Week 1 - G - Infertility and assisted conception (IUI,ICSI, IVF)

Question 1

How many couples does infertility affect? Of these couples, how many require assisted contraception treatment?

Answer 1

Infertility affects 1in7 couples and approximately half of these require assisted contraception treatment

Question 2

What is infertility defined as? What is the difference between primary and secondary infertility?

Answer 2

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

Question 3

What are the potential reasons for an increase in infertility in the world and therefore the greater need for assisted contraception treatment?

Answer 3

Increasing parental age

Increasing incidence of chalmydia

Male factor infertility

Increase in obesity

Question 4

What is the single most common reason for couples requiring assisted contraception treatment? (ACT)

Answer 4

Male factor infertility - 60% of which is idiopathic

Question 5

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

Answer 5

Max of 4 units per week of alcohol and no smoking allowed

BMI of 19-29 for both males and females

Question 6

What is screened for in the blood before somebody undergoes ACT?

Answer 6

A screen for blood borne viruses is carried out - HepB/C and HIV

Question 7

What are the assisted conception treatment options?

Answer 7

Donor insemination

Intrauterine insemination

IVF - in vitro fertilisation

ICSI - intracytoplasmic sperm injection

Fertility preservation

Surrogacy

Question 8

What happens in intrauterine insemintation? (IUI)

Answer 8

Prepared semen is injected into the uterine cavity around the time of ovulation

Question 9

What percentage of couples who try for a pregnancy, manage to get pregnant after 1 year?

Answer 9

Roughly 85% of couples will manage

Question 10

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?

Answer 10

92% of the remaining 15% will manage to become pregnant after 2 years of trying

Question 11

What are the guidelines for a patient wanting to get IVF treatment? (what age, how long, how many cycles of IUI)

Answer 11

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)

Question 12

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?

Answer 12

This is where the treatment given essentially ‘turns’ off the ovaries to better control ovulation and egg maturation during treatment

Question 13

What drugs are given in the down regulation step of IVF treatment? What are the side effects of this step?

Answer 13

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

Question 14

How does giving a GnRH agonist or analogue cause downregulation of the overies?

Answer 14

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)

Question 15

After taking the GnRH for severeal days, why is an ultrasound scan carried out?

Answer 15

This scan is carried out to confirm the uterine lining is thin and eggs are ready to be harvested

Question 16

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

Answer 16

The next step is ovarian stimulation

Question 17

How is ovarian stimulation carried out? What hormone is given and what does it cause?

Answer 17

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

Question 18

WHat is seen on the ovary and endometrium ultrasound scan? What is given to mimic the LH surge to cause ovulation?

Answer 18

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

Question 19

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?

Answer 19

Man remain abstinent for at least 72 hours prior but no more than one week

Question 20

What are the four things the semen is assessed for?

Answer 20

Volume

Density - numbers of sperm

Motility - what proportion are moving

Progression - how well they move

Question 21

What is stage 4 of the IVF treatment? (we now have both the oocyte and sperm)

Answer 21

Fertilisation

Question 22

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?

Answer 22

Normal development of human embryo

• Morula (8-16 cell) - 72-96hours
• Blastocyst - 5-6 days
• Normal implantation occurs roughly on day 7

Question 23

What is the usual day of embryo transfer into the uterus? How many embryo are normally transferred into the uterus?

Answer 23

Usual day of transfer is day 5 after fertilisation

Normally one embryo is transferred (max is 3 if execeptional circumstances)

Question 24

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?

Answer 24

Ultrasound guided embryo transfer is the most efficient technique currently available

Question 25

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?

Answer 25

Progesterone suppositories are for 2 weeks post transfer

Pregnancy test 16 days post egg recovery

Question 26

What are the 6 stages of IVF treatment? (give a small description for each stage)

Answer 26

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Question 27

What are the side effects of GnRH agonist in stage 1 of IVF? What four things are analysed in the semen?

Answer 27

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

Question 28

What were the different methods of assisted contraception treatment again?

Answer 28

Donor insemination

Intrauterine insemination

In-vitro fertilisation

Intracytoplasmic sperm injection

Fertility preservation

Surrogacy

Question 29

What are indications for intracytoplasmic sperm injection (ICSI)?

Answer 29

Severe male factor infertility

Previously failed IVF treatment

Preimplantation genetic diagnosis

Question 30

If the male has azoospermia, what has to be done to obtain sperm for ICSI?

Answer 30

Surgical aspiration of sperm from testicular tissue or epididymis

Question 31

How many sperm are injected into an egg in ICSI?

Answer 31

Single sperm injected into an egg and incubated at 37degrees overnight

Fertilised egg will be implanted on roughly day 5

Question 32

What are three big complications of assisted conception treatment?

Answer 32

Multiple pregnancy

Ovarian Hyperstimulation syndrome (OHSS)

Ectopic pregnancy

Question 33

Which particular medication used in the IVF treatment has an association with ovarian hyperstimulation sydrome?

Answer 33

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.

Question 34

What are the symptoms of OHSS?

Answer 34

Abdominal distension and discomfort

Nausea + diarrhoea

Breathlessness

Question 35

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?

Answer 35

If pre embryo transfer Elective freeze of embryos for 2-3 months and then transfer

Question 36

What is the management of OHSS if the embryo has already been transferred?

Answer 36

Manage with bloods and scans

Reduce thrombotic risk

Analgesia

Question 37

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?

Answer 37

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

Question 38

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?

Answer 38

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

Question 39

What are the success rates in IVF treatment of infertility?

Answer 39

Success rates for IVF treatment are currently ~35% and reduce past the age of 35