Infertility and Assisted Conception

Question 1

examples of indications for ART?

Answer 1

endometriosis
male factor
tubal disease
multiple male and female factors
unexplained infertility
ovulatory disorders
multiple female factors
fertility preservation in cancer, transgender patients and social reasons
to avoid transmission of blood born viruses between patient s(HIV etc)
pre-implantation diagnosis of inherited conditions
single parents or same sex couples
surrogacy when absent/abnormal uterus

Question 2

what criteria must parents meet before ART?

Answer 2

alcohol (4 units per week in females)
weight (BMI 19-29)
stop smoking
0.4mg folic acid for 12 weeks pre-conception (5mg increase is risk of NTD/obese)
rubella immunisation
up to date with cervical smears
avoid occupational exposure to hazzards
manage any drugs
screen for blood borne viruses (hep B/C and HIV)
assess ovarian reserve (antral follicle count or AMH)
offer supportive counselling

Question 3

what ART treatments are available?

Answer 3

donor insemination
intra-uterine insemination (IUI)
IVF
intra-cytoplasmic sperm injection (ICSI)
fertility preservation
surrogacy

Question 4

indications for IUI?

Answer 4

mostly in same sex relationships
or can be used in sexual problems (ED etc)
discordant BBV
abandoned IVF

Question 5

what happens in IUI?

Answer 5

prepared semen inserted into uterine cavity around time of ovulation
can be done in natural ovulation if possible or can stimulate ovulatory cycle

Question 6

indications for IVF?

Answer 6

unexplained infertility (>2 years duration)
pelvic disease (endometriosis, tubal disease, fibroids etc)
anovulatory infertility (after failed ovulation induction)
failed intra-uterine insemination (after 6 cycles)

Question 7

step 1 in IVF?

Answer 7

down regulation
- synthetic gonadatrophin releasing hormone analogue or agonist (causes ovaries to become very quiet and stop follicular development and endometrium to thin)
allows precise timing of oocyte recover by using HCG trigger

Question 8

side effects of down-regulation?

Answer 8

can give menopause like symptoms
hot flushes and mood swings
nasal irritation
headaches

Question 9

step 2 in IVF?

Answer 9

ovarian stimulation
- gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/-LH)
causes follicular development
(can be self administered via S/C injection)

Question 10

imaging in step 1 vs step 2?

Answer 10

1 = ovary is plain round organ, endometrium is thin
2 = 3+ follicles can be seen in ovary, endometrium is thicker

Question 11

what is given to stimulate release of the follicle from follicular wall?

Answer 11

HCG injection

mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery

Question 12

how is male semen collected?

Answer 12

abstinence for 72 hours before hand then produced either in ward or at home but must be delivered within 1 hr
assessed for
- volume
- density (number of sperm)
- motility (what proportion are moving)
- progression (how well they move)

Question 13

step 3 in IVF?

Answer 13

oocyte collection

collect follicular fluid in hope that egg is in there?

Question 14

risks of oocyte collection?

Answer 14

bleeding
pelvic infection
failure to obtain oocyte

Question 15

how are oocytes collected?

Answer 15

embryologist searches through follicular fluid and identifies eggs and surrounding mass of cells
oocytes are collected into cell culture medium and incubated at 37 degrees for 5 days until blastocyst stage

Question 16

step 5 of IVF?

Answer 16

fertilisation
two pronuclei seen in egg
- male and female genetic information
approximately 60% of eggs fertilise

Question 17

when are eggs transferred or cryopreserved?

Answer 17

day 5

either put back into uterus or frozen

Question 18

step 6 of IVF?

Answer 18

embryo transfer

• normally transfer 1 embryo (max 3 in exceptional circumstances)
• luteal support = progesterone suppositories for 2 weeks
• pregnancy test 16 days after oocyte recovery

Question 19

IVF summary?

Answer 19

day 1 = bleed
day 21 = down regulation
2-3 weeks later = baseline scan
8-9 days after = ovarian stimulation (LH/FSH), then hCG injection
then egg recovery
then embryo transfer
then pregnancy test after 16 days

Question 20

indications for ICSI?

Answer 20

severe male infertility
previous failed IVF
preimplantation genetic diagnosis

Question 21

special circumstance in ICSI?

Answer 21

will need surgical sperm aspiration if azoospermia is present
(sperm is extracted from epididymis (if obstructive) or testicular tissue (if non-obstructive))

Question 22

process of ISCI?

Answer 22

each egg is stripped
sperm immobilised
single sperm injected
incubate at 37 degrees overnight

Question 23

possible complication of ART?

Answer 23

ovarian hyper-stimulation syndrome

Question 24

how is OHSS prevented?

Answer 24

low dose protocols

use antagonist for suppression

Question 25

how is OHSS managed before embryo transfer?

Answer 25

elective freeze of embryos

single embryo transfer

Question 26

how is OHSS managed after embryo transfer?

Answer 26

monitor with scans and bloods
reduce risk of thrombosis (fluids, TED stockings and fragmin)
analgesia
hospital admission if required for IV fluids/more intensive monitoring/paracentesis

Question 27

another rare complication of IVF?

Answer 27

multiple pregnancy

Question 28

how can multiple pregnancy be prevented?

Answer 28

move to blastocyst transfer
improved cryopreservation
increase in single embryo transfer

Question 29

another complication of IVF?

Answer 29

ectopic pregnancy

2-3X higher risk in IVF

Question 30

overall success rate of IVF?

Answer 30

35%

Question 31

phases in ovarian follicular development?

Answer 31

tonic phase
- primary and secondary follicle to antral follicle (65 days)
growth phase
- antral follicle (3-5mm) to pre-ovulatory follicle (20mm), dependent on gonadotrophin

Question 32

what happens in follicular growth in a stimulated cycle?

Answer 32

gonadotrophins during early follicular phase results in synchronised growth of all follicles