Infertility + Assisted Conception Flashcards
How is ovarian reserve tested
antral follicle count or AMH
what is AMH
anti-mullerian hormone is a substance produced by granulosa cells in the ovarian follicles
production decreases and then stops as the follicles grow. There is almost no AMH made in follicles >8mm
when can AMH be tested
any day of a woman cycle
how can AMH be a fertility test
AMH is only produced in small follicles so blood levels can be used to measure the size of the pool of growing follicles
Women with may small follicles, e.g. PCOS will have high AMH
Women that have few remaining follicles and those that are close to menopause have low AMH
what must BMI of both partners be to be considered for fertility treatment
between 19-29
Indications for intra-uterine insemination (IUI)
unexplained infertility
mild/moderate endometriosis
mild male infertility
how does IUI work
prepared semen inserted into uterine cavity around the time of ovulation
Indications for IVF (in-vitro fertilisation)
unexplained infertility >2 years
pelvic disease (endometriosis, tubal disease, fibroids)
anovulatory infertility
mild male factor infertility
what needs to happen to women about to under go IVF treatment
down regulation- puts women artificially into menopause so there is no spontaneous ovulation
what is used to induce down regulation
synthetic GnRH analogue
administered as injection/spray
how is follicular development encouraged in IVF
ovarian stimulation- gonadotrophin hormone containing either synergic or urinary gonadotrophin (FSH +/- LH)
Side effects of ovarian stimulation
mild allergic reaction
Ovarian hyperstimulation syndrome
sign of thickened endometrium on USS
Triple line
what is the method for sperm collection in IVF
abstinence for 72 hours
ejaculated sample
what factors are assessed in a sperm sample
volume
density- number of sperm
motility- what proportion are moving
progression- how well they are moving
how are oocytes collected
in theatre
risks of oocyte collection
bleeding, infection, failure to obtain oocytes
how can you tell if an egg has been fertilised
two pronuclei
at what day after fertilisation does it become a blastocyst
day 5
what day is the embryo usually transferred to the mum
day 5
what is given as luteal support during embryo transfer
progesterone suppositories for 2 weeks
what are the indications for intra-cytoplasmic sperm injection (ICSI)
severe male factor infertility
previous failed IVF
preimplantation genetic diagnosis
what is ICSI
when you inject sperm into the egg
how are sperm retrieved for ICSI
Extraction from epididymis (if obstructive infertility) testicle (if non-obstructive)
what will be required in azoospermia
surgical sperm aspiration
what is OHSS and its symptoms
Ovarian Hyper Stimulation Syndrome
Enlarged ovaries- excess follicles
Symptoms- abdo pain, bloating, nausea, diarrhoea, SOB
How is OHSS prevented
only transfer one embryo in IVF
anti-thrombotic drugs
monitor closely
current IVF success rate
35%
complications of assisted conception
multiple pregnancies
ectopic pregnancy
OHSS
which chromosome has the sex determining region
Y chromosome
what are the 2 primitive genital tracts
Wolffian ducts
Mullerian ducts
which primitive duct becomes male genitals
wolffian duct
which primitive duct becomes female genitals
mullerian duct
what causes the development of the male genital tract
testosterone + mullerian inhibiting factors cause mullerian duct to degenerate + wolffian ducts to become male tract
what causes the development of the female genital tract
without stimulus of male testicular hormones, wolffian duct degenerates + mullerian duct becomes female genital tract
why are males with CF infertile
absent vas deferens
where are sperm aspirated from
epididymis
what is dropping of the testes into the scrotum dependent on
androgens
what is cryptorchidism
undescended testes
what does cryptorchidism cause
decreased sperm count
usually still fertile if unilateral
what is orchidopexy? why is it done?
surgically descending the testes
reduces risk of germ cell cancer
what cells in the testes produce testosterone
leydig cells
where does spermatogenesis occur
Sertoli cells in seminiferous tubules
function of Sertoli cells
form a blood-testes barrier
provide nutrients
phagocytosis
secretion of seminiferous tubule fluid, androgen binding globulin, inhibin + activin hormones
what stimulates spermatogenesis
FSH + testosterone
what inhibits FSH secretion
inhibin
what stimulates release of testosterone
LH
what does the release of testosterone do to GnRH + LH
works by negative feedback to decrease GnRH + LH
Where is FSH released from? What is its action? how is it inhibited?
released from granulosa cells in anterior pituitary
acts on Sertoli cells to stimulate spermatogenesis
inhibin released from sertoli cells decreases FSH
where is LH released from? What is its action? how is it inhibited?
released from theca cells in the anterior pituitary
acts on leydig cells to release tesosterone
inhibited by negative feedback from testosterone
what type of hormone is testosterone? what is it derived from?
steroid hormone derived from cholesterol
what is testosterone protective against
osteoporosis
route of sperm
testes - epididymis - vas deferens - ejaculatory duct - urethra
what structure produces seem into ejaculatory duct
seminal vesicles
function of bulbourethral glands
secretion of mucus lubricant
function of the prostate gland
produces alkaline fluid + clotting enzymes
ejaculation is under what control
SYMPATHETIC
there is smooth muscle contraction
how does an erection occur
blood fills the corpora cavernosa
erection is under what control
PARASYMPATHETIC
Most common cause of male infertility
idiopathic
obstructive causes of male infertility
CF, vasectomy, infection
non-obstructive causes of male infertility
undescended testes, chemotherapy, tumour, chromosomal abnormality, endocrine problem, semen abnormality
genetic conditions that cause male infertility
Kleinfelters ( 47 XXY)
Robertsonian translocation
endocrine causes of male infertility
pituitary tumours- acromegaly, cushings, prolactinoma
Hypothalmic causes- Kallmans syndrome, tumours
Thyroid- hyper/hypothyroidism
Diabetes
Steroid abuse
why does Kallman’s syndrome cause infertility
do not produce GnRh- therefore no LH, FSH or testosterone
normal testes volume in adults
12-25 mls
what is globozoospermia
round sperm
investigations for male infertility
semen analysis endocrine profile (LH, FSH, Testosterone, Prolactin, TSH) Chromosome analysis Testicular biopsy Scrotal Scan
clinical + endocrine features of an obstructive cause
Clinical: normal testicular volume, normal secondary sexual characteristics, vas deferens may be absent (CF)
Endocrine: normal LH, FSH, Testosterone
clinical + endocrine features of a non-obstructive cause
Clinical: low testicular volume, reduced secondary sexual characteristics
Endocrine: high LH + FSH and low testosterone
(note all would be low in Kallman’s)
what methods of assisted conception can be used when male infertility is the problem
IUI
ICSI
Surgical sperm aspiration
donor sperm
