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Week 1- assisted conception Flashcards

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1
Q

What is assisted conception treatment?

A

Any treatment which involves gametes outside of the body.

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2
Q

Why is demand for assisted conception treatment increasing?

A 
Increasing parental age
Increasing chlamydia
Male factor infertility 
ACT more successful
Bigger range of ACT
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3
Q

Other than parents struggling to have babies, when else may you use ACT?

A

Cancer patients- for preservation of eggs
Treatment to avoid transmission of blood borne viruses between patients
Treatment for single parents or same sex couples.

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4
Q

What advice is given to couples before they undergo ACT?

A

Females are limited to 4 units a week of alcohol.
BMI must be between 19-29
Stop smoking
Give 0.4mg folic acid from preconception-12 weeks gestation
Check if female is immune to rubella- if not immunise
Check cervical smears are up to date
Occupational factors- exposure to hazards
Drugs- prescribed, over the counter and recreational.
Screen for blood borne viruses
Assess ovarian reserve
Counselling

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5
Q

What ACT treatments are available?

A 
Donor insemination
Intra-uterine insemination
In-vitro fertilisation 
Intra-cytoplasmic sperm injection
Fertility preservation
Surrogacy
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6
Q

What indications are there for intrauterine insemination?

A

Sexual problems, unexplained infertility, mild or moderate endometriosis, mild male factor infertility

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7
Q

Describe the process of intrauterine insemination?

A

The sperm is inserted into the uterine cavity around the time of ovulation.

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8
Q

What indications are there for in-vitro fertilisation?

A 
Unexplained infertility (> 2 years)
Pelvic disease (endometriosis, tubal disease, fibroids)
Anovulatory infertility (after failed ovulatory induction)
Male factor infertility (if greater than 1 x10^6 motile sperm present)
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9
Q

Describe the down regulation stage in IVF?

A

Give a synthetic GnRH analogue or agonist. This reduces cancellation from ovulation and improves success rates. Allows precise timing of oocyte recover by using a HCG trigger.
A scan is also performed.

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10
Q

What side effects can be experienced in the down regulation stage of IVF?

A

Hot flushes and mood swings
Nasal irritation
Headaches

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11
Q

Describe the ovarian stimulation stage of IVF?

A

This occurs once you are happy the patient is down-regulated.
Then injections of gonadotrophins (FSH or LH) are given. Can be self-administered as a subcut injection.
This causes follicular development.

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12
Q

What is the mans semen assessed for in IVF treatment?

A

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

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13
Q

What risks are there with oocyte collection in theatre?

A

Bleeding
Pelvic infection
Failure to collect oocytes

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14
Q

How do you select an egg in IVF?

A

In the embryological lab- they go through follicular fluid and identify eggs and the surrounding mass of cells. They collect them and incubate them.

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15
Q

How many eggs fertilise normally in IVF?

A

Approximately 60%.

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16
Q

Describe the hormones, egg release and development of the normal human embryo?

A

Normal LH surge
Egg is released 36 hours later
Fertilisation occurs in the ampulla normally.
By day 4 the morula is formed. By day 5 they differentiate into a blastocyst.

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17
Q

At what day does transfer and cryopreservation (cooling to low temps) occur?

A

Day 5.

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18
Q

When does implantation of the embryo into the uteral cavity occur in IVF?

A

Day 7.

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19
Q

How many embryos are usually transferred in IVF?

A

Usually 1- but a maximum of 3 in exceptional circumstances.

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20
Q

What support do you need to give patients once the fertilised eggs have been transferred?

A

Progesterone depositories for 2 weeks.

Pregnancy test 16days after oocyte extraction.

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21
Q

What are the indications for intra-cytoplasmic sperm injection?

A

Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis.

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22
Q

What do you do if the man has azoospermia in ICSI?

A

Surgical sperm aspiration- can be withdrawn from epidydimus if obstructive or testicular tissue if non-obstructive.

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23
Q

Describe the process of intra-cytoplasmic sperm injection

A

The egg is stripped
The sperm is demobilised
The sperm is injected into the egg.
Incubated

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24
Q

What complications are associated with ART?

A

Ovarian hyperstimulation syndrome

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25
What is ovarian hyper stimulation syndrome?
Enlarged ovaries- due to excess follicles
26
What symptoms are associated with ovarian hyper stimulation syndrome?
Abdominal pain/bloating Nausea/diarrhoea Breathless
27
What treatment can be offered if ovarian hyper stimulation syndrome occurs before embryo transfer?
Electric freeze- freeze the embryos and wait 2-3 months to transfer them then. Single embryo transfer
28
What treatment can be offered if ovarian hyper stimulation syndrome occurs after embryo transfer?
Monitoring with scans and bloods Reduce risk of thrombosis- fluids, TED stockings, fragmin Analgesia Hospital admission if IV fluids are required.
29
What other issues are there with ART?
No eggs retrieved (however very uncommon) Surgical risks of oocyte retrieval Surgical risks of surgical sperm aspiration Failed fertilisation Problems in early pregnancy e.g. ectopic pregnancy Increased risk in on-going pregnancy Psychological problems
30
What determines our gender?
The presence/absence of a Y chromosome. | Even if you have one X, you are still a girl.
31
Describe the development of the internal reproductive tract?
The Y chromosome has the sex-determining region, causing the development of testis from the biopotential gonad. Fetal testes secrete testosterone and mullerian inhibiting factors.
32
What are the two primitive genital tracts called?
Mullerian- produce female genital system | Wolffian- produce male genital system
33
If you are going to be female, what primitive tracts will be suppressed and which will be left?
Wolffian will be supressed | Mullerian will be allowed.
34
If you are going to be male, what primitive tracts will be suppressed and which will be left?
Mullerian will be surpressed | Wolffian will be allowed.
35
At what stage can you determine whether a baby will be a boy or a girl?
16 weeks gestation.
36
What is testicular feminisation?
Someone is born looking like a female but when they hit puberty they don't develop breasts. They actually have a male chromosome but female genitalia.
37
What causes testicular feminisation?
Congenital insensitivity to androgens. X linked recessive disorder Androgen induction of Wolffian duct does not occur however Mullarian suppression does. Causes them to be born phenotypically female with external genitalia female, absent uterus and ovaries and a short vagina.
38
When does testicular feminisation commonly present?
At puberty with lack of pubic hair and amenorrhoea.
39
Why is it important that the testes descend?
Lower temp outside the body to facilitate spermatogenesis.
40
What muscle controls where the testis sit in the scrotal sac?
Dartos muscle.
41
What is the medical term for undescended testis?
Cryptorchidism- the individual has reached adulthood but the testis are not yet descended.
42
What is the implications on fertility in cryptorchidism?
If unilateral they are usually still fertile however it reduces the sperm count.
43
Do you treat cryptorchidism?
Orchidoplexy should be performed if they are below 14 years to minimise the risk of testicular germ cell cancer.. If an adult- consider orchidectomy
44
What are the erectile tissues in the penis?
Corpus cavernosum | Corpus spongiosum
45
What is the function of the testes?
Spermatogenesis (occurs in the seminiferous tubules) | Production of testosterone.
46
What cells in the testes produce testosterone?
Leydig cells.
47
What is the role of Sertoli cells?
Form a blood-testis barrier- this protects the sperm from antibody attack. Provides a suitable fluid composition which allows later development of sperm Provide nutrients Phagocytosis- destroy defective cells and removes surplus cytoplasm Secrete seminiferous tubule fluid Secrete androgen binding globulin Secrete inhibin and activin hormones
48
What is the function of androgen binding globulin?
Keeps the concentration of testosterone high (by binding to it) in the lumen
49
What is the role of inhibin and activin hormones?
Regulates FSH secretion and controls spermatogenesis.
50
What is the role of seminiferous tubule fluid?
Carries the sperm to the epididymis.
51
What hormone stimulates the production of testosterone?
LH.
52
What does gonadotrophin releasing hormone do? | Which hormone controls this by negative feedback?
Stimulates the anterior pituitary to release FSH and LH. | Testosterone causes less GnRH to be released by negative feedback.
53
What does lutinising hormone do on the male reproductive tract?
Stimulates the leydig cells to produce testosterone.
54
What does follicle stimulating hormone do to the male reproductive tract? Which hormone regulates FSH?
Acts on Sertoli cells to enhance spermatogenesis. Regulates by negative feedback from inhibin
55
Where is testosterone secreted into?
The blood and seminiferous tubules.
56
What are the effects of testosterone before birth?
Masculinises the male reproductive tract and promotes descent of testis.
57
What are the effects of testosterone at puberty?
Promotes puberty and male characteristics
58
What are the effects of testosterone in an adult?
Controls spermatogenesis | Secondary male characteristics (male body shape, deepens voice, thickens skin, libido)
59
What cell secretes inhibin and activin? What is their function?
Sertoli cells | Inhibin inhibits FSH. Activin stimulates FSH.
60
What occurs to spermatozoa after ejaculation?
They become liquified (by enzymes in the prostate gland) Capacitation- a series of biochemical and electrical events occurring before fertilisation Chemoattraction to oocyte and bind to zona pellucida of oocyte. Acrosome reaction Hyperactive motility Penetration and fusion with oocyte membrane Zonal reaction.
61
Which area of the Fallopian tube does fertilisation occur?
Ampulla
62
What is the function of the epididymis and vas deferens?
Exit route from testes to urethra, concentrate and store sperm, site for sperm maturation.
63
What is the function of the seminal vesicles?
``` Produce semen into ejaculatory duct. Supply fructose Secrete prostaglandins (stimulates motility) Secrete fibrinogen (clot precursor) ```
64
What is the function of the prostate gland?
Produces alkaline fluid (neutralises vaginal acidity) | Produces clotting enzymes to clot semen inside female.
65
What is the function of the bulbourethral gland?
Secrete mucus to act as a lubricant
66
What is the definition of male infertility?
Failure of the sperm to normally fertilise the egg.
67
What can cause of male infertility?
Idiopathic Obstructive Non-obstructive
68
What is the most common cause of male infertility?
Idiopathic
69
Name some examples of obstructive pathologies causing male infertility?
Cystic fibrosis Vasectomy Infection
70
Name some examples of non-obstructive pathologies causing male infertility?
``` Congenital- crytorchidism Infection- mumps, Iatrogenic- chemotherapy/radiotherapy Pathological- testicular tumour Genetic- chromosonal e.g. Kleinfelters syndrome Specific semen abnormality- azoospermia, Systemic disorder Endocrine disorder ```
71
What are the common endocrine causes of male infertility?
Pituitary tumours- hyperprolactinaemia (decreases LH, FSH and testosterone), acromegaly, cushings Hypothalmic cause- Thyroid disorders Diabetes Steroid abuse (decrease LH, FSH and testosterone) Androgen insensitivity (normal or raised LH and testosterone)
72
What examinations would you do in male infertility?
General examination- including secondary male characteristics Genital examination- testicular volume, presence of vas deferens and epididymus, penis (urethral orifice), presence of variceal or swelling.
73
What is the normal testicular volume for adults? | In prepubertal boys?
12-25mls. | 1-3mls
74
What testicular volume are you likely to be infertile if you are below?
5mls.
75
What do they analyse the semen for?
``` Volume Density- number of sperm Motility- what proportion are moving Progression- how well they move? Morphology ```
76
What does an obstructive male infertility show like on examination?
Normal testicular volume Normal secondary sexual characteristics Vas deferens may be absent Endocrine- normal LH, FSH, testosterone
77
What does a non-obstructive male infertility show like on examination?
Low testicular volume Reduced secondary sexual characteristics Present vas deferens Endocrine- High FSH and LH, low testosterone
78
What life style factors can be changed to help maximise fertility in the male?
``` Frequent sexual intercourse Less than 4 units a day of alcohol Stop smoking BMI less than 30 Avoid tight fitting underwear and long hot baths Certain occupations ```
79
When is intra-uterine insemination indicated?
Mildly reduced sperm count
80
When is intra-cytoplasmic sperm injection indicated?
Very low sperm count
81
When is surgical sperm aspiration indicated?
Azoospermia
82
When is donor sperm insemination indicated?
Azoospermia or very low sperm count Genetic conditions Infectious
83
What does oligoasthenospermia mean?
Low sperm count and motility
84
What does teratoasthenospermia mean?
Low motility and abnormal forms
85
Which drug is an ovulatory inducer?
Clomefene citrate.

Reproduction (34 decks)

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