Infertility and assisted conception Flashcards
Define assisted conception treatment
Any treatment that involves gametes outside the body
_ in _ couples in the UK require assessment of fertility
1 in 6 couples in the UK require assessment of fertility
Why is the demand for ACT rising?
- increasing parental age
- increasing chlamydia
- male factor infertility
- increasing range of ACT
- improved success rates
What are the indications for ACT aside from infertility
- fertility preservation in cancer, transgender patients and social reasons
- treatment to avoid transmission of blood born viruses between patient
- pre-implantation diagnosis of inherited disorders
- treatment of single parents or same sex couples
- treatment with surrogacy the absent/ abnormal uterus
What are the lifestyle modifications that must be made before ACT treatment begins
Alcohol- limit to 4 units per week Weight- between 19-29 optimal form males and females Smoking- stop Occupational- avoid hazards Stop recreational drugs
What must be done before ACT begins?
Must take folic acid 0.4mg/day preconception- 12 weeks gestation
Check if female immune to rubella
Check cervical smears up to date
Check prescribed drugs
Assess for blood borne viruses: HIV, hep B/C
Assess ovarian reserve: antral follicle count or AMH
Counselling
how must the dose of folic acid be altered if the patient is obese?
5mg increase
What ACT treatments are currently available?
Donor insemination IUI IVF ICSI Fertility preservation Surrogacy
What are the indications for IUI
Sexual problems, same sex relationships, discordant BBV, abandoned IVF
How is IUI performed?
Can be in natural/stimulated cycle
Prepared semen inserted into uterine cavity around time of ovulation
What are the indications for IVF?
- Unexplained infertility >2 years duration
- Pelvic disease (endometriosis, tubal disease, fibroids)
- Anovulatory infertility (after failed ovulation induction)
- Failed intra-uterine insemination (after 6 cycles)
describe ovarian folliculogenesis
85 days long
- tonic phase (65 days)
- growth phase (20 days)
Describe the tonic phase of folliculogenesis
Primary and secondary follicles to antral follicles
Describe the growth phase of folliculogenesis
Antral follicles 3-5mm to pre-ovulatory follicle (20mm)
What is the growth phase of folliculogenesis dependent on?
Gonadotrophin
In a stimulated cycle __________ during early follicular phase result in ______ growth of all follicles (___mm a day)
In a stimulated cycle gonadotrophins during early follicular phase result in synchronised growth of all follicles (1.5mm a day)
What are the stages of IVF?
- down regulation
- ovarian stimulation
- oocyte collection
- fertilisation
What happens in the down regulation phase
Synthetic gonadotrophin releasing hormone analogue or agonist given
Reduces cancellation from ovulation and improves success rate
How is the timing of oocyte recovery controlled?
by using HCG trigger
What is the side effect of down regulation
Hot flushes and mood swings
Nasal irritation
Headaches
What happens during the ovarian stimulation phase?
Gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH/;H)
Can be self-administered (injection)
Causes follicular development
What does the HCG injection do?
Mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery
What is required from men undergoing semen retrieval?
Abstinence for 72 hours beforehand
Sample prepared at home within 1 hour and kept warm, or in ward
What is semen assessed for?
Volume
Density- numbers of sperm
Motility- what proportion are moving
Progression- how well they move
How is a semen sample prepared?
Prepared to remove plasma and concentrate
What are the risks of oocyte collection
Bleeding
Pelvic infection
Failure to obtain oocytes
What happens to the follicular fluid in the embryology lab?
Embryologist searches through the follicular fluid to identify eggs and surrounding mass of cells
Collects them into culture medium
Incubated at 37 degrees Celcius
Approximately __% of eggs fertilise normally in IVF
Approximately 60% of eggs fertilise normally in IVF
What day does transfer or cryopreservation normally take place?
Day 5
How many embryos are transferred
Normally transfer 1 embryo (maximum 3 in exceptional circumstances
What supports embryo transfer?
Luteal support: Progesterone suppositories for 2 weeks
When does the patient take a pregnancy test after IVF?
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 male has azoospermia?
Surgical sperm aspiration
Can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)
Describe the process of ICSI
- Each egg is stripped
- Sperm immobilised
- Single sperm injected
- Incubate at 37 degrees overnight
What is the presentation of mild OHSS
Abdominal bloating
Mild abdominal pain
Ovarian size usually <8 cm
What is the presentation of moderate OHSS
Moderate abdominal pain
Nausea +/- vomiting
US evidence of ascites
Ovarian size usually 8-12cm
What is the presentation of severe OHSS
Clinical ascites (+/- hydrothorax) Oliguria (<300ml/day or <30ml/hr) Haematocrit >0.45 Hyponatraemia Hypo-osmolality Hyperkalaemia Hypoproteinaemia Ovarian size usually >12cm
What is the presentation of critical OHSS
Tense ascites/large hydrothorax
Haematocrit >0.55
White cell count >25000/ml
Approximately __% of patients develop OHSS
1%
How can OHSS be prevented?
Low dose protocols
Use of antagonist for suppression
What is the treatment for OHSS before embryo transfer?
Elective freeze
Single embryo transfer
What is the treatment for OHSS after embryo transfer?
- monitoring with scans and bloods
- reduce risk of thrombosis: fluids, TED stockings and fragmin
- analgesia
- hospital admission if required IV fluids/more intensive monitoring/paracentesis
What measures have been taken in ACT to decrease multiple pregnancy?
Move to blastocyst transfer
Improved cryopreservation
Increase in single embryo transfer
The incidence of ectopic pregnancy is increased - fold in IVF?
2-3
What is a heterotopic pregnancy and what is the risk in IVF?
Approximately 1%
When a intrauterine and ectopic pregnancy occur simultaneously
List some of the problems with IVF and ICSI
- No eggs retrieved
- Surgical risks of oocyte retrieval
- Surgical risks of surgical sperm aspiration
- failed fertilisation
- psychological problems
- failed treatement
What are the risks of oocyte retrieval?
Bleeding
Infection
What are the risks of sperm aspiration
Haematoma
Infection
What are the problems in early pregnancy common in ACT?
Increase miscarriage and ectopic pregnancy
What are the problems in on-going pregnancy common in ACT?
Possible increase in prematurity and intra-uterine growth retardation, congenital abnormalities
What is the overall success rate for IVF?
35%
What is the role of HFEA?
Regulate all treatment & research
Consider welfare of child
Rights of people seeking treatment to appropriate care
Respect for human life at all stages of development
