Infertility Assisted Conception Flashcards
What is meant by Assisted Conception Treatment (ACT)?
any treatment in which involves gametes outside the body
How many couples require assessment of infertility in UK and how many of these then go on to require ACT?
1 in 6 require assessment
half of these will require ACT
What percentage of live births in the UK come from ACT?
2%
Why is demand for ACT increasing?
- increasing parental age
- increasing chlamydia infection
- male factor infertility,
- increasing range of ACT
- improved success rates
In 2016, Scottish legislation changed so that patients are waiting no longer than how many months for ACT?
Aim for all patients to be waiting <12 months for treatment
How many cycles of ACT are patients offered on the NHS in Scotland?
- up to three cycles of IVF/ICSI
- where there is a reasonable expectation of a live birth
What type of ACT is commonly used if male factor infertility is causing difficulty getting pregnant?
Intra-cytoplasmic Sperm Injection (ICSI)
What type of ACT is more popular if couples have unexplained infertility?
IVF
How have the indications for ACT treatment changed in recent years? i.e. who is now included in the guidelines to be treated?
- Increase single (female/male) and same sex couples
- Increase in treatment with surrogate
- Increase in transgender referral
What other services can be offered alongside ACT for specific patient groups?
- Fertility preservation in cancer/ transgender patients/ social reasons
- Tx to avoid transmission of blood born viruses (BBV)
- Pre-implantation diagnosis of genetic disorders
- Treatment with surrogacy when absent /abnormal uterus
What criteria should be discussed prior to beginning treatment?
- Alcohol: females limit <4 units per week
- Drugs: prescribed, OTC and recreational
- BMI: 19-29 optimal both male and female
- Stop smoking
- Folic acid: 0.4mg/day
- Immunise mother against Rubella
- Check last cervical smear
- Avoid exposure to hazards (e.g. occupation)
- Screen for BBV
- Assess ovarian reserve
- Offer supportive counselling
What different forms of ACT are available?
- Donor insemination
- Intra-Uterine Insemination (IUI)
- In Vitro Fertilisation (IVF)
- Intra-Cytoplasmic Sperm Injection (ICSI)
- Fertility Preservation
- Surrogacy
When would intra-uterine insemination be indicated?
- sexual problems
- same sex relationships
- BBV
- abandoned IVF
How is an intra-uterine insemination carried out?
- Can be a natural OR stimulated cycle
- Prepared semen inserted into uterine cavity around time of ovulation
What are the indications for IVF?
- Unexplained Infertility (> 2 years)
- Pelvic disease (endometriosis, tubal disease, fibroids)
- Anovulatory infertility (after failed ovulation induction)
- Failed Intra-uterine insemination (after 6 cycles)
What are the main stages of IVF treatment?
1 - Down Regulation 2 - Ovarian Stimulation 3 - Oocyte collection - theatre 4 - Fertilisation 5 - Embryo Transfer
What is involved in the process of down regulation in IVF and what is the function of this?
- Synthetic GnRH analogue given (Buserelin) nasal spray
FUNCTION:
- Reduces cancellation from ovulation
- improves success rates
- Allows precise timing of oocyte recover by using HCG trigger
What side effects do women experience from the GnRH analogues given to down regulate them before IVF?
- Hot flushes and mood swings (like menopausal symp.)
- Nasal irritation
- Headaches
How are the ovaries stimulated in preparation for IVF?
- Given synthetic FSH/LH
- usually a self-administered s/c injection
- Causes follicular development (usually multiple)
What is used in IVF to simulate the LH peak which usually causes ovulation?
HCG injection - given 36 hours before oocyte recovery
When does semen need to be produced for an IVF treatment, and what should be assessed on semen analysis before this?
Abstinence for 72 hours
Then produced in ‘Men’s room’ or at home (within 1 hour before)
Analyse for:
- volume
- density
- motility
- progressive motility
What risks are associated with oocyte collection in theatre?
- Bleeding
- Pelvic infection
- Failure to obtain oocytes
How many embryos are normally transferred in IVF?
Normally transfer 1 embryo (max 3 in exceptional circumstances)
risk of multiple pregnancy with multiple embryo transfer
What medication must be given after embryo transfer in IVF?
Luteal Support (as no corpus luteum has developed to do this) => progesterone suppositories for 2 weeks
How soon after egg retrieval can a pregnancy test be taken?
16 days after oocyte recovery
What are the indications for the use of ICSI?
- Severe male factor infertility
- Previous failed fertilisation with IVF
- Pre-implantation genetic diagnosis
Where is sperm surgically aspirated from in an obstructive cause of azoospermia?
extracted from epididymis
Where is sperm surgically aspirated from in a patient with non-obstructive azoospermia?
testicular tissue (non-obstructive)
Describe what happens during ICSI
Each egg is stripped
Sperm immobilised
Single sperm injected
Incubate at 370C overnight
How is ovaran hyperstimulation syndrome prevented?
Prevention:
- Low dose protocols
- Use of antagonist for suppression
How is ovarian hyper-stimulation treated BEFORE an embryo is transferred to the mother?
- Elective freeze
- Single embryo transfer
How is Ovarian hyper-stimulation treated AFTER an embryo is transferred to the mother?
- Monitor with scans and bloods
- Reduce risk of thrombosis
=> Fluids, TED stockings and fragmin - Analgesia
- Hospital admission if IV fluids/more intensive monitoring req’d
What are the main complications of ACT?
Ovarian hyperstimulation
Multiple pregnancy
The UK aim to have a rate of multiple pregnancy under what percentage?
10%
What are the overall success rates for IVF/ICSI?
35% (roughly 1 in 3)
What are the HFEA responsible for with regards to all ACT?
- Regulate all treatment and research
- Consider welfare of child
- Rights of people seeking treatment to appropriate care
- Respect for human life at all stages of development
