Infertility and Assisted Conception Flashcards
What is ACT?
- Assisted Conception Treatment
- RX involving gametes OUTSIDE the body
Why is ACT demand rising?
- increasing PARENTAL age
- Increasing cases of chlamydia
- MALE infertility
- increased RANGE of ACT
- improved success rates
Why do people seek IVF or ICSI?
- endometriosis
- male factor
- Tubal Disease
- unexplained
- Ovulatory disorder
What are recent changes that have occurred for ACT indications?
- increase in single and same sex couples
- increase in rx with surrogate
- increase in transgender referral
Name other indications for Assisted conception treatment.
- fertility pservation in CANCER, transgender
- rx to avoid transmission of blood born viruses (Hep B, C, HIV)
- pre-implantation dx of inherited disorder
- rx of single parents/ same sex couples
- rx with surrogacy
How should the people prepare before the rx begins?
- Limit alcohol intake to 4 units/week
- WGT: 19-29 (M and F)
- no smoking
- FOLIC ACID: 0.4mg/day—12 weeks gestation
- —-increase to 5mg if risk of NTD/Obese
- Rubella check
- Cervical smear
- Occupational hazards
- Drugs
- Hep B/C nad HIV
- assess Ovarian reserve; antral Follicle count or AMH
- Counselling
What is IUI, and what are its indications?
- PREPARED semen is inserted into uterine cavity at time of ovulation
- “intra-uterine insemination”
What are the indications for IUI?
- sexual problems
- same sex relationships
- abandoned IVF
- discordant BBV (blood borne virus)
What is IVF?
in vitro fertilisation
WHat are the indications for IVF?
- unexplained infertility >2years
- pelvic disease (fibroids, endometriosis, tubal disease)
- Anovulatory infertility (after failed ovulation induction)
- Failed IUI (after 6 cycles)
How long does ovarian folliculogenesis take place?
85 days
What are the phases of ovarian follicular development?
- Tonic Phase (65 days) - Iary and IIary follicles to ANTRAL follicles
- Growth phase (20 days) - antral follicles 3-5mm>20mm pre-ovulatory follicle —-depends on gonadotropin
What occurs in a stimulated cycle of gonadotropins?
- early follicular phase results in SYNCHRONISED growth of all follicles
What do you mean by downregulation during IVF rx?
- administration of Pulsatile synthetic gonadotropin releasing hormone agonist/analogue
- reduces cancellation from ovulation (improves success rates)
- —–precise timing for oocyte recover (using HCG trigger)
What are the S/Es of downregulation?
- hot flushes
- mood swings
- nasal irritation
- headaches
What are the 6 stages of IVF?
- Downregulation
- Ovarian Stimulation
- Oocyte Collection
- Lab fertilisation
- Transfer and cryopreservation
- Embryo transfer
Why does the IVF rx start with supression of the ovaries with the use of synthetic GNRH agonist?
- helps to have a little control of the ovarian cycle of the lady
- can actually plan for stimulation of ovulation by HCG trigger
How are the ovaries stimulated?
- pt is given gonadotropin hormone containing synthetic or URINARY gonadotropins (FHS/LH)
- self-administered (s.c injection)
- causes follicular development
How does the ultrasound scan change when compared to the down regulation stage and stimulation stage?
- endometrium has thickened
- folllicular appearance of ovaries has appeared
What is the semen assessed for?
- Volume
- Density (# of sperms)
- Motility (what proportion move)
- Progression (how well they move)
What are the risks of oocyte collection?
- bleeding
- pelvic infection
- failure to obtain oocytes
What is the procedure for men to obtain their sperm ?
- abstinence for 72 hrs
- produced in the men’s room
What is the role of the embryologist?
- search the follicular fluid for eggs
- collect them into cell culture and INCUBATE at 37*C
What percent of eggs may fertilize normally?
- 60%~
When is the embryo transferred?
- Day 5 of the Blastocyst stage
What occurs with embryo transfer?
- normally 1 is transferred (max 3 in exceptional circumstances)
- luteal support : PROGESTERONE suppositories for 2 weeks
When is the pregnancy test performed?
- 16 days after oocyte recovery
What is ICSI?
-intra-cytoplasmic sperm injection
What are the indications for ICSI?
- Severe male factor infertility
- previous failed fertilisation with IVF
- pre-implantation genetic diagnosis
How to treat obstructive azoospermia?
- surgical sperm ASPIRATION
When does ovulation occur in the uterine cycle?
- day 14
- start secretory phase
How ICSI work?
- Egg is Stripped
- Sperm is immobilized
- Single Sperm INJECTED
- incubate at 37* C overnight
What are the features of moderate Ovarian Hyper-stimulation syndrome?
MODERATE OHSS: -moderate abdominal pain
nausea and vomitting
-USG evidence iof ASCITES
- 8-12cm3 size of ovaries
How may severe OHSS present as?
- clinical ascites (+/- hydrothorax)
- hyponatremia
- hypo-osmolality
- hyperkalemia
- hypoproteinemia
- ovarian size >12cm3
- OLIGOURIA
How to prevent OHSS?
- suppress the ovaries! with antagonists
What treatment is required after embryo transfer?
- scan and blood monitoring
- reduce thrombosis risk (FLUIDS/ TED stockings/ FRAGMIN)
- analgesia
- hospital admission if IV fluids and intensive monitoring is needed
How to reduce MULTIPLE pregnancy>
- move embryo at BLASTOCYST stage
- improve CRYOPRESERVATION
What pregnancy complications may arise from ART?
- ECTOPIC pregnancy: incidence increases 2-3 fold
- increase risk of heterotropic pregnancy
