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Y4 Obstetrics and Gynaecology > Infertility & assisted conception > Flashcards

Infertility & assisted conception Flashcards

1
Q

How common is infertility ?

A

Very, affects 1:6 couples (15%)

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2
Q

List some of the reasons for increasing rates of infertility

A
  • Women are older when trying to concieve
  • Rise in chlamydia infections
  • Increase obesity
  • Increase in male factor infertility
  • Increased awareness of infertility treatments available
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3
Q

List the factors which increase the chances of conception

A
  • Women < 30
  • Previous pregnancy
  • < 3yrs trying to concieve
  • Intercourse occuring around ovulation
  • Womans BMI 18.5-30
  • Both partners non-smokers
  • Caffeine intake < 2 cups daily
  • No recreational drug use
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4
Q

What happens to fertility as we get older ?

A
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5
Q

Define infertility

A

This is failure to achieve clinical pregnancy after ≥ 12 months of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child

This can be further divided into:

  1. Primary = couple have never concieved
  2. Secondary = couple previously concieved but pregnancy was not successful e.g. misscariage or ectopic pregnancy
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6
Q

What reasurance should be be given to couples presenting with concerns over infertility ?

A

Reasure that 84% of couples will concieve within the 1st year of having unprotected sexual intercourse & 92% will within 2 years

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7
Q

What is the initial general advice provided to couples wishing/struggling to concieve ?

A
  • Folic acid 400 micrograms (5mg if them or partner have a NTD, or previous baby with NTD, or a fam history of NTD’s or they have diabetes)
  • Aim for BMI 20-25
  • Advice regular sexual intercourse every 2-3 days
  • Smoking, alcohol & caffeine advice
  • Stop recreational drugs or methadone
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8
Q

List the general different causes of infertility

A
  • Male factor infertility
  • Multiple factors (female & male)
  • Multiple factors (female only)
  • Tubal factor
  • Endometriosis
  • Diminished ovarian reserve
  • Ovulatory dysfunction
  • Uterine factor - structural
  • Unexplained
  • Other causes
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9
Q

Ovulatory dysfunction is covered in ovulatory disorders deck in Endocrine week 5

A
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10
Q

What are the causes of tubal disease resulting in infertility ?

A
  • PID - usually due to chlamydia or gonorrhoea resulting in hydrosalpinx or pyosalpinx
  • Endometriosis
  • Transperitoneal spread from abdo infections e.g. appendicitis, abdominal abscess etc
  • Following procedures - IUCD insertion, hysteroscopy, HSG, ectopic pregnancy, sterilisation
  • Fibroids
  • Polyps
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11
Q

What are the uterine/ structural abnormalities (affecting meeting of egg & sperm) which can result in infertility ?

A
  • Fibroids
  • Vaginal septum
  • Adhesions
  • Polyps
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12
Q

What are the causes of male factor infertility ?

A

IDIOPATHIC: most common cause (>50%)

OBSTRUCTIVE: vasectomy, cystic fibrosis (congenital absence of vas deferens), infection

NON-OBSTRUCTIVE:

  • Congenital: Cryoptorchidism
  • Infection: mumps orchitis
  • Iatrogenic: chemotherapy/radiotherapy
  • Pathological: testicular tumour
  • Genetic: chromosomal (Klinefelter’s syndrome, microdeletions of Y chromosome, Robertsonian translocation)
  • Specific semen abnormality e.g. globozoospermia
  • Systemic disorder
  • Endocrine
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13
Q

When should someone be investigated for a cause of infertility ?

A

Once they meet the definition of it i.e. after 12 months of trying

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14
Q

How should infertility be initially investigated ?

A

See as couple in designated infertility clinic & carry out:

History: infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH, POH

Examination of female:

  • BMI
  • General examination, assessing body hair distribution, galactorrhoea
  • Pelvic examination, assessing for uterine and ovarian abnormalities/tenderness/mobility

Examination of male:

  • BMI
  • General examination
  • Genital examination, assessing size/position testes, penile abnormalities, presence vas deferens, presence varicoceles
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15
Q

What are the initial female investigations which should be done in someone presenting with infertility ?

A
  • Endocervical swab for chlamydia
  • Cervical smear if due
  • Blood for rubella immunity
  • Midluteal progesterone level (day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles), progesterone > 30nmol/l suggestive ovulation
  • Test of tubal patency: hysterosalpingiogram or laparoscopy

Others if indicated: e.g. hysteroscopy, ultrasound scan, endocrine profile and chromosomes

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16
Q

What is the 1st line investigation for investigating tubal patency ?

A

1st line = Hysterosalpingiogram (HSG)

Done in women who are not known to have comorbidities/risk factors of tubal/ pelvic pathology e.g. PID, previous ectopic pregnancy or endometriosis) or when laparoscopy is contraindicated i.e. obesity, previous pelvic surgery, Crohn’s disease

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17
Q

What is the 2nd line investigation done for assessing tubal patency and when is it done ?

A

2nd line = Laparoscopy

Done if:

  • They have possible tubal/pelvic disease: e.g.PID
  • Known previous pathology: e.g. ectopic pregnancy, ruptured appendix, endometriosis
  • History suggestive of pathology: e.g. dysmenorrhoea, dysparunia
  • Previously abnormal HSG
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18
Q

When is hysteroscopy performed in the assessment of a women presenting with infertility ?

A

Only performed in cases where suspected or known endometrial pathology: i.e. uterine septum, adhesions, polyp

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19
Q

When is pelvic ultrasound performed in the assessment of a women with infertility

A
  • Perform when abnormality on pelvic examination: e.g. enlarged uterus /adnexal mass
  • When required from other investigations: e.g. possible polyp seen at HSG
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20
Q

If a women being investigated for infertility has an anovulatory cycle or infrequent periods what additional investigations should be done ?

A

Endocrine profile:

  • Urine HCG
  • Prolactin
  • TSH
  • Testosterone and SHBG
  • LH, FSH and oestradiol
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21
Q

If a women being investigated for infertility has hirtuism what additional investigations should be done ?

A

Testosterone and SHBG

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22
Q

If a women being investigated for infertility presents with amenorrhoea what additional investigations should be done ?

A
  • Endocrine profile (as in anovulatory cycle)
  • Chromosome analysis
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23
Q

What is the treatment of ovulatory disorders causing infertility ?

A

Refer to ovulatory disorders deck in endocrine week 5

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24
Q

What are the 2 main reasons reproductive surgery is used in the management of infertility ?

A
  1. Primary surgical treatment for infertility
  2. Surgery to enhance IVF outcome
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25
Q

What are the main conditions causing infertility which are treated by surgery ?

A
  1. Pelvic adhesions
  2. Grade 1& 2 Endometriosis
  3. Chocolate cysts in Ovary
  4. Tubal Block
26
Q

What is the surgical treatment done for infertility due to mild tubal disease ?

A

Tubal surgery

27
Q

What is the surgical treatment done for infertility due to proximal tubal obstruction ?

A

Either selective salpingography + tubal catherterisation or hysteroscopic tubal cannulation

28
Q

What is the surgical treatment done for infertility due to hydrosalpinges before IVF and why ?

A

Laproscopic salpingectomy - this is done because it improves the chances of live birth with IVF treatment

29
Q

What is the surgical treatment done for inferility because of intrauterine adhesions ?

A

Hysteroscopic adhesiolysis

30
Q

What is the surgical treatment of endometriosis causing infertility ?

A
  • Minimal or mild endometriosis tx = surgical ablation or resection of endometriosis + laparoscopic adhesiolysis
  • Women with ovarian endometriomas tx = laparoscopic cystectomy
  • Women with moderate or severe endometriosis tx = surgery
31
Q

What is the treatment of fibroids causing infertility ?

A

Polypectomy or myomectomy

32
Q

What is the treatment of uterine septum causing infertility?

A

Metroplasty

33
Q

What is the treatment of unexplained infertility ?

A
  • 1st line = try to concieve for a total of 2 years
  • 2nd line = after trying to concieve natrually treat with IVF
34
Q

List the different causes for needing assisted conception treatment (ACT)

A
  • Endometriosis
  • Male factor infertility
  • Tubal disease
  • Multiple male and female factors
  • Unexplained
  • Ovulatory disorder
  • Multiple female factors
  • Fertility preservation in cancer patients
  • Treatment to avoid transmission of blood born viruses between patients
  • Pre-implantation diagnosis of inherited disorders
  • Treatment of single parents or same sex couples
  • Others: cryopreservation of gametes for social reasons, treatment when absent/abnormal
35
Q

What needs to be done before ACT begins ?

A
  • Alcohol: females limit to 4 units per week
  • Weight: between 19-29 optimal both male and female
  • Smoking: advise to stop smoking
  • Folic acid: 0.4mg/day preconception-12 weeks gestation (5mg increase risk NTD/obese)
  • Rubella: check if female immune to rubella, if not immunise
  • Cervical smears: check up to date according to national screening programme
  • Occupational factors: exposure to hazards
  • Drugs: prescribed, over-the-counter and recreational such as steroids
  • Screen for blood born viruses: hep B/C and HIV
  • Assess ovarian reserve: antral follicle count or AMH
  • Counselling: offer supportive counselling
36
Q

List the different ACT avaliable

A
  • Donor insemination
  • Intra-Uterine Insemination (IUI)
  • In Vitro Fertilisation (IVF)
  • Intra-Cytoplasmic Sperm Injection (ICSI)
  • Fertility Preservation
  • Surrogacy
37
Q

What are the indications for intrauterine insemination (IUI) ACT?

A
  • sexual problems (physical or psychological) or same sex relationships
  • discordant BBV
  • unexplained infertility
  • mild or moderate endometriosis
  • mild male factor infertility
  • abandoned IVF
38
Q

Describe what is done in IUI

A
  • Can be in natural/stimulated cycle
  • Prepared semen inserted into uterine cavity around time of ovulation
39
Q

What are the indications for In vitro fertilisation (IVF) ACT ?

A
  • Unexplained infertility (> 2 years durations) (if < 40 give 3 cycles, if 40-42 only 1 cycle)
  • Pelvic disease (endometriosis, tubal disease, fibriods)
  • Anovulatory infertility (after failed ovulation induction)
  • Male factor infertility (if > 1 X 106 motile sperm)
  • Failed Intra-uterine insemination (after 6 cycles)
  • Others (pre-implantation genetic diagnosis)
40
Q

List the main steps that make up IVF ACT

A
  1. Down regulation
  2. Ovarian stimulation
  3. Oocyte collection
  4. Fertilisation
  5. Day 5 after fertilisation - day of transfer & cryopreservation
  6. Embryo transfer
41
Q

Describe what down regulation is in relation to IVF

A
  • Down-regulation essentially “turns off” the ovaries to better control ovulation and egg maturation during treatment.
  • It allows precise timing of oocyte recovery by using HCG trigger
42
Q

How is down regulation during IVF treatment achieved ?

A

Using a GnRH agonist or antagonist.

43
Q

What are the side effects a patient may experience from recieiving down regulation of their ovaries ?

A
  • Hot flushes and mood swings
  • Nasal irritation
  • Headaches
44
Q

How is down regulation of the ovaries confirmed in IVF treatment ?

A

Using a US scan

45
Q

Describe what happens during the second stage of IVF treatment (ovarian stimulation)

A
  • The goal of this process is to produce as many eggs as possible for collection
  • Patient is given injections of Gonadotrophin Hormone containing either synthetic or urinary gonadotrophins (FSH+/- LH) for 8-14 days
  • A trigger shot of HCG (mimics the LH surge) is then given to stimulate ovulation 36hrs prior to oocyte collection
46
Q

Prior to oocyte collection what does the male partner need to do during IVF treatment ?

A

Provide semen (needs to abstain for 72hrs prior to this) which then needs to be assesed for:

  • Volume
  • Density - numbers of sperm
  • Motility - what proportion are moving
  • Progression - how well they move
47
Q

What are the risks accompanied with oocyte collection ?

A
  • Bleeding
  • Pelvic infection
  • Failure to obtain oocytes
48
Q

After oocyte collection what is done ?

A
  • Search through the follicular fluid
  • Identify eggs and surrounding mass of cells
  • Collect them into cell culture medium
  • Incubate at 370C
49
Q

What is the 4th stage of IVF treatment ?

A

Ferilisation - artificially (done outside the women by scientists)

50
Q

Following fertilisation of the oocyte by scientists during IVF treatment when is the fertilised oocyte (embryo) transferred and what is also done ?

A
  • Embryo is transferred on day 5 after fertilisation
  • Cryopreservation of the other collected eggs is done I believe
51
Q

What happens to fertility as we get older ?

A
52
Q

How long after embryo transfer should a pregnancy test be done to confirm if IVF treatment has been successful or not ?

A

16 days

53
Q

What are the indications for intracytoplasmic sperm injection (ICSI)?

A
  • Severe male factor infertility (< 1x106)
  • Previous failed fertilisation with IVF
  • Preimplantation genetic diagnosis
54
Q

When doing ICSI, if the patient has azoospermia what needs to be done for sperm collection ?

A

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

55
Q

What are the main complications of assisted reproductive treatments ?

A
  1. Ovarian hyperstimulation syndrome (OHSS)
  2. Multiple pregnancies
  3. Ectopic pregnancies
56
Q

What are the signs/symptoms of OHSS?

A
57
Q

What assisted reproductive treatment is the most likely to result in OHSS?

A

IVF

58
Q

What is done to try to prevent OHSS in IVF treatment ?

A

Prevention:

  • Low dose protocols
  • Use of antagonist for suppression (referring to GnRH anatagnoist)
59
Q

What is the treatment of OHSS?

A

Treatment before embryo transfer:

  • Elective freeze
  • Single embryo transfer

Treatment after embryo transfer:

  • Monitoring with scans and bloods
  • Reduce risk thrombosis: Fluids, TED stockings and fragmin
  • Analgesia
  • Hospital admission if required IV fluids/more intensive monitoring/paracentesis
60
Q

List some of the additional problems with assissted reproductive treatments

A
  • No eggs retrieved (very uncommon: 0.2%)
  • Surgical risks of oocyte retrieval (bleeding, infection)
  • Surgical risks of surgical sperm aspiration (haematoma, infection)
  • Failed fertilisation (approx. 4%)
  • Problems in early pregnancy: increase miscarriage and ectopic pregnancy
  • Increase risk in on-going pregnancy (possible increase in prematurity and intra-uterine growth retardation, congenital abnormalities)
  • Psychological problems
  • Failed treatment
61
Q

What is the success rates of IVF treatment ?

A

Approx. 35%

Y4 Obstetrics and Gynaecology (63 decks)

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