Module 4: Fertility Management Flashcards
What is ART?
Assisted Reproductive Technologies
What is ovulation induction?
A form of ART where hormones are given to stimulate ovulation.
What is intrauterine insemination (IUI)?
A form of ART where insemination is done in a clinic instead of through intercourse.
What is IVF?
In Vitro Fertilization, a form of ART where the sperm and egg are fertilized outside of the body in a glass or lab and the embryo is transferred into the uterus afterwards.
What is ICSI?
Intracytoplasmic Sperm Injection, a form of ART where one healthy sperm is injected into an egg.
What is the definition of infertility?
The inability to conceive after 12 months of unprotected intercourse
What is the #1 reason for infertility?
Postponement of pregnancy until the later years.
What is primary ovarian infertility?
Ovulatory dysfunction
What is secondary ovarian infertility?
The inability to transport ova/embryo due to blocked fallopian tubes
What uterus conditions cause infertility?
- Congenital Abnormalities
- Fibroids
- Asherman’s
What factors can cause infertility in women?
- Ovarian
- Uterine
- Cervical (trap semen)
- Immunologic (attack semen)
What gender is more responsible for the inability to conceive?
It’s equal.
Men 40%
Women 40%
Unexplained 20%
What factors cause infertility in men? (3)
- Varicocele
- Testicular failure
- Tubular obstruction
What conditions cause testicular failure? (6)
- Mumps
- Torsion
- Orchitis
- Testicular cancer
- Frequent marijuana use
- Undescended testes
What is orchitis?
Inflammation
What is the medical term for undescended testes?
Cryptorchidism
What causes tubular obstruction in men?
The Vas Deferens not connecting with sperm
If a woman has open fallopian tubes, what type of ART would be used to treat infertility?
Ovulation induction
How is US used during ovulation induction?
Monitoring the cycle to visualize only one graafian follicle
What is a varicocele?
A mass of varicose veins in the spermatic cord
Why is IUI usually done? (3)
Because of a male factor.
- Unexplained infertility
- Donor insemination
- Same sex couples
How is US used during IUI?
Not usually done, possibly to assess for congenital abnormalities.
Why is ovulation induction usually done?
To treat infertility due to a hormonal imbalance (ovulation impairment of graafian follicle production).
Why is IVF usually done? (4)
- Blocked fallopian tubes
- Impaired eggs
- Impaired sperm
- Unexplained infertility
What are the steps of IVF? (6)
- Lab tests and US
- Ovarian suppression
- Ovarian stimulation
- Multiple egg/oocyte removal
- Insemination in lab
- Embryo transfer into uterus
What is administered to hyper stimulate the ovaries during IVF treatments?
Gonadotropins
What lab work is done for IVF?
- Bloodwork
2. FSH (follicle stimulating hormone)
Why is FSH tested during IVF treatments?
It shows the number or eggs left or ovarian age
What indicates that eggs are in the ovaries?
FSH of less than 10
What is US used to assess in IVF? 3
- Uterus (fibroids, congenital abnormalities)
- Adnexa (hydrosalpinx)
- Ovaries (cysts, pcos, BAFC)
What is BAFC?
Baseline Antral Follicle Count
Number of small antral follicles observed at
the beginning of the menstrual cycle
What BAFC indicates a poor ovarian response?
Less than 10
What is a hydrosalpinx?
A blocked fallopian tube filled with serous clear fluid
What is a HSG?
Hysterosalpingogram
Contrast is injected into the uterus and xrays are taken to assess the uterine cavity (for abnormalities) and the patency of the fallopian tubes.
What is a SHG?
Sonohysterogram
Saline is injected into the uterus and an US is performed to assess the uterine cavity and the patency of the fallopian tubes
Why is seeing free fluid a good sign during a sonohysterogram?
It indicates the fallopian tubes are patent
What is the most reliable test to assess fallopian patency?
Hysterosalpingogram
What are the complications of HSG and SHG? (4)
- Infection
- Fainting
- Spotting
- HSG - Radiation and iodine allergy
What is downregulation?
When GnRH Agonist is administered to suppress natural ovulation into a temporary state of menopause during IVF treatment
Why is ovulation suspended during IVF treatment?
- Prevents premature ovulation
- Allows control over timing of the
IVF cycle
What is an ovarian suppression check?
US to make sure no new findings have occurred such as an ovarian cyst
How long is medication injected for during IVF ovarian stimulation?
9-14 days
When are US’s done to monitor ovarian stimulation during IVF and what are they looking for?
Day 4, Day 7 and then every second day after day 7 while on FSH (ex: 9, 11, 13)
Monitor size and number of follicles on each ovary
How is oocyte retrieval done during IVF? (4)
- Patient is sedated
- A needle is inserted through the vaginal wall under endovaginal guidance
- Follicular fluid, cells and eggs are aspirated into test tube
- Eggs are examined under microscope for quality
During IVF, how long after egg retrieval is the semen sample collected?
1-3 hours
During IVF, after insemination what does the embryologist assess the zygotes for? (5)
- Cell division
- Timing of division
- Cell size
- Cellular components
- Any fragmentation
When are embryos transferred to the uterus during IVF?
Day 3 or 5 after retrieval (better assessment of implantation abilities)
How many embryos are transferred?
Usually just one (2-8 is common but bordering irresponsible).
What is a day 5 embryo?
A blastocyst
What factors determine the number of embryos transferred during IVF?
- Mothers age
- Quality of embryos
- Previous fertility history
(More than one may be implanted)
What is IVF high risk of?
Ectopic pregnancy
What is US used to assess after embryo transfer during IVF?
- Confirmation of pregnancy at 6-8 weeks
- Rule out multiples
- Rule out ectopic
How do you track the growth of follicles with US during IVF?
Measure 3 dimensions of the largest 3 follicles in each ovary
How many graafian follicles is ideal for IVF?
One
Why should the pouch of douglas be checked for free fluid during IVF?
FF indicates ovulation could have occurred
What should NOT be used during the EV US for ART?
- Lubricated condoms (spermicidal)
- Latex
- KY jelly
What drugs are used in ART?
- Clomid: Clomiphene Citrate (CC)
- Pergonal
- Gonadotropin-releasing hormone agonist (GnRH agonist)
- Human Chorionic Gonadotropin (hCG)
What does clomid: Clomiphene Citrate do?
Stimulates the pituitary to secrete increasing amounts of FSH that usually produces one graafian follicle per month
What does pergonal do?
Stimulates FSH and LH to produce multiple graafian follicles per month
What is human menopausal gonadotropin (hMG)?
Pergonal - natural hormone in post menopausal women
What is GnRH agonist?
Gonadotropin-releasing hormone agonist
Stops pituitary from recognizing GnRH from the hypothalamus and allows IVF specialists to control the cycle
What is hCG?
Human Chorionic Gonadotropin induces ovulation and encourages implantation
What is ovarian hyper stimulation syndrome?
A complication of fertility drug use causing multiple theca luteal cysts and multiple graafian follicles in each ovary that can cause shock and death
What factors can cause OHSS?
- Pergonal used with hCG
2. Multiple gestations
What are the sonographic features of OHSS?
- Fluid outside of ovary
- Pleural effusions
- Acites
How often do patents stimulated with pergonal and hCG develop multiple follicles?
Pergonal = 35-60% of cases
Pergonal and hCG together = 80% of cases
Why are multiple follicles considered high risk?
Multiple follicles = multiple pregnancies = higher risk of complications and miscarriage
Mother may choose to reduce number of embryos
What drugs are given after the transfer and when?
- HCG is given on day of transfer and every second day for three more doses to encourage implantation
- Progesterone is given until 10 weeks gestation until the placenta takes over
What are the reasons for unsuccessful IVF?
- Ovaries don’t respond to hormones
- No eggs in follicular fluid
- Ova fail to fertilize or grow
- Failure to implant
What is the most common problem in unsuccessful
IVF?
Failure to implant
How can zygotes be preserved?
Through cryopreservation good zygotes can be preserved in liquid nitrogen for later attempts
What is GIFT?
Gamete Intrafallopian Transfer
Oocytes and sperm are injected into the ampulla of the fallopian via laparoscopy (considered more natural than IVF).
What is ZIFT?
Zygote intrafallopian transfer
1 day old zygotes are placed into the fallopian tubes
What is the advantage of ZIFT?
The embryo develops in the fallopian tube
How thick should the endometrium be for implantation?
6 mm
Why does OHSS occur?
Increased capillary permeability plus multiple ruptured follicles
