Module 4 : Fertility Management Flashcards
what is infertility
- inability to conceive after 12 months of unprotected intercourse
what is the #1 reason for infertility
- postponement of pregnancy until the later years
what percentage does infertility in women account for
- 40%
4 areas of infertility in women
- ovarian
- uterine
- cervical
- immunologic
two types of ovarian infertility
- primary \+ ovulatory dysfunction - secondary \+ inability to transport ova/embryo \+ blocked fallopian tube
3 reasons for uterine infertility
- congenital abnormalities
- fibroids
- asherman’s
immunologic reasons for infertility in women
- hostile cervix
- reproductive organs kill all the sperm
what percentage does infertility in men account for
40%
three areas of infertility in men
- varicocele
- testicular failure
- tubular obstruction
6 reasons for testicular failure
- mumps
- torsion
- orchitis
- testicular cancer
- frequent marijuana use
- undescended testes (cryptorchidism)
what is tubular obstruction
- vas deferens not connecting to sperm
what accounts for the other percent of infertility
- 20% idiopathic
what does ART stand for
- assists reproductive technology
what are the four services in ART
- ovulation induction
- intrauterine insemination (IUI)
- in vitro fertilization (IVF)
- intracytoplasmic sperm insertion (ICSI)
what is the first step of ART for sonography
- ovulation induction
+ fertility drugs are used to ensure ovulation occurs
what is ovulation impairment
- no Graafian follicle produced
what is our role in ovulation induction
- monitor the cycle with ultrasound
+ trying to achieve only one Graafian follicle
what is step 2 of ART for sonography
- intrauterine insemination (IUI)
for what circumstances is IUI usually down
- male infertility
- unexplained infertility
- donor insemination
- same sex couples
what is the third step in ART for sonography
- in vitro fertilization
definition of IVF
- fertilization in a glass or lab
- egg and sperm are fertilized outside the body
4 reasons for IVF
- blocked fallopian tubes
- impaired eggs
- impaired sperm
- unexplained infertility
6 steps to IVF
1) initial lab and ultrasound investigations
2) ovarian suppression
+ stopping normal ovulatory cycle
3) ovarian stimulation
+ gonadotropins administered to hyper stimulate ovaries
+ more than one egg is produced
4) egg or oocyte retrieval
5) insemination
6) embryo transfer
what are the 5 investigations done before IVF
- lab blood work
- ultrasound
- hysterosalpingogram
- sonohysterogram
what blood work is done before IVF
- ovarian reserve testing
what hormone does ovarian reserve testing look at and what does is giver information on
- tests for FSH
- insight into number of eggs left or ovarian age
what number of FSH indicated that eggs are present
< 10 indicates eggs
what is ultrasounds role in investigating before IVF
- assess uterus \+ fibroids \+ congenital abnormalities - asses adnexa \+ hydrosalpinx - assess ovaries \+ cysts PCOS \+ ovarian cysts \+ baseline astral follicle count
what is the basal antral follicle count
- number of small antral follicles observed at the beginning of the menstrual cycle
what is a poor BAFC
- < 10 poor ovarian response
hysterosalpingogram (HSG) role pre IVF
- dye or contrast is injected into the uterus
- assessing uterine cavity for congenital abnormalities
- assess patency of Fallopian tubes
+ contrast spilling into the posterior culdesac indicates one Fallopian tube patent
sonohysterogram (SHG) role pre IVF
- saline injected into uterus
- ultrasound guided
- assess uterine cavity
- patency of Fallopian tubes
4 complications associated with HSG and SHG
- infection
- fainting
- HSG
+ radiation - spotting
how are the ovaries suppressed in the second step of IVF
- down regulation
what is down regulation
- GnRH agonist is given to stop natural ovulation
- temporary state of menopause
- prevents premature ovulation
- CONTROLS TIMING OF IVF CYCLE
what is the ovarian suppression check
- ultrasound to ensure no new finding such as ovarian cyst has occurred
what is step 3 of IVF trying achieve
- trying to achieve super ovulation
- medication injected for 9-14 days
when is ultrasound performed during step 3 of IVF and what is for
- day 4 day 7
- every 2nd day after day 7 while on FSH
- to monitor size and number of follicles on each ovary
what is done during step 4 of IVF
- oocyte retrieval
- patient is sedated
- done under EV guidance
- a needle is inserted through the vaginal wall
- follicular fluid cells and egg are aspirated into a test tube
- eggs are examined under a microscopic for quality
when is the semen sample collected for insemination
- 1-3 hours after egg retrieval
+ conventional insemination in a Petri dish
+ intracytoplasmic sperm injection
what 5 things does the embryologist assess the zygotes for
- cell division
- timing of division
- cell size
- cellular components
- any fragmentation
when are the embryos transferred
- day 3 or 5 after retrieval
what stage are the embryos at by day 5
- blastocyst stage
- better assessment of implantation abilities
- usually only ONE embryo is transferred
what three factors determine number of embryos implanted
- mothers age
- quality of embryos
- previous fertility history
2 major sonographic contributions to IVF
- confirmation of pregnancy and number
- 6-8 weeks gestation
sonographic protocol
- ovulation induction
+ follicular monitoring - routine pelvic ultrasound
- track the growth of follicles
+ 3 dimensions of the 3 largest follicles on EACH ovary - check the pouch of Douglas for free fluid
+ indicates ovulation has occurred
rules to EV with ART
- DO NOT use a condom that has lubrication (spermicide)
- DO NOT use gel or KY jelly on condom
- WATER ONLY
3 major hormone drugs
- clomid
- pergonal
- hCG
clomid characteristics
- increase FSH
- acts like a normal cycle
- only one Graafian follicle
pergonal characteristics
- stimulates FSH and LH
- more than one follicle matures per cycle
hCG characteristics
- induces ovulation and encourages implantation
what is ovarian hyper stimulation syndrome and what causes it
- ovary creates a lot of follicles
- occurs with drugs used in fertility management
+ PERGONAL AND HCG - results in
+ ascites
+ pleural effusion
+ possible thromboembolic states
+ shock and death
chances of multiple gestation with pergonal
- causes multiple follicles
- 35% - 60%
chances of multiple gestation with pergonal and HCG
80% of all cases
steps after transfer is complete
- HCG is given on the day of transfer
- given every other day for 3 more doses
- encourages implantation
- progesterone continued until 10 weeks gestation until placenta takes over
most common reason for unsuccessful IVF
- FAILURE TO IMPLANT
what is cryopreservation
- good quality zygotes cryopreserved in liquid nitrogen for later attempts at pregnancy
what is gamete intrafallopian transfer GIFT
- oocyte and sperm are injected into the ampulla of the Fallopian tube
- done by laparoscopy
- can be done using EV
- done when couples unexplained infertility or endometriosis
what is zygote intrafallopian tube transfer ZIFT
- modification to IVF
- 1 day old zygotes are placed into the Fallopian tubes
