Infertility and Assisted Conception Flashcards
what risk factors must be considered in infertility
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)
what must be screened for when dealing with infertility
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)
how is ovarian reserve tested
antral follicle count
or
AMH
what is AMH
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
when can a AMH test be done
any day of a woman cycle
how can AMH be a fertility test
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.
what treatments are available for infertility
Donor insemination Intra-Uterine Insemination (IUI) In Vitro Fertilisation (IVF) Intra-Cytoplasmic Sperm Injection (ICSI) Fertility Preservation Surrogacy
what are the indications for intra-uterine insemination
unexplained infertility
mild or moderate endometriosis
mild male factor infertility
how does IUI work
Prepared semen inserted into uterine cavity around time of ovulation
when is IVF indicated
Unexplained (> 2 years durations)
Pelvic disease (endometriosis, tubal disease, fibriods)
Anovulatory infertility
Male factor infertility (only when its mild)
Others (pre-implantation genetic diagnosis)
what needs to happen to women about to go under IVF
down regulation
- put women artificially into menopause so there is no spontaneous ovulation
how does down regulation work
Synthetic Gonadotrophin releasing hormone analogue or agonist
Administered as a spray or injection
what are side effects of down regulation
Hot flushes and mood swings
Nasal irritation
Headaches
how is follicular development encouraged in IVF
ovarian stimualtion
- Gonadotrophin Hormone containing either synthetic or urinary gonadotrophins (FSH+/- LH)
- Can be self-administered sc injection
what are side effects of ovarian stimulation
Mild allergic reactions
Ovarian Hyper Stimulation Syndrome (OHSS) (i.e. when there is too many eggs)
what classic appearance does a thickened endometrium have on ultrasound
classic triple line seen
what is the method for sperm sampling in IVF
Abstinence for 72 hours beforehand
Ejaculated samples
what is assessed from a sperm sample
Volume
Density - numbers of sperm
Motility - what proportion are moving
Progression - how well they move
how are oocytes collected
theatre
what are the risks of oocyte collection
bleeding
pelvic infection
failure to obtain oocytes
how can you tell an egg has been fertilised
Two pronuclei
at what day after fertilisation does it become a blastocyst
day 5
what stage is usual day of transfer and cryopreservation
day 5
- blastocyst stage
what are the measures taken in embryo transfer
Normally transfer 1 embryo (max 3 in exceptional circumstances)
Luteal Support
: progesterone suppositories for 2 weeks
:pregnancy test
when do people get there scans in IVF
Baseline scan
- before FSH or hMG injection
Action scan
- 8/9 days later before hCG injection
what are indications for Intra Cytoplasmic Sperm Injection (ICSI)
Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis
what is ICSI
when you inject the sperm into the egg
how can the sperm be retrieved for ICSI
Can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)
what will be require in azoospermia
surgical sperm aspiration
what is OHSS and symptoms
Ovarian Hyper Stimulation Syndrome
- Enlarged ovaries
- Excess Follicles
Sx
- abdo pain/bloating
- nausea/diarrhoea
- breathless
how do we try to prevent OHSS
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
what regulates all ART activities
HFEA
what is the current success rate of IVF
35%
what are the complications of ART
multiple pregnancies
OHSS
ectopic pregnancies
what are the parts involved in IVF treatment
down regulation ovarian stimulation oocyte retrieval embryo transfer luteal support
what chromosome has the sex determining region
Y chromosome
what are the 2 primitive genital tracts in the foetus
Wolffian ducts = becomes the male genitals
Mullerian ducts = becomes the female genitals
what causes the development of the male internal genital tract
Fetal testes secretes dihydrotestosterone (and Mullerian inhibiting factors)
Mullerian ducts degenerate
Wolffian ducts»_space; repro tract
what causes the development of the female internal genital tract
Without stimulus of male testicular hormones, fetus will develop female internal genital tract
Wolffian ducts degenerate
Mullerian ducts»_space; repro tract
why are males with CF infertile
absent vas deferens
where is sperm aspirated from
epididymis
what is the testes dropping into the scrotal sac before birth dependant on
androgen
what is crytorchidism
undescended testes
what does crytorchidism cause
reduced sperm count
- if unilateral usually still fertile
why is a orchidopexy [surgically descending the testes] done
to reduce risk of testicular germ cell cancer
what cells in the testis are responsible for testosterone production
leydig cells
where does spermatogenesis happen
sertoli cells in the seminiferous tubules
what is the function of sertoli cells
form a blood testes barrier provide nutrients phagocytosis secrete seminiferous tubule fluid secrete androgen binding globulin secrete inhibin and activin hormones
what stimulates spermatogenesis
FSH + testosterone
what inhibits the secretion of FSH
inhibin
what stimulates the release of testosterone
LH
what does testosterone decreased the release of
GnRH and LH
what does FSH act on to stimulate spermatogenesis
sertoli cells
FSH and LH are stimulated by GnRH = what cells in the anterior pituitary produce them
FSH -> Granulosa cells
LH -> Theca cells
what is testosterone protective against
osteoporosis
how does the sperm fertilise the egg - what are the stages after ejaculation
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
what produces semen into ejaculatory duct
seminal vesicles
what secretes mucus to act as lubricant
bulbourethral glands
what is the route of sperm
Testes ➔ epididymis ➔ vas deferens ➔ ejaculatory duct ➔ urethra
how does an erection occur
blood fills corpora cavernosa (under parasympathetic control)
under what control is ejaculation
sympathetic
how can male infertility be categorised
idiopathic - most common
obstructive - CF, vasectomy, infection
non-obstructive - chemo/radiotherapy, Cryoptorchadism, tumour
what genetic conditions can cause male infertility
Klinefelter’s syndrome
microdeletions of Y chromosome
Robertsonian translocation
what are endocrine causes of male infertility
pituitary tumours - acromegaly, cushings, prolactinoma
hypothalmic cause - tumour, Kallman’s syndrome
thyroid disorders - hyper/hypothyroid
diabetes
CAH
androgen insensitivity
steroid abuse
why does Kallman’s syndrome cause infertility
do not produce GnRH, therefore no LH, FSH or testosterone
what is the normal testicular volume in adults
12-25 mls
Ix for male infertility
Semen analysis
Repeat semen analysis in 6 wks
Endocrine profile [LS, FSH, testosterone, PRL, TSH]
Chromosome analysis
Testicular biopsy
Scrotal scan
what are the clinical and endocrine features of an obstructive cause of male infertility
Clinical Features:
normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent
Endocrine features:
Normal LH, FSH and testosterone
what are the clinical and endocrine features of a non-obstructive cause of male infertility
Clinical Features:
low testicular volume
reduced secondary sexual characteristics
vas deferens present
Endocrine features:
High LH, FSH and low testosterone
what is the assisted conception method used when male infertility is the problem
IUI
ICSI
Surgical Sperm Aspiration
Donor sperm
