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Reproductive & Sexual Health > Infertility and assisted conception > Flashcards

Infertility and assisted conception Flashcards

1
Q

Define assisted conception treatment

A

Any treatment that involves gametes outside the body

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2
Q

_ in _ couples in the UK require assessment of fertility

A

1 in 6 couples in the UK require assessment of fertility

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3
Q

Why is the demand for ACT rising?

A
  • increasing parental age
  • increasing chlamydia
  • male factor infertility
  • increasing range of ACT
  • improved success rates
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4
Q

What are the indications for ACT aside from infertility

A
  • 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
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5
Q

What are the lifestyle modifications that must be made before ACT treatment begins

A 
Alcohol- limit to 4 units per week
Weight- between 19-29 optimal form males and females
Smoking- stop
Occupational- avoid hazards
Stop recreational drugs
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6
Q

What must be done before ACT begins?

A

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

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7
Q

how must the dose of folic acid be altered if the patient is obese?

A

5mg increase

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8
Q

What ACT treatments are currently available?

A 
Donor insemination
IUI
IVF
ICSI
Fertility preservation
Surrogacy
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9
Q

What are the indications for IUI

A

Sexual problems, same sex relationships, discordant BBV, abandoned IVF

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10
Q

How is IUI performed?

A

Can be in natural/stimulated cycle

Prepared semen inserted into uterine cavity around time of ovulation

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11
Q

What are the indications for IVF?

A
  • Unexplained infertility >2 years duration
  • Pelvic disease (endometriosis, tubal disease, fibroids)
  • Anovulatory infertility (after failed ovulation induction)
  • Failed intra-uterine insemination (after 6 cycles)
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12
Q

describe ovarian folliculogenesis

A

85 days long

  • tonic phase (65 days)
  • growth phase (20 days)
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13
Q

Describe the tonic phase of folliculogenesis

A

Primary and secondary follicles to antral follicles

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14
Q

Describe the growth phase of folliculogenesis

A

Antral follicles 3-5mm to pre-ovulatory follicle (20mm)

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15
Q

What is the growth phase of folliculogenesis dependent on?

A

Gonadotrophin

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16
Q

In a stimulated cycle __________ during early follicular phase result in ______ growth of all follicles (___mm a day)

A

In a stimulated cycle gonadotrophins during early follicular phase result in synchronised growth of all follicles (1.5mm a day)

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17
Q

What are the stages of IVF?

A
  1. down regulation
  2. ovarian stimulation
  3. oocyte collection
  4. fertilisation
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18
Q

What happens in the down regulation phase

A

Synthetic gonadotrophin releasing hormone analogue or agonist given

Reduces cancellation from ovulation and improves success rate

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19
Q

How is the timing of oocyte recovery controlled?

A

by using HCG trigger

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20
Q

What is the side effect of down regulation

A

Hot flushes and mood swings
Nasal irritation
Headaches

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21
Q

What happens during the ovarian stimulation phase?

A

Gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH/;H)

Can be self-administered (injection)

Causes follicular development

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22
Q

What does the HCG injection do?

A

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

23
Q

What is required from men undergoing semen retrieval?

A

Abstinence for 72 hours beforehand

Sample prepared at home within 1 hour and kept warm, or in ward

24
Q

What is semen assessed for?

A

Volume
Density- numbers of sperm
Motility- what proportion are moving
Progression- how well they move

25
Q

How is a semen sample prepared?

A

Prepared to remove plasma and concentrate

26
Q

What are the risks of oocyte collection

A

Bleeding
Pelvic infection
Failure to obtain oocytes

27
Q

What happens to the follicular fluid in the embryology lab?

A

Embryologist searches through the follicular fluid to identify eggs and surrounding mass of cells
Collects them into culture medium
Incubated at 37 degrees Celcius

28
Q

Approximately __% of eggs fertilise normally in IVF

A

Approximately 60% of eggs fertilise normally in IVF

29
Q

What day does transfer or cryopreservation normally take place?

A

Day 5

30
Q

How many embryos are transferred

A

Normally transfer 1 embryo (maximum 3 in exceptional circumstances

31
Q

What supports embryo transfer?

A

Luteal support: Progesterone suppositories for 2 weeks

32
Q

When does the patient take a pregnancy test after IVF?

A

16 days after oocyte recovery

33
Q

What are the indications for ICSI?

A
  • Severe male factor infertility
  • Previous failed fertilisation with IVF
  • Preimplantation genetic diagnosis
34
Q

What is required if the male has azoospermia?

A

Surgical sperm aspiration

Can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)

35
Q

Describe the process of ICSI

A
  • Each egg is stripped
  • Sperm immobilised
  • Single sperm injected
  • Incubate at 37 degrees overnight
36
Q

What is the presentation of mild OHSS

A

Abdominal bloating
Mild abdominal pain
Ovarian size usually <8 cm

37
Q

What is the presentation of moderate OHSS

A

Moderate abdominal pain
Nausea +/- vomiting
US evidence of ascites
Ovarian size usually 8-12cm

38
Q

What is the presentation of severe OHSS

A 
Clinical ascites (+/- hydrothorax)
Oliguria (<300ml/day or <30ml/hr)
Haematocrit >0.45
Hyponatraemia
Hypo-osmolality
Hyperkalaemia
Hypoproteinaemia
Ovarian size usually >12cm
39
Q

What is the presentation of critical OHSS

A

Tense ascites/large hydrothorax
Haematocrit >0.55
White cell count >25000/ml

40
Q

Approximately __% of patients develop OHSS

A

1%

41
Q

How can OHSS be prevented?

A

Low dose protocols

Use of antagonist for suppression

42
Q

What is the treatment for OHSS before embryo transfer?

A

Elective freeze

Single embryo transfer

43
Q

What is the treatment for OHSS after embryo transfer?

A
  • 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
44
Q

What measures have been taken in ACT to decrease multiple pregnancy?

A

Move to blastocyst transfer
Improved cryopreservation
Increase in single embryo transfer

45
Q

The incidence of ectopic pregnancy is increased - fold in IVF?

A

2-3

46
Q

What is a heterotopic pregnancy and what is the risk in IVF?

A

Approximately 1%

When a intrauterine and ectopic pregnancy occur simultaneously

47
Q

List some of the problems with IVF and ICSI

A
  • No eggs retrieved
  • Surgical risks of oocyte retrieval
  • Surgical risks of surgical sperm aspiration
  • failed fertilisation
  • psychological problems
  • failed treatement
48
Q

What are the risks of oocyte retrieval?

A

Bleeding

Infection

49
Q

What are the risks of sperm aspiration

A

Haematoma

Infection

50
Q

What are the problems in early pregnancy common in ACT?

A

Increase miscarriage and ectopic pregnancy

51
Q

What are the problems in on-going pregnancy common in ACT?

A

Possible increase in prematurity and intra-uterine growth retardation, congenital abnormalities

52
Q

What is the overall success rate for IVF?

A

35%

53
Q

What is the role of HFEA?

A

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

Reproductive & Sexual Health (54 decks)

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