infertility and assisted conception Flashcards
What 9 factors have to be considered before embarking on infertility management?
Alcohol:
-limit consumption to 4units/wk to prevent fetal-alcohol syndrome
Weight:
- 19-29 optimal BMI for males and females
- self-funded infertility treatment is offered to females with a BMI of up to 35
Stop smoking
Folic acid:
- given 0.4mg/day for 3mths pre and post conception
- 5mg if increased risk neural tube defects
Rubella:
-check immunity and vaccinate female 1 mth pre-conception
Smear - up to date
Occupation: exposure to toxins?
Drugs:
- prescribed
- OTC
- recreational
BBV:
-HIV/Hep B and C
Who is intra-uterine insemination indicated for? what is the method used?
Indications:
- unexplained infertility
- mild/mod. endometriosis
- mild male factor infertility
Method:
- can be a natural or stimulated cycle
- prepared semen is inserted to uterine cavity around time ovulation
Who is IVF indicated for? what is the method in broad terms?
- Unexplained >2yrs duration or if over 38yo >1yr
- pelvic disease: endometriosis/tubal disease/fibroids
- anovulatory infertility
- male factor infertility: <1x10^6 motile sperm
- others e.g. pre-implantation diagnosis
Method: egg and sperm mixed invitro and best embryos transferred
Who is ICSII indicated for and what method is used?
Indications:
- severe male factor infertility
- previously failed IVF
Methods:
-same as IVF but sperm is then injected into egg = egg is stripped and sperm immobilised and single sperm is injected and then is incubated 37degrees overnight
-surgical aspiration is for azoospermia
Describe the treatment regime for egg collection and embryo transfer?
Day 1 is the first day of period
Day 21: downregulation for 2-3 weeks
After 2-3 weeks: baseline scan and ovarian stimulation starts for 8-9 days
After 6-8 days of ovarian stimulation have an action scan:
- see stimulated ovary and thickened endometrium
- plan HCG injection (has to be done 36hrs prior to collection)
After 8-9 days of ovarian stimulation: HCG injection
36hrs post-HCG injection:
- egg collection
- started on progesterone suppositories for 2 weeks (cyclogest morning and night)
In-vitro fertilisation and embryo is cultured
Transfer, 5 days after collection
After 16 days pregnancy test., if positive - transvaginal USS 5 weeks after transfer
What is used for downregulation in egg retrieval? what are the side effects?
-buserelin (GnRH analogue, prevents pituitary from stimulating LH surge)
-spray/injections
S/E: hot flushes/mood swings/nasal irritation/headaches
What is looked for on the baseline scan?
-done 2-3 weeks after down regulation to ensure ovaries arent producing follicles and that endometrium is thin
What is used for ovarian hyperstimulation? what are the side effects?
Gonadotrophin hormone (FSH or hMG injections morning and night)
- ovaries are stimulated to produce many follicles
- can be self-administered
Side effects:
- mild allergic rxns
- ovarian hyperstimulation syndrome (OHSS)
Action scan:
- is a stimulated ovary and thickened endometrium always seen?
- what is done if there is a poor response to FSH?
- what risk is also assessed on this?
- no, 40-50% have a slow response: repeat scan 72hrs later
- poor response to FSH = abandon treatment or up FSH dose
- Assess for risk OHSS
what does the HCG injection mimic?
LH surge
Describe egg collection?
- > 35degrees
- search through follicular fluid and identify eggs with surrounding cell mass
- collect into cell culture medium
- incubate at 37 degrees
Sperm sample:
-How long does the male have to be abstinent for?
72hours
What 4 things are sperm assessed for?
- volume
- density (no. of sperm)
- motility (proportion that are moving)
- progression (how well are they moving)
prepare to remove from seminal plasma and concentrate
How many embryos are transferred?
HFEA code of practice:
- <40yrs of age = no more than 2 embryos
- > 40yrs of age: 3 if exceptional circumstances only
What is ovarian hyperstimulation syndrome?
OHSS
- most serious consequence of induction of ovulation
- ovaries may form over 20 follicles = enlarged
vasoactive mediators are then released from hyperstimulated ovaries and increase capillary permeability:
-fluid shift to intercellular compartment
=pericardial/pleural effusion
=ascites
=haemoconcentrate inc risk thombosis
=liver/kidney dysfunction
