Infertility and Assisted Conception Flashcards
How many couples in the UK require assessment for infertility? How many of these go on to require fertility treatment?
1/6 require assessment, half of these go on to require treatment
The demand for ACT is rising because of what?
Increasing parental age, chlamydia infection, male factor infertility and increased successes of ACT
3 chlamydia infections gives what risk of infertility?
50% chance of blocked tubes or vas deferens
Treatment of ‘infertility’ for who is not provided on the NHS?
Single parents
Who is surrogacy used as a treatment option for?
Same sex male couples and women with an absent or abnormal uterus
What advice should you give to couples who are trying to conceive about sex?
Have sex 2-3 times a week and avoid lubricants which are toxic to sperm
Females should limit their alcohol consumption to what?
< 4 units per week
What is the advice about weight for couples before starting IVF?
Both male and female partners should have a BMI between 19 and 29
Are individuals eligible for IVF is they smoke?
No (male and female)
What is folic acid used for? How and when should it be given?
It reduces the risk of neural tube defects. 0.4mg/day should be taken pre-conception to 12 weeks gestation and this should be increased to 5mg if there is any increased risk of neural tube defects or if the mother is obese
Before starting IVF treatment, you should check that the mother is immunised against what?
Rubella
What are couples going through IVF screened for before starting?
Blood borne viruses
The type of fertility treatment that is used depends on what?
The cause of the infertility
Describe what happens in intra-uterine insemination?
Fast moving sperm are isolated from sluggish ones and are injected directly into the uterus shortly after ovulation
What are the indications for intra-uterine insemination?
Sexual problems, same sex relationships, BBV, abandoned IVF
What fertility treatment is used to inject donor sperm or into a surrogate?
Intra-uterine insemination
IVF can be used if there has been unexplained infertility for how long?
> 2 years
What are some examples of pelvic diseases that may require the use of IVF?
Endometriosis, tubal disease, fibroids
IVF can be used if intra-uterine insemination has failed how many times?
6 cycles
What is the single biggest predictor of IVF success?
A woman’s age
What is ICSI?
Essentially the same process as IVF except fertilisation is achieved by injecting a single sperm into each mature oocyte rather than mixing multiple sperm with each oocyte
What are the 3 main indications for ICSI?
Severe male factor infertility, previously failed IVF, preimplantation genetic diagnosis
If a couple are having ICSI and there is azoospermia, what must be done?
Surgical aspiration of sperm
Where is sperm aspirated from in ICSI if there is a) obstructive b) non-obstructive male infertility?
a) epididymis b) testicular tissue
After the sperm has been injected into the egg during ICSI, it should be incubated overnight at what temperature?
37 degrees
How long does ovarian follicular development take?
85 days
Describe the first phase of ovarian follicular development?
Tonic phase, takes 65 days, primary and secondary follicles develop into antral follicles
Describe the second phase of ovarian follicular development?
Growth phase, takes 20 days, antral follicles develop into pre-ovulatory follicles
In a normal menstrual cycles, during the early follicular phase, what do gonadotrophins do?
Result in synchronised growth of all ovarian follicles
What is the first stage of IVF treatment and why is it done?
Down regulation: essentially turns off the ovaries to allow better control of ovulation and egg maturation during treatment
What medications can be used to induce ovarian down regulation?
GnRH agonists/antagonists
How do GnRH agonists cause ovarian down regulation?
They flood the body with ‘fake’ GnRH causing the ovaries to become overwhelmed and shut down the production of LH/FSH after 3 weeks
How do GnRH antagonists cause ovarian down regulation?
Blocks the release of GnRH so no LH/FSH is produced almost immediately
What are the aims of ovarian downregulation in IVF?
To allow more than 1 follicle to develop into a mature egg, and allow the eggs to stay within the follicles so they can be easily harvested
What are some side effects of ovarian down regulation?
Hot flushes, moodswings, nasal irritation, headaches
What is the second stage of IVF? What medication is given?
Ovarian hyperstimulation: daily SC FSH injections are given
What is the function of giving FSH injections in IVF?
To mature the follicles (hopefully more than 1 mature egg is produced)
What monitoring is used during the ovarian hyperstimulation phase of IVF?
On day 8, and every 2 days after, a pelvic US is done
In the ovarian hyperstimulation stage of IVF, once a lead follicle has reached 18mm and two more have reached 16mm, what is given to the patient?
hCG injection
What is the purpose of the hCG injection given in IVF? When is it given?
To mimic LH and trigger ovulation, it is given 36 hours before oocyte collection
After producing a sample, the semen has to be used within how long?
1 hour
A man has to abstain from ejaculation for how long before providing a semen sample for IVP?
72 hours
Oocyte collection for IVF occurs where? What are the risks?
In theatre - bleeding, pelvic infection, failure to obtain oocytes
Once oocytes have been collected, they should be incubated at what temperature?
37 degrees
How are the oocytes fertilised for IVF?
Up to 50,000 sperm are added to a Petri dish containing a single mature egg
Approximately what proportion of oocytes obtained from IVF will fertilise normally?
60%
After fertilisation in IVF, when is the pronuclei transferred into the mother?
After 5 days, at the blastocyst stage
How many embryos are normally transferred in IVF?
Usually just one
What is the maximum number of embryos that can be transferred into mother in IVF under exceptional circumstances?
Three
How are embryos inserted into the mother in IVF?
Directly into the uterus via ultrasound guidance
What is given as luteal support after the embryo has been inserted in IVF? How long for?
Progesterone suppositories for 2 weeks
When should you do a pregnancy test in IVF?
16 days after oocyte recovery
What are some risk factors for ovarian hyperstimulation syndrome?
Young age, low BMI, PCOS
What are some mild presentations of ovarian hyperstimulation syndrome?
Abdominal bloating, mild pain and ovarian size < 8cm
What are some features of more severe ovarian hyperstimulation syndrome?
Ascites, oliguria, hyponatraemia, hyperkalaemia, ovarian size > 12cm
Ovarian hyperstimulation syndrome is associated with capillary leakage which can result in what?
Pleural effusion, pericardial effusion, ascites, intravascular volume depletion
When does ovarian hyperstimulation syndrome normally present? What would be classed as a late presentation?
Normal = 2-3 days after oocyte collection / late = 7-10 days after
How can ovarian hyperstimulation syndrome be prevented?
Using low dose protocols and GnRH antagonists for suppression
What are some treatment options for ovarian hyperstimulation syndrome before embryo transfer?
Elective freezing or a single embryo transfer
What are some treatment options for ovarian hyperstimulation syndrome after embryo transfer?
Monitoring with scans and bloods, thromboprophylaxis, IV fluids, drainage of any fluid collections
What are the 2 main risks to the foetuses associated with multiple pregnancy?
Foetal growth restriction and premature birth
The risk of multiple pregnancies with IVF can be reduced how?
Moving to blastocyst transfer, improved cryopreservation, increased single embryo transfer
What is the relationship between IVF and ectopic pregnancy?
2-3 fold increase with IVF
