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Reproduction SB > Infertility and Assisted Conception > Flashcards

Infertility and Assisted Conception Flashcards

1
Q

what risk factors must be considered in infertility

A

Alcohol: females limit to 4 units per week

Weight: between 19-29 optimal both male and female

Smoking: advise to stop smoking

Folic acid: 0.4mg/day preconception-12 weeks gestation (5mg increase risk NTD)

Cervical smears: check up to date according to national screening programme

Occupational factors: exposure to hazards

Drugs: prescribed, over-the-counter, any internet remedies and recreational (steroids, opiate abuse, cannabis)

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2
Q

what must be screened for when dealing with infertility

A

Rubella: check if female immune to rubella, if not immunise

Screen for blood born viruses: hep B/C and HIV (can still treat them but have to consider how to store the eggs or other treatment options)

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3
Q

how is ovarian reserve tested

A

antral follicle count
or
AMH

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4
Q

what is AMH

A

anti-mullerian hormone is a substance produced by granulosa cells in ovarian follicles.

Production is highest in preantral and small antral stages (less than 4mm diameter) of development.

Production decreases and then stops as follicles grow. There is almost no AMH made in follicles over 8mm.

Levels are fairly constant

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5
Q

when can a AMH test be done

A

any day of a woman cycle

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6
Q

how can AMH be a fertility test

A

Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.

Women with many small follicles, i.e. PCOS have high AMH hormone values

Women that have few remaining follicles and those that are close to menopause have low anti-mullerian hormone levels.

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7
Q

what treatments are available for infertility

A 
Donor insemination
Intra-Uterine Insemination (IUI)
In Vitro Fertilisation (IVF)
Intra-Cytoplasmic Sperm Injection (ICSI)
Fertility Preservation
Surrogacy
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8
Q

what are the indications for intra-uterine insemination

A

unexplained infertility
mild or moderate endometriosis
mild male factor infertility

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9
Q

how does IUI work

A

Prepared semen inserted into uterine cavity around time of ovulation

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10
Q

when is IVF indicated

A

Unexplained (> 2 years durations)

Pelvic disease (endometriosis, tubal disease, fibriods)

Anovulatory infertility

Male factor infertility (only when its mild)

Others (pre-implantation genetic diagnosis)

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11
Q

what needs to happen to women about to go under IVF

A

down regulation

- put women artificially into menopause so there is no spontaneous ovulation

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12
Q

how does down regulation work

A

Synthetic Gonadotrophin releasing hormone analogue or agonist
Administered as a spray or injection

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13
Q

what are side effects of down regulation

A

Hot flushes and mood swings
Nasal irritation
Headaches

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14
Q

how is follicular development encouraged in IVF

A

ovarian stimualtion

  • Gonadotrophin Hormone containing either synthetic or urinary gonadotrophins (FSH+/- LH)
  • Can be self-administered sc injection
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15
Q

what are side effects of ovarian stimulation

A

Mild allergic reactions

Ovarian Hyper Stimulation Syndrome (OHSS) (i.e. when there is too many eggs)

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16
Q

what classic appearance does a thickened endometrium have on ultrasound

A

classic triple line seen

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17
Q

what is the method for sperm sampling in IVF

A

Abstinence for 72 hours beforehand

Ejaculated samples

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18
Q

what is assessed from a sperm sample

A

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

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19
Q

how are oocytes collected

A

theatre

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20
Q

what are the risks of oocyte collection

A

bleeding
pelvic infection
failure to obtain oocytes

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21
Q

how can you tell an egg has been fertilised

A

Two pronuclei

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22
Q

at what day after fertilisation does it become a blastocyst

A

day 5

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23
Q

what stage is usual day of transfer and cryopreservation

A

day 5

- blastocyst stage

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24
Q

what are the measures taken in embryo transfer

A

Normally transfer 1 embryo (max 3 in exceptional circumstances)

Luteal Support
: progesterone suppositories for 2 weeks
:pregnancy test

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25
Q

when do people get there scans in IVF

A

Baseline scan
- before FSH or hMG injection

Action scan
- 8/9 days later before hCG injection

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26
Q

what are indications for Intra Cytoplasmic Sperm Injection (ICSI)

A

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

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27
Q

what is ICSI

A

when you inject the sperm into the egg

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28
Q

how can the sperm be retrieved for ICSI

A

Can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)

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29
Q

what will be require in azoospermia

A

surgical sperm aspiration

30
Q

what is OHSS and symptoms

A

Ovarian Hyper Stimulation Syndrome

  • Enlarged ovaries
  • Excess Follicles

Sx

  • abdo pain/bloating
  • nausea/diarrhoea
  • breathless
31
Q

how do we try to prevent OHSS

A

before embryo transfer

  • elective freeze
  • single embryo transfer

after embryo transfer

  • monitoring [scans, bloods]
  • antithrombotic
  • analgesia
  • Hospital admission if required IV fluids/more intensive monitoring/paracent
32
Q

what regulates all ART activities

A

HFEA

33
Q

what is the current success rate of IVF

A

35%

34
Q

what are the complications of ART

A

multiple pregnancies
OHSS
ectopic pregnancies

35
Q

what are the parts involved in IVF treatment

A 
down regulation
ovarian stimulation
oocyte retrieval
embryo transfer
luteal support
36
Q

what chromosome has the sex determining region

A

Y chromosome

37
Q

what are the 2 primitive genital tracts in the foetus

A

Wolffian ducts = becomes the male genitals

Mullerian ducts = becomes the female genitals

38
Q

what causes the development of the male internal genital tract

A

Fetal testes secretes dihydrotestosterone (and Mullerian inhibiting factors)

Mullerian ducts degenerate

Wolffian ducts&raquo_space; repro tract

39
Q

what causes the development of the female internal genital tract

A

Without stimulus of male testicular hormones, fetus will develop female internal genital tract

Wolffian ducts degenerate

Mullerian ducts&raquo_space; repro tract

40
Q

why are males with CF infertile

A

absent vas deferens

41
Q

where is sperm aspirated from

A

epididymis

42
Q

what is the testes dropping into the scrotal sac before birth dependant on

A

androgen

43
Q

what is crytorchidism

A

undescended testes

44
Q

what does crytorchidism cause

A

reduced sperm count

- if unilateral usually still fertile

45
Q

why is a orchidopexy [surgically descending the testes] done

A

to reduce risk of testicular germ cell cancer

46
Q

what cells in the testis are responsible for testosterone production

A

leydig cells

47
Q

where does spermatogenesis happen

A

sertoli cells in the seminiferous tubules

48
Q

what is the function of sertoli cells

A 
form a blood testes barrier
provide nutrients
phagocytosis 
secrete seminiferous tubule fluid 
secrete androgen binding globulin
secrete inhibin and activin hormones
49
Q

what stimulates spermatogenesis

A

FSH + testosterone

50
Q

what inhibits the secretion of FSH

A

inhibin

51
Q

what stimulates the release of testosterone

A

LH

52
Q

what does testosterone decreased the release of

A

GnRH and LH

53
Q

what does FSH act on to stimulate spermatogenesis

A

sertoli cells

54
Q

FSH and LH are stimulated by GnRH = what cells in the anterior pituitary produce them

A

FSH -> Granulosa cells

LH -> Theca cells

55
Q

what is testosterone protective against

A

osteoporosis

56
Q

how does the sperm fertilise the egg - what are the stages after ejaculation

A 
1 - chemoattraction to oocyte 
2 - docking to zona pellucida of oocyte 
3 - acrosome reaction
4 - hyperactivitiy motility  
5 - penetration and fusion with oocyte membrane
6 - zonal reaction
57
Q

what produces semen into ejaculatory duct

A

seminal vesicles

58
Q

what secretes mucus to act as lubricant

A

bulbourethral glands

59
Q

what is the route of sperm

A

Testes ➔ epididymis ➔ vas deferens ➔ ejaculatory duct ➔ urethra

60
Q

how does an erection occur

A

blood fills corpora cavernosa (under parasympathetic control)

61
Q

under what control is ejaculation

A

sympathetic

62
Q

how can male infertility be categorised

A

idiopathic - most common

obstructive - CF, vasectomy, infection

non-obstructive - chemo/radiotherapy, Cryoptorchadism, tumour

63
Q

what genetic conditions can cause male infertility

A

Klinefelter’s syndrome

microdeletions of Y chromosome

Robertsonian translocation

64
Q

what are endocrine causes of male infertility

A

pituitary tumours - acromegaly, cushings, prolactinoma

hypothalmic cause - tumour, Kallman’s syndrome

thyroid disorders - hyper/hypothyroid

diabetes
CAH
androgen insensitivity
steroid abuse

65
Q

why does Kallman’s syndrome cause infertility

A

do not produce GnRH, therefore no LH, FSH or testosterone

66
Q

what is the normal testicular volume in adults

A

12-25 mls

67
Q

Ix for male infertility

A

Semen analysis
Repeat semen analysis in 6 wks
Endocrine profile [LS, FSH, testosterone, PRL, TSH]
Chromosome analysis

Testicular biopsy
Scrotal scan

68
Q

what are the clinical and endocrine features of an obstructive cause of male infertility

A

Clinical Features:
normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent

Endocrine features:
Normal LH, FSH and testosterone

69
Q

what are the clinical and endocrine features of a non-obstructive cause of male infertility

A

Clinical Features:
low testicular volume
reduced secondary sexual characteristics
vas deferens present

Endocrine features:
High LH, FSH and low testosterone

70
Q

what is the assisted conception method used when male infertility is the problem

A

IUI
ICSI
Surgical Sperm Aspiration
Donor sperm

Reproduction SB (30 decks)

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