IVF and its complications Flashcards
What counts as 1 round of IVF
Ovarian stimulation and transfer of any resultant fresh/frozen embryos
If <40yrs and no conception after 2 years/12 cycles IUI how many round of IVF offered?
3 full cycles IVF
If 40-42 and no conception after 2 years/12 IUI, how many rounds of IVF
1 full cycle if -
1) No previous IVF
2) No evidence low ovarian reserves
3) Discussed long term implications of IVF & pregnancy
If reaches 40 during treatment, complete the current full cycle
What is pre-treatment? Who is offered to?
COCP or POP or oestrogen used before ovarian down regulation/stimulation. ?improves exogenous hormone therapy, minimises risk ovarian cyst formation
Does not effect chances of live birth
What medications can be offer for ovarian down regulation?
GnRH agnost - inital stimulation phase then reversible inhibition of pituitary function
Prevents LH surge
Long protocol 2 weeks before
Short protocol simultaneously with stimulation
Only use if low risk OHSS
GnRH antagonist, few days before
What medications are given for controlled ovarian stimulation?
- Urinary or recombinant gonadotrophins, max FSH 450 IU/day
- Can be used in combination with clomifene
- USS monitoring should be offered
How is ovulation triggered?
hCG, recombinant LH and GnRH - mimic LH surge
What is given for luteal-phase support?
Progesterone for 8 weeks
HCG - higher risk of OHSS
How is oocyte retrival performed?
Laparoscopically or via USS
Offer sedation
Can surgical collected sperm by used for IVF?
No immature, would need to perform ICSI
Surgical techniques for sperm retrival?
Percutaneous epididymal sperm aspiration (PESA)
Testicular sperm aspiration (TESA) or testicular fine needle aspiration (TEFNA)
Testicular sperm extraction (TESE) from a testicular biopsy
Microsurgical epididymal sperm aspiration (MESA)
What % of IVF babies are multiple pregnancies?
1 in 4 (1 in 80 spontaneous)
How thick should the endometrial lining be for embryo transfer?
5mm
How many eggs should be transfer if <37yrs depending on N of full cycle IVF?
1st: 1 embryo
2nd: 1 top quality embryo, consider 2 non top quality
3rd: No more than 2
How many eggs should be transfer if 37-39 yrs depending on N of full cycle IVF?
1st&2nd: 1 top quality embryo, consider 2 non top quality
3rd: No more than 2
How many eggs should be transfer if 40-42yrs depending on N of full cycle IVF?
Consider double embryo transfer
When is tubal surgery offered before IVF?
If disease of the Fallopian tube - hydrosalpinx
Can offer salpingectomy or occluding blocked/diseased tubes to increase live birth rate
Risks of IVF on pregnancy
- Multiple pregnancy
- Preterm birth
- Low birth weight
- Congenital abnormality
- Vertical transmission of genetic disease
- Increased perinatal mortality
Singleton IVF, how much more likely to have preterm birth?
2 fold
How much more likely to have small for gestational age baby with IVF?
40-60%
How much more likely to have congenital abnormality with IVF?
30-40%
The live birth rates during IVF are improve if the embryo is transferred at which stage?
40% higher if transferred after blastocyst stage
When comparing ages matched controlled which maternal risks are higher with IVF?
Higher risk
- C/S
- MOH
- PIH/PET
- GDM
Risks during oocyte retrival?
Intra-peritoenal haemorrhage 0.2%
Pelvic infection 0.4%
Injury to ovary/pelvic viscera
When is risk of ovarian torsion greatest following IVF?
Early pregnancy following OHSS
Risk of ectopic pregnancy in IVF pregnancy
2-11%
How common is OHSS in IVF cycles?
33% stimulated IVF
Moderate 3-6%
Severe 0.3-0.5%
Can OHSS occur with clomifene induction or monofolicular induction with gonadotrophins?
Yes but very rare
Risk factors for OHSS
PCOS
High dose gonadotrophins
Increase AFC
High levels AMH
Pregnancy and multiple pregnancy
Previous OHSS
Less with GnRH antagonists vs agonists
What are the definitions for early and late onset OHSS?
Early within 7 days - from exogenous hCG
Late 10+ days, related to pregnancy, endogenous hCG
Is early or late onset OHSS more severe?
Late is more likely to be severe and longer lasting
What questions should be asked when assessing OHSS?
Time of onset of symptoms relative to trigger
Medication used for trigger (hCG or GnRH agonist)
Number of follicles on final monitoring scan
Number of eggs collected
Were embryos replaced and how many?
Polycystic ovary syndrome diagnosis?
Ask re symptoms:
Abdominal bloating
Abdominal discomfort/pain, need for analgesia
Nausea and vomiting
Breathlessness, inability to lie flat or talk in full sentences
Reduced urine output
Leg swelling
Vulval swelling
Associated comorbidities such as thrombosis
What should be included in examination for OHSS?
General: assess for dehydration, oedema (pedal, vulval and sacral); record heart rate, respiratory rate, blood pressure, body weight
Abdominal: assess for ascites, palpable mass, peritonism; measure girth
Respiratory: assess for pleural effusion, pneumonia, pulmonary oedema
What Ix should be order for OHSS?
Full blood count
Haematocrit (haemoconcentration)
C-reactive protein (severity)
Urea and electrolytes (hyponatraemia and hyperkalaemia)
Serum osmolality (hypo-osmolality)
Liver function tests (elevated enzymes and reduced albumin)
Coagulation profile (elevated fibrinogen and reduced antithrombin)
hCG (to determine outcome of treatment cycle) if appropriate
Ultrasound scan: ovarian size, pelvic and abdominal free fluid. Consider ovarian Doppler if torsion suspected
Consider: ABG, ECG/ECHO, CXR, CTPA V/W
What categorises Mild OHSS
Abdo bloating, mild abdo pain
Ovarian size <8cm
What categorises Moderate OHSS
Moderate abdo pain
Nausea +/- vomit
USS evidece asictes
Ovarian size 8-12cm
What categorises Severe OHSS
Clinical ascites (+-hydrothorax)
Oliguria <300mls/day or <30ml/hr
Haematocrite >0.45
Hyponatramiea Na < 135
Hypo-osmolality <282
Hyperkalaemia >5
Hypoproteinaemia albumin <35
Ovarian size >12
What categorises Critical OHSS
Tense ascites/large hydrothorax
Haematocrit >0.55
WCC >25
Oligouria/anuria
VTE
ARDS
Other comps: Other thrombosis, renal failure, ovarian torsion/rupture
What outpatient care can be provided for mild-moderate OHSS
Avoid NSAIDs
LMWH
Drink at least 1L per day, fluid balance chart, if +ve fluid balance >1L, urgent review
Safety net worsening OHSS
Can offer parencentesis as OP
Who should be offered inpatient care
Critical OHSS
Unable to achieve pain control
Unable to maintain adequate fluid intake due to nausea
Worsening OHSS despite OP intervention
Unable to attend for regular FU
What inpatient care should be provided?
Daily review: Weight, abdo girth, fluid intake/outake daily, bloods (FBC, haematocrit, electrolytes, osmolality, LFT, CRP)
Fluid management: Oral, guided by thirst → if considering colloids (HES), for ITU review
LMWH
What are the indications for paracentesis?
- Severe abdo distention and pain from ascites
- SOB/resp compromise from ascites
- Oliguria despite fluid replacement, increased intr abdominal pressure, causing reduced perfusion
Pregnancies complicated by OHSS are more likely to have which other complications?
PET
Preterm labour
In obstructive azoospermia, how should stem be collect for IVF?
Collected directly from testicle - TESA (testicular sperm aspiration) or TESE (testicular sperm extraction)
Hyperprolactinoma but < 1000 what should you consider?
Exclude causes such as stress, recent breast examination, drug-induced.
Repeat test under appropriate conditions + TSH to exclude primary hypothyroidism. PCOS may be associated with prolactin levels up to 2500mIU/L pelvic USS to exclude diagnosis.
Hyperprolactinoma >1000, what test should you order?
Serum prolactin > 1000mIU/L CT / MRI of pituitary fossa. Macro-adenomas usually associated with prolactin levels > 5000mIU/L while micro-adenomas are associated with levels of 1500 4000mIU/L.
Questions reports secondary infertility, previous miscarriage with ERCP. What Ix?
Hysteroscopy to rule out ashermanns syndrome.
PCOS, no pregnancy with ovulation induction with clomifene, bloods show ovulation. What test?
Test tubal patency with Lap and Dye.
Preferrable Lap as can also offer ovarian drilling if tubes patent.
If not patent can offer IVF.
What level should day 21 progesterone be to evidence ovulation?
> 10
If ?POF what test should be performed?
Random FSH
Which is the most appropriate mechanism to diagnose absence of the vas deferens?
Scrotal examination
What % of men with unilateral absence of the vans deferens have unilateral renal agenesis?
And bilateral absence?
Unilateral: 25%
Bilateral: 10%
