infertility & assisted conception

Question 1

indications for assisted conception treatment?

10

Answer 1

Endometriosis
Male factor
Tubal disease
multiple factors
unexplained
multiple male factors
Fertility preservation in cancer patients
to avoid transmission of blood born viruses
pre implantation diagnosis of inherited disorders
single parents/same sex couples

Question 2

prior to ACT what factors must be considered?

Answer 2

alcohol- females limit to 4 units per week
weight- BMI between 19-29
smoking- advise to stop smoking
folic acid-0.4mg/day preconception- 12 wks gestation
Rubella- check if mum immune, if not immunise
cervical smear- check up to date
occupational factors- exposure to hazards
Drugs- prescribed/OTC/recreational
Screen for blood borne viruses- hep B/C & HIV
asses ovarian reserve- astral follicle count or AMH (anti-mullerian hormone)

Question 3

What treatments are available? (7)

Answer 3

Donor insemination 
Intra-uterine insemination (IUI)
In vitro Fertilisation (IVF)
Inta cytoplasmic sperm injection (ICSI)
Fertility Preservation 
Surrogacy

Question 4

IUI

• indications?
• Method?

Answer 4

-unexplained infertility
Mild or moderate endometriosis
Mild male factor infertility

-natural/stimulated cycle with the prepared semen insert into uterine cavity around time of ovulation

Question 5

IVF

-indications

Answer 5

-Unexplained infertility (> 2 yrs duration)
pelvic disease (endometriosis, tubal disease, fibroids)
Anovulatory infertility
Male factor infertility
other e.g. pre implantation genetic diagnosis

Question 6

describe the process of down regulation:

• what hormone is used?
• how is it given and what does it do?
• SE?
• signs at start on US?

Answer 6

-synthetic gonadotrophin releasing hormone analogue or agonist

-administered as spray or injection
reduces cancellation from ovulation improves success rates
allows precise timing of oocyte recover by using HCG trigger

-hot flush and mood swings
nasal irritation
headaches

-ovary will have few follicles and the endometrium will be thin

Question 7

process of ovarian stimulation:

• hormone used?
• how is it given and what does it do?
• SE?
• on US?

Answer 7

-Gonadotrophin hormone (contains either synthetic or urinary LH/FSH)

-self administered by injections
causes follicular development

-mild allergic reaction
ovarian hyper stimulation syndrome

-larger ovary with many follicles
thickened endometrium

Question 8

Action scan

• why is this performed?
• what does it allow you to do?

Answer 8

• to asses response to treatment, 40-50% have a slow response and so need to repeat scan 72 hrs later
• asses risk for ovarian hyper stimulation syndrome
• plan date/timing of HCG injection (this mimics LH causing resumption of meiosis in oocyte, 36 hrs before oocyte recovery.

Question 9

Sperm sample

• how are they collected?
• how are they asses?

Answer 9

-abstinence for 72 hrs previously then in men’s room in hospital

-volume
Density- no. of sperm
motility- what proportion are moving
Progression- how well they move

Question 10

what are the risks of oocyte collection?

Answer 10

bleeding
pelvic infection and abscess
failure to obtain oocytes

Question 11

what do you see when egg is fertilised?

-on what day is the embryo transferred/cryopreserved?

Answer 11

2 pronuclei can be seen

-day 5

Question 12

Embryo transfer

• how many transferred?
• hormonal support?

Answer 12

• normally one at a time but max 3

- luteal support from progesterone and suppositories for 2 weeks

Question 13

when is a pregnancy test carried out?

Answer 13

16 days after embryo transfer

Question 14

ICSI

• indications?
• what is required in azoospermia?
• method?

Answer 14

-severe male factor infertility
prev failed IVF
Preimplantation genetic diagnosis

-surgical sperm aspiration

-each egg is stripped, sperm immobilised
single sperm injected
incubate at 37 deg C overnight

Question 15

Ovarian hyperstimulation syndrome

• what is it?
• presenation?
• on US?
• treatment (if embryos have been transferred and if not?)

Answer 15

-enlarged ovaries with excess follicles

-Abdo pain
nausea/diarrhoea
Breathless

-huge ovaries with many follicles, worry with there are more than 20 eggs

-before transfer:
coasting (withdraw gonadotrophins)
elective freeze
single embryo transfer

After transfer:
monitoring with scans and bloods
Antithrombotic: Fluids, TED stockings and fragmin
Analgesia
Admission if require, paracentesis

Question 16

Other problems associated with fertility treatment? (8)

Answer 16

no eggs retrieved
surgical risks of oocyte retrieval/sperm aspiration
failed fertilisation
ectopic pregnancy
non-continuing pregnancy
inc risk in ongoing preg 
psychological problems

Question 17

what is the success rate of IVF?

Answer 17

35% :/