Week 1 - G - Infertility and assisted conception (IUI,ICSI, IVF) Flashcards
How many couples does infertility affect? Of these couples, how many require assisted contraception treatment?
Infertility affects 1in7 couples and approximately half of these require assisted contraception treatment
What is infertility defined as? What is the difference between primary and secondary infertility?
Infertility is failure to achieve clinical pregnancy after 12 months of unprotected sexual intercourse
Primary infertility - couple have never concieved
Secondary infertility - already concieved but struggling to conceive again
What are the potential reasons for an increase in infertility in the world and therefore the greater need for assisted contraception treatment?
Increasing parental age
Increasing incidence of chalmydia
Male factor infertility
Increase in obesity
What is the single most common reason for couples requiring assisted contraception treatment? (ACT)
Male factor infertility - 60% of which is idiopathic
There are a number of indications for couples to seek assisted conception treatment There is however some preconceptual advice for having a baby What is the alcohol limit pre ACT and smoking limit? What BMI is recommended
Max of 4 units per week of alcohol and no smoking allowed
BMI of 19-29 for both males and females
What is screened for in the blood before somebody undergoes ACT?
A screen for blood borne viruses is carried out - HepB/C and HIV
What are the assisted conception treatment options?
Donor insemination
Intrauterine insemination
IVF - in vitro fertilisation
ICSI - intracytoplasmic sperm injection
Fertility preservation
Surrogacy
What happens in intrauterine insemintation? (IUI)
Prepared semen is injected into the uterine cavity around the time of ovulation
What percentage of couples who try for a pregnancy, manage to get pregnant after 1 year?
Roughly 85% of couples will manage
Of the 85% who manage to get pregnant within one year of trying, the rest are said to have problems within infertility Of the remaining 15%, what percentage manages to get pregnant before 2 years?
92% of the remaining 15% will manage to become pregnant after 2 years of trying
What are the guidelines for a patient wanting to get IVF treatment? (what age, how long, how many cycles of IUI)
guidelines recommend that IVF treatment should be offered to women
under the age of 43
who have been trying to get pregnant through regular unprotected sex for 2 years or
who have had 12 cycles of artifical insemination (IUI)
In vitro Fertilisation (IVF) occurs over a six step process The first stage of IVF treatment is down regulation of the ovaries What does down regulation mean here?
This is where the treatment given essentially ‘turns’ off the ovaries to better control ovulation and egg maturation during treatment
What drugs are given in the down regulation step of IVF treatment? What are the side effects of this step?
Gonadotrophin releasing hormone (GnRH) analogue or agonist is given for the down regulation step of IVF treatment
Side effects - hot flushes and mood swings, headaches and nasal irritation
How does giving a GnRH agonist or analogue cause downregulation of the overies?
Initially there is a ‘flare’ response to the medication which results in an increase in LH and FSH levels. After this response the pituitary gland becomes desensitized to the GnRH and therefore there is reduced LH and FSH release causing downregulation of the ovaries to produce oestrogen (and progesterone)
After taking the GnRH for severeal days, why is an ultrasound scan carried out?
This scan is carried out to confirm the uterine lining is thin and eggs are ready to be harvested
After down regulation of the ovary is carried out, there is now better control of egg ovulation and maturation during the treatment WHat is the next step in the IVF treatment? It involves making the ovary produce multple eggs
The next step is ovarian stimulation
How is ovarian stimulation carried out? What hormone is given and what does it cause?
Ovarian stimulation is carried out by administering gonadotrophic hormones containing synthetic or urinary gonadortrophins (FSH +/- LH)
This stimulates the ovary to produce multiple eggs via fllicular development
WHat is seen on the ovary and endometrium ultrasound scan? What is given to mimic the LH surge to cause ovulation?
Can see multiple follicles in the ovary
Can see a thickened endoometrium which is good for oocyte implantation
bHCG (beta human chorionic gonadtrophin) is given to mimic the LH surge
In the third step, after down regulation and ovarian stimulation Both gametes are retrieved - ie oocyte is collected in thatre and a man provides semen How long must the man remain abstinent for before providing his urine sample?
Man remain abstinent for at least 72 hours prior but no more than one week
What are the four things the semen is assessed for?
Volume
Density - numbers of sperm
Motility - what proportion are moving
Progression - how well they move
What is stage 4 of the IVF treatment? (we now have both the oocyte and sperm)
Fertilisation
Approximately 60% of the eggs fertilise normally in fertilisation stage of IVF treatment
- What day is morula formed? What cell size is it between?
- What day is blastocyst formed?
- What day is implantation in normal development of human embryo?
Normal development of human embryo
- Morula (8-16 cell) - 72-96hours
- Blastocyst - 5-6 days
- Normal implantation occurs roughly on day 7
What is the usual day of embryo transfer into the uterus? How many embryo are normally transferred into the uterus?
Usual day of transfer is day 5 after fertilisation
Normally one embryo is transferred (max is 3 if execeptional circumstances)
No matter how good the IVF laboratory culture environment is, the physician can ruin everything with a carelessly performed embryo transfer. The entire IVF cycle depends on delicate placement of the embryos at the proper location near the middle of the endometrial cavity The importance of proper embryo transfer technique for successful IVF cannot be overstated What is the most efficiency transfer technique currently available?
Ultrasound guided embryo transfer is the most efficient technique currently available
What medication is given as support after the embryo transfer has been carried out? After the egg was recovered (oocyte collection), how long after this is a pregnancy test carried out?
Progesterone suppositories are for 2 weeks post transfer
Pregnancy test 16 days post egg recovery
What are the 6 stages of IVF treatment? (give a small description for each stage)
https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/pjpgpngjpg-15FDAF4FB0C44AB3A90.png
What are the side effects of GnRH agonist in stage 1 of IVF? What four things are analysed in the semen?
Side effects are * Nasal irritation * Hot flushes and mood swings * Headaches
Semen analysis * Volume * Density - number of sperm * Motility - what proportion are moving * Progression - how they move
What were the different methods of assisted contraception treatment again?
Donor insemination
Intrauterine insemination
In-vitro fertilisation
Intracytoplasmic sperm injection
Fertility preservation
Surrogacy
What are indications for intracytoplasmic sperm injection (ICSI)?
Severe male factor infertility
Previously failed IVF treatment
Preimplantation genetic diagnosis
If the male has azoospermia, what has to be done to obtain sperm for ICSI?
Surgical aspiration of sperm from testicular tissue or epididymis
How many sperm are injected into an egg in ICSI?
Single sperm injected into an egg and incubated at 37degrees overnight
Fertilised egg will be implanted on roughly day 5
What are three big complications of assisted conception treatment?
Multiple pregnancy
Ovarian Hyperstimulation syndrome (OHSS)
Ectopic pregnancy
Which particular medication used in the IVF treatment has an association with ovarian hyperstimulation sydrome?
Ovarian hyperstimulation syndrome is particularly associated with injection of a hormone called human chorionic gonadotropin (hCG) which is used for inducing final oocyte maturation and/or triggering oocyte release.
What are the symptoms of OHSS?
Abdominal distension and discomfort
Nausea + diarrhoea
Breathlessness
Enlarged ovaries get very leaky into the abdominal cavity causing ascites, nausea, diarrhoea, breathlessnesss (diarrhoea because the ascites pushes on the bowel) (breathlessness because the ascites pushes on the diaphragm) Can see enlarge follicles Management pretransfer?
If pre embryo transfer Elective freeze of embryos for 2-3 months and then transfer
What is the management of OHSS if the embryo has already been transferred?
Manage with bloods and scans
Reduce thrombotic risk
Analgesia
If more than one embryo is replaced in the womb as part of IVF treatment, there’s an increased chance of producing twins or triplets. What are associated problems with multiple pregnancies?
Child could have a low birthweight
Long term conditions such as CF or cerebral palsy
Prematurity is also more common in multiple pregnancies and so is the need for a cesarean section
If there is a positive pregnancy in IVF treatment after the 16 days, when is the scan carried out to make sure there arent any ectopic pregnancies or other abnormalities? What are the symptoms of ectopic pregnancy?
If you have a positive pregnancy test after IVF, you’ll have a scan at 6 weeks to make sure the embryo is growing properly and that your pregnancy is normal
Abdominal pain, bleeding, fainting, D&V - always think of ectopic pregnancy in a sexually active women with these symptoms
What are the success rates in IVF treatment of infertility?
Success rates for IVF treatment are currently ~35% and reduce past the age of 35
