Infertility and Assisted Conception Flashcards
examples of indications for ART?
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
what criteria must parents meet before ART?
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
what ART treatments are available?
donor insemination intra-uterine insemination (IUI) IVF intra-cytoplasmic sperm injection (ICSI) fertility preservation surrogacy
indications for IUI?
mostly in same sex relationships
or can be used in sexual problems (ED etc)
discordant BBV
abandoned IVF
what happens in IUI?
prepared semen inserted into uterine cavity around time of ovulation
can be done in natural ovulation if possible or can stimulate ovulatory cycle
indications for IVF?
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)
step 1 in IVF?
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
side effects of down-regulation?
can give menopause like symptoms
hot flushes and mood swings
nasal irritation
headaches
step 2 in IVF?
ovarian stimulation
- gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/-LH)
causes follicular development
(can be self administered via S/C injection)
imaging in step 1 vs step 2?
1 = ovary is plain round organ, endometrium is thin 2 = 3+ follicles can be seen in ovary, endometrium is thicker
what is given to stimulate release of the follicle from follicular wall?
HCG injection
mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery
how is male semen collected?
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)
step 3 in IVF?
oocyte collection
collect follicular fluid in hope that egg is in there?
risks of oocyte collection?
bleeding
pelvic infection
failure to obtain oocyte
how are oocytes collected?
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
step 5 of IVF?
fertilisation
two pronuclei seen in egg
- male and female genetic information
approximately 60% of eggs fertilise
when are eggs transferred or cryopreserved?
day 5
either put back into uterus or frozen
step 6 of IVF?
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
IVF summary?
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
indications for ICSI?
severe male infertility
previous failed IVF
preimplantation genetic diagnosis
special circumstance in ICSI?
will need surgical sperm aspiration if azoospermia is present
(sperm is extracted from epididymis (if obstructive) or testicular tissue (if non-obstructive))
process of ISCI?
each egg is stripped
sperm immobilised
single sperm injected
incubate at 37 degrees overnight
possible complication of ART?
ovarian hyper-stimulation syndrome
how is OHSS prevented?
low dose protocols
use antagonist for suppression
how is OHSS managed before embryo transfer?
elective freeze of embryos
single embryo transfer
how is OHSS managed after embryo transfer?
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
another rare complication of IVF?
multiple pregnancy
how can multiple pregnancy be prevented?
move to blastocyst transfer
improved cryopreservation
increase in single embryo transfer
another complication of IVF?
ectopic pregnancy
2-3X higher risk in IVF
overall success rate of IVF?
35%
phases in ovarian follicular development?
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
what happens in follicular growth in a stimulated cycle?
gonadotrophins during early follicular phase results in synchronised growth of all follicles
