic or urinary gonadotrophins (FSH+-LH)
Can be self-administered sc injection
Causes follicular development
What are the side effects of ovarian stimulation?
Mild allergic reactions
Ovarian hyper stimulation syndrome (OHSS)
What happens if the action scan shows a slow response (40-50%)?
Repeat scan 72hrs later
What happens if the action scan indicates a poor response to FSH?
Abandon treatment/increased dose of FSH (8% are abandoned)
What should be done at the action scan?
Assess for risk of OHSS
Plan date/timing of HCG injection
What does the HCG injection in IVF do?
Mimics LH causing resumption of meiosis in oocyte, 36hrs before oocyte recovery
How long should men be abstinent prior to giving a sperm sample for IVF?
72hrs
What criteria are used in assessment of sperm?
Volume
Density-numbers of sperm
Motility- what proportion are moving
Progression- how well they move
What are some risks in oocyte collection?
Bleeding
Pelvic infection
Failure to obtain oocytes
What does an embryologist do to the oocyte sample?
Search through follicular fluid
Identify eggs and surrounding mass of cells
Collect them into cell culture medium
Incubate at 37’C
What occurs at the embryo transfer stage of IVF?
Normally transfer 1 embryo (max 3 in exceptional cases)
Luteal support: progesterone suppositories for 2 weeks, then pregnancy test
When is Intra Cytoplasmic Sperm Injection (ICSI) indicated?
Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis
If the male is azoospermic, what is required in ART?
Surgical sperm aspiration
How can surgical sperm aspiration be carried out?
From epididymis (if obstructive) From testicular tissue (if non-obstructive)
What happens during ICSI at the lab stage?
Each egg is stripped
Sperm immobilised
Incubate at 37’C overnight
What is OHSS?
Enlarged ovaries, excess follicles
What are the symptoms of OHSS?
Abdominal pain/bloating
Nausea/diarrhoea
Breathless
What is the treatment for OHSS before embryo transfer?
Coasting
Elective freeze
Single embryo transfer
What is the treatment for OHSS after embryo transfer?
Monitoring with scans and bloods
Antithrombotic: Fluids, TED stockings and fragmin
Analgesia
Hospital admission if required IV fluids/more intensive monitoring/paracentesis
What are some complications of ART?
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
What is the current success rate for IVF?
35%
