Infertility and Assisted Conception Flashcards
What is ACT?
Any treatment which involved gametes outside the body
How many couples in the UK will require ACT to fall pregnant?
One in six
Why is the demand for ACT rising?
Increasing parental age Increased chlamydia Male factor infertility Increasing range of ACT Improved success rates
What is the current access for ACT treatment in the UK?
Less than 12 months
Eligible patients (under 40) can be offered 3 cycles of IVF/ICSI where there is a reasonable expectation of a live birth
One partner has no biological child
What are other indications for ACT aside from heterosexual couples unable to conceive?
Same sex or single people
Fertility preservation in cancer, transgender patients and social reasons
Treatment to avoid transmission of BBV between patients
Pre-implantation diagnosis of inherited disorders
Treatment with surrogacy when absent/ abnormal uterus
What are some things that women should do before treatment begins for assisted conception?
Limit alcohol to 4 units a week Weight; BMI between 19-29 Stop smoking Folic acid; 400 mcg or 5mg if specific risk factors Rubella immunisation Cervical smears up to date Occupational factors Drugs Screen for BBV Assess ovarian reserve; antral follicle count or AMH Counselling
Who should receive the higher 5mg dose of folic acid preconception?
If increased risk of NTD Diabetes Obese Antiepileptic drugs Folate antagonists Smokers
What different treatments are available under ACT?
Donor insemination IUI IVF ICSI Fertility preservation Surrogacy
What are the indications for IUI?
Sexual problems
Same sex relationship
Discordant BBV
Abandoned IVF
What are the methods for IUI?
Natural or stimulated cycle
Prepared semen inserted into uterine cavity at time of ovulation
What size should the follicle be to insert sperm for IUI?
17-18mm
What are the indications for IVF?
Unexplained (>2 years duration) Pelvic disease (endometriosis, tubal disease, fibroids) Anovulatory infertility (after failed ovulation induction) Failed IUI (after 6 cycles)
How many couples will get pregnant within 2 years of trying?
Around 95/100
What is the tonic phase of ovarian follicular development?
Primary and secondary follicles to antral follicles
What is the growth phase of ovarian follicular development?
Antral follicles (3-5mm) to preovulatory follicle (20mm), dependent on gonadotrophin
What is down regulation?
Synthetic GnRH agonist to reduce ovarian production of follicles
Allows precise timing of oocyte recover by using hCG trigger
What are side effects to downregulation?
Mini menopause; hot flushes, mood swings, nasal irritation, headaches
What should you seen on down regulation scans of the ovary and endometrium?
No follicular development in ovary
Thin endometrium
What is ovarian stimulation?
Gonadotropin hormone containing synthetic or urinary gonadotrophins (FSH +/- LH)
Self administered SC injection
Results in follicular development
What should the stimulation scan of the ovary and endometrium look like?
Ovary should see follicular development
Endometrium thickening
When should you plan the hCG injection?
36 hours before oocyte recovery to help release the follicles from the follicular wall
How long should men be abstinent before providing semen?
72 hours
What are the semen assessed for?
Volume
Density
Motility
Progression
What are the risks to oocyte collection?
Bleeding
Pelvic infection
Failure to obtain oocytes
What will the embryologist do when they receive the follicular fluid from the oocyte collection?
Search through the follicular fluid
Identify eggs and surrounding mass of cells
Collect them into medium culture
Incubate at 37 degrees
What will the egg do once fertilised?
Two pro-nuclei
Will continue to cleave
When will a blastocyst form?
Day 5
When is the transfer performed?
Usually day 5 of the mature blastocyst
How many blastocysts are transferred?
1 (max 3 in exceptional circumstances)
What hormones are given in the embryo transfer?
Luteal support; as the corpus luteum won’t form, need to produce progesterone for 2 weeks
When is a pregnancy test performed?
16 days after oocyte recovery
What are the indications for ICSI?
Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis
What is required if the man has azoospermia?
Surgical sperm aspiration; extracted from epididymis or testicular tissue
When is surgical sperm aspiration from the epididymis?
Obstructive azoospermia
When is surgical sperm aspiration from the testicular tissue?
Non-obstructive azoospermia
What is the method for ICSI?
Each egg is stripped
Sperm immobilised
Single sperm injected
Incubate at 37 degrees overnight
What are the complications for ICSI?
Hypospadias Chromosomal abnormalities (Klinefelter's)
What is the most serious side effect of ART?
Ovarian Hyper-stimulation Syndrome
What is mild OHSS?
Abdominal pain
Abdominal bloating
Ovarian size usually <8cm
What is moderate OHSS?
Mod abdo pain
N+V
USS ascites
Ovarian size usually 8-12 cm
What is severe OHSS?
Clinical ascites Oliguria (<300 ml/day <30 ml/hr) Haematocrit >0.45 Hyponatraemia <135 Hypo-osmolality <282 mOsm/kg Hyperkalaemia >5 Hypoproteinemia <35 g/l Ovarian size >12 cm
What is critical OHSS?
Tense ascites Haematocrit >0.55 WCC > 25,000/ml Oliguria/ anuria Thromboembolism ARDS
How many patients will develop OHSS?
1% will develop severe OHSS
How can OHSS be prevented?
Low dose protocols
Use of antagonists for supression
Should you treat OHSS before embryo transfer?
Yes; freeze embryos
hCG will result in worsening of OHSS
How should OHSS be treated after the embryo transfer?
Monitor with scans and bloods
Reduce risk of thrombosis; fluids, TED stockings and fragmin
Analgesia
Hospital admission if IV fluids required/ more intensive monitoring/ paracentesis
How can the risk of multiple pregnancies be reduced?
Move to blastocyst transfer
Improved cytopreservation
Increase in single embryo transfer
How many babies born fro ART are multiple pregnancies in the UK?
Approx. 10%
What is the IVF success rate?
35%
What are other problems assoc with ART aside from OHSS, multiple pregnancies and ectopic pregnancies?
No eggs retrieved Surgical risks of oocyte retrieval Surgical risks of surgical sperm aspiration Failed fertilisation Problems in early pregnancy Increased risk of on-going pregnancy Psychological problems Failed treatment
What are the surgical risks assoc with surgical sperm aspiration?
Haematoma
Infection
How does the HFEA regulate ART activities?
Regulates all treatment and research
Considers welfare of child
Rights of people seeking treatment to appropriate care
Respect for human life at all stages of development
What are the main steps to ART?
Down regulation Ovarian stimulation Oocyte collection Fertilisation Transfer Luteal support
