Week 7 Flashcards
What is the definition of Infertility?
- Primary vs. Secondary?
Infertility is defined as the inability to achieve pregnancy after 12 months of unprotected sexual intercourse or therapeutic donor insemination in women < 35 years and 6 months in women ≥ 35 years of age.
- Primary infertility: infertility in persons who have never achieved pregnancy
- Secondary infertility: infertility in persons who have previously achieved at least one pregnancy
Prevalence of Infertilty?
Give an overview of the basic causes of infertility?
In Australia, the results of the 2006 National Fertility Survey showed that, across all age groups, 1 in 6 couples (16.7%) fail to achieve pregnancy after a year of trying
Causes of Female Infertility
- 9 Ovulatory dysfunction?
- 3 Tubal/pelvic causes?
- 6 Uterine causes?
- 4 Cervical causes?
Uterine causes
1. Uterine leiomyoma
2. Endometrial polyps
3. Bicornuate uterus
4. Septate uterus
5. Asherman syndrome
6. Mayer Rokitansky-Kuster Hauser syndrome
Cervical causes
1. Trauma (e.g., following cryotherapy, conization)
2. Immune factors (e.g., antisperm antibodies in the cervical mucus)
3. Diethylstilbestrol exposure in utero
4. Cervical anomalies (e.g., insufficient cervical mucus production)
Causes of Male Infertility
- Primary hypogonadism - 3 Testilcular? 3 Systemic? 3 Genetic?
- 6 Secondary hypogonadism causes?
- Sperm transport disorders?
Sperm transport disorders
1 - Obstructive azoospermia
- Absence of spermatozoa in semen despite normal spermatogenesis due to structural or functional abnormalities (e.g., obstruction, absence, dysfunction) along the sperm transport system (epididymis, vas deferens, ejaculatory duct)
- Possible causes include infection (e.g., gonorrhoea), iatrogeny (e.g., due to vasectomy), congenital (e.g., absent vas deferens in patients with cystic fibrosis), or genetic conditions (e.g., decreased sperm motility in primary ciliary dyskinesia).
2 - Sexual dysfunction
- Anejaculation
- Premature ejaculation
Causes of Male Infertility
- Endocrine & Systemic Disorders: Congenital? Acquired? Systemic?
- Primary testicular defects in spermatogenesis: Congenital? Acquired? Systemic? Genetic?
- Sperm transport disorders: Sexual dysfunction?
What history are you going to take from a couple with infertility issues?
What will be involved in the evaluation of female infertility?
- 8 Physical Examination?
- 7 Ovulatory function assessment?
- 4 Ovarian reserve assessment?
- 4 Structural uterine, tubal, and pelvic assessment?
Female infertility evaluation focuses on ovulatory function, ovarian reserve, and structural abnormalities.
What will be involved in the evaluation of male infertility?
- 6 Physical Examination?
- 6 Investigations?
Male infertility evaluation focuses on medical history and semen parameters.
General principles of management of infertile couples
- Ovulatory dysfunction?
- Sperm transport disorders?
List 4 lifestyle modifications for promoting fertility?
- Nutritional supplements?
- Weight management?
- Advice on tobacco, alcohol and recreational drugs?
- Advice on ovulation prediction to determine the fertile window?
Overview of lifestyle modifications for promoting fertility
Lifestyle modification and counselling includes:
1. optimising nutrition
2. appropriate body weight and exercise
3. avoiding tobacco and recreational drugs and minimising alcohol intake
4. discussing the normal fertile period and timing of sexual activity.
What is Assisted reproductive technology? 2 Types?
History and examination in infertility?
Laboratory investigations of infertility
- Females?
- Males?
When should you refer a couple for fertility treatment?
What are the causes of Causes of anovulatory infertility?
Describe an approach to ovulation induction in a woman with anovulatory infertility?
What tests do you need to perform before starting ovulation induction?
- What drug may be used a pre-treatment and why?
- Typical pretreatment regimen?
A typical progestogen pretreatment regimen is:
- medroxyprogesterone 10 mg orally, once daily for 10 days
OR
- norethisterone 5 mg orally, once daily for 10 days.
Outline 3 Drugs you may use in a woman for ovulation induction?
Gonadotrophins for ovulation induction
Ovulation induction with gonadotrophins involves use of:
- FSH, which recruits and matures follicles during the first few days of treatment [Note 5], followed by
- high-dose (5000 to 10 000 units) hCG, which acts like luteinising hormone (LH) to trigger active ovulation of a single dominant mature follicle. This is known as the ‘hCG trigger injection’ (also used in in-vitro fertilisation).
The main hazards of ovulation induction with gonadotrophins are development of multiple follicles (leading to a multiple pregnancy) and ovarian hyperstimulation syndrome (OHSS). Therefore, they should only be used be used with specialist guidance and monitoring.
Note 5: Some females who lack LH (eg as a result of severe hypothalamic or pituitary disorders) may also need a small dose of recombinant LH or a very low dose of hCG in the follicular phase.
How do you Assess a response to ovulation induction?
- Confirming ovulation after induction?
- Assessing for multiple follicles in ovulation induction?
Polycystic ovary syndrome and subfertility
- Treatment options?
Outline the approach to treating Endometriosis-related infertility?
Outline an approach to male infertility treatment?
List of commonly used tests to assess fertility?
World Health Organization classification of anovulation - Group 1, 2, & 3 and their causes?
4 Barriers to access and 3 Barriers to success of infertility treatment, and suggested mitigation strategies for them?
Outline an algorithm to an approach to managing infertility.
What is Intrauterine insemination?
- Outline the IUI Treatment Cycle?
- What are the benefits and risks of IUI?
Intrauterine insemination
- Intrauterine insemination involves washing sperm to remove chemicals in seminal fluid that may otherwise lead to uterine contractions. The washed sperm is placed in the uterus at the time of ovulation.
- Intrauterine insemination can be combined with ovulation induction. It can also be used alone in erectile dysfunction, couples where sexual or other difficulties preclude penetrative sexual intercourse, abnormalities of cervical mucus, unexplained infertility, or when donor sperm is used (eg for same-sex couples or people conceiving without a partner). Contraindications are tubal blockages and very poor sperm quality.
What is In-vitro fertilisation (IVF)?
- Outline the IVF Treatment cycle?
During your natural menstrual cycle, multiple follicles start growing. However, usually only 1 follicle is destined to ovulate and release an egg, as the rest go through cell death (atresia). During IVF, hormone injections are used to stimulate the ovaries to help enables multiple follicles to develop and be monitored and result in the multiple eggs being collected. When the developing follicles reach a certain size, indicating their potential of containing a mature egg (eggs ready to be fertilised with sperm), they are retrieved in an ultrasound-guided procedure under light anaesthetic. The eggs collected are placed with the sperm of your partner, or a donor in a culture dish in the laboratory to allow the eggs to hopefully fertilise, and embryos to develop. The embryos are monitored, and development is assessed over a period of time. Three to five days later, if suitable, one is placed into the uterus of the woman or person undergoing treatment in a procedure called an embryo transfer. If there is more than one embryo, the remaining embryo/s can be frozen and used in future treatment known as a frozen embryo transfer (FET).
What are the benefits and risks of IVF?
What are the success rates of IVF?
What are is Intracytoplasmic sperm injection (ICSI)?
- Benefits & Risks?
Intracytoplasmic sperm injection (ICSI)
- ICSI is sperm selection procedure used to overcome male factor infertility, which includes low sperm count, low sperm motility (movement), poor sperm morphology (shape) and problems with ejaculation. It may also be used in cycles involving frozen partner sperm, donor sperm, frozen eggs, or when no eggs become fertilised in a previous cycle with IVF.
- ICSI follows the same process as IVF, except in ICSI the embryologist uses a microscope to select a single sperm that is injected into the egg to hopefully achieve fertilisation.
- For couples with male factor infertility, research has shown ICSI is warranted to fertilise the eggs and give them a chance of having a baby. But for couples who don’t have male factor infertility, there is little evidence to demonstrate that using ICSI as the sperm selection technique in these circumstances increases the likelihood of a pregnancy.
Describe 11 complications/risks of treatment with in-vitro fertilisation IVF.
What is Ovarian hyperstimulation syndrome?
Ovarian hyperstimulation syndrome (OHSS)
- Definition?
- Pathophysiology?
- 9 Clinical features?
- 5 Diagnostics?
- Management?
- 6 Complications?
Diagnostics in OHSS
1. CBC (↑ Hct, leukocytosis)
2. Serum electrolyte concentrations
3. Renal function tests
4. Liver function tests
5. Transvaginal ultrasound: ascites and ovarian enlargement
A couple has been unable to get pregnant since their marriage 18 months ago. The woman is a healthy 24-year-old lawyer with regular normal menstrual periods. She has no significant past medical history. Her husband is similarly healthy. How would you proceed to evaluate this couple?
What parameters are assessed in semen analysis? What are the pathological findings?
You have investigated a couple for infertility. The male’s semen analysis shows no sperm. What would you do to define a diagnosis? What treatments are available?
Further Diagnostic Steps:
1. Hormonal Testing: Hormonal tests, such as measuring follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and prolactin levels, can help determine if the issue is related to hormonal imbalances.
2. Genetic Testing: Genetic testing can identify any chromosomal abnormalities or genetic mutations that might be causing azoospermia.
3. Imaging: Imaging techniques like scrotal ultrasound can help identify any anatomical abnormalities that might be causing obstructive azoospermia.
4. Testicular Biopsy: In cases of non-obstructive azoospermia, a testicular biopsy can be performed to assess whether there is any sperm production happening within the testes. This can help determine the potential for sperm retrieval for assisted reproductive techniques.
A 30-year-old woman has a history of repeated episodes of PID. She has been trying to conceive for 2 years without success. What management options are available if there are bilateral hydrosalpinges - and how successful are these treatments?
Hydrosalpinx/pyosalpinx: accumulation of fluid/pus in the fallopian tubes due to chronic inflammation and consequent stenosis.
- After PID resolves, the damaged fallopian tube can become blocked, fill with sterile fluid, and become enlarged. Damage to the fallopian tube from previous surgery or adhesions can also result in hydrosalpinx.
- Hydrosalpinx may be associated with pain or may be asymptomatic except for tubal factor infertility.
- Hydrosalpinx in patients undergoing in vitro fertilization (IVF) has negative consequences on the rates of pregnancy, implantation, early pregnancy loss, preterm birth, and live delivery
A 32-year-old woman complains of light menstrual blood loss and long cycles. She wishes to become pregnant but is concerned that she may not be ovulating. How would you investigate her? If she is not ovulating, what treatment options are available?
Pathophysiology: Irregular secretion of gonadotropins → short luteal phase, and lack of progesterone → endometrium remains in the proliferative phase → irregular menses and heavy menstrual bleeding
How does this relate to changes in cervical mucus and basal body temperature? How is this information used for contraception (Billing method) or fertility enhancement?
Infertility Hx Taking?
Infertility Examination?
Infertility - Investigations?
Definitions:
- Perimenopause?
- Menopause?
- Postmenopause?
Pathophysiology of Menopause?
- 5 Things caused by a ↓ in Estrogen?
↓ Estrogen Causes:
1. Vaginal epithelium becomes thinner & less rugose = atrophic vaginitis = dyspaerunia, vaginal dryness and “burning”
2. ↑ vaginal pH & ↑ growth of pathogenic organisms = recurrent UTIs
3. Atrophy of urethral mucosa = Urinary symptoms (frequency, dysuria, incontinence)
4. ↓blood supply to pelvic floor muscles = ↓ pelvic floor muscle tone = uterovaginal prolapse (lots of other stuff causes this too)
5. Hot flushes = wake up at night (some women only) = insomnia = fatigue during the day
Menopause
- 11 Signs/Symptoms?
- What percentage of women get sxs?
- Examination? (4)
Examination
1. Calculate BMI
2. BP
2. Breast exam
3. Vaginal exam:
- If appropriate, do a pap smear
- ? atrophic vaginal epithelium (pale / lack of normal rugae / visible blood vessels or petechial haemorrhages)
- ? prolapse (get patient to cough
- ? vaginal tear
Menopause - Treatment
- HRT use Near Menopause (<60yr old women) - 5 Benefits & 2 Risks?
Treatment
- Symptoms related to genitourinary atrophy = vaginal estrogen therapy
- Hormone replacement therapy (HRT) consists of oestrogen alone or a combination of oestrogen and progesterone. HRT may be in the form of tablets, transdermal patches, intravaginal creams/tablets/rings.
- In otherwise healthy women, the absolute risk of an adverse event is extremely low. Thus, perimenopausal women should be reassured that taking estrogen (either unopposed or combined with progestin) for the management of menopausal symptoms is a safe therapeutic intervention for many women.
HRT use Many Years Post-menopause (>60yrs)
- 1 Benefit?
- 5 Risks?
HRT Regimens?
Clinical guidelines for the prevention and treatment of osteoporosis in postmenopausal women and older men?
In postmenopausal women with established osteoporosis a reduction in risk of vertebral fractures is seen with raloxifene 60 mg/day, however the incidence of non-vertebral fractures has not been shown to be reduced. Consequently, it is recommended that raloxifene be mainly used in postmenopausal women with milder OP or in women with predominantly spinal OP.
Explain the physical effects of the menopause and peri-menopause.
4 Benefits of HRT?
Serious, Common, Other Adverse Effects of HRT?
7 Disadvantages of HRT?
Adverse effects of HRT
- Serious: thromboembolic events, estrogen-sensitive cancer (e.g., endometrial cancer, breast cancer).
- Common: mood swings, headache, gastrointestinal upset (e.g., nausea, bloating), weight gain, retained fluid, breast pain, breakthrough bleeding
- Other: stress urinary incontinence, gallbladder disease
5 Contraindications to Systemic HRT for Menopause?
Contraindications to Systemic HRT for Menopause
1. Unexplained vaginal bleeding
2. Estrogen-sensitive cancer (e.g., endometrial or breast cancer)
3. Chronic liver disease
4. Current or prior DVT, stroke, thromboembolic disease, or thrombophilia
5. Coronary artery disease or myocardial infarction
Approach to starting HRT for menopause?
Types of systemic menopausal hormone therapy and the appropriate subgroups of menopausal patients?
Estrogen dosages for systemic menopausal hormone therapy?
Do not use estrogen-only systemic therapy except in individuals who have had a total hysterectomy.
oral
1. 17-beta estradiol
2. estradiol valerate
3. conjugated estrogens
transdermal patch
1. estradiol
transdermal gel
1. estradiol gel sachets
2. estradiol gel pump
Cyclical combined formulations for systemic menopausal hormone therapy?
low-dose estrogen with cyclical progestogen
1. oral low-dose estrogen+progestogen
2. transdermal low-dose estrogen gel and oral progestogen
medium-dose estrogen with cyclical progestogen
1. oral medium-dose estrogen +progestogen
2. transdermal medium-dose estrogen+progestogen patch
2. transdermal medium-dose estrogen gel and oral progestogen
Continuous combined formulations for systemic menopausal hormone therapy?
low-dose estrogen with progestogen
1. oral estrogen+progestogen
transdermal estrogen gel and oral progestogen
medium-dose estrogen with progestogen
- oral estrogen+progestogen transdermal estrogen+progestogen patch
- transdermal estrogen gel and oral progestogen
Suggested management for adverse effects of systemic MHT other than unscheduled vaginal bleeding?
Describe the implications for public health in relation to the treatment of the menopause.
The treatment of menopause has important implications for public health due to the significant impact that menopause-related symptoms and health issues can have on women’s quality of life and overall well-being. Menopause is a natural biological process that marks the end of a woman’s reproductive years, typically occurring around the age of 50, but it can vary. Addressing the needs of women going through menopause is essential for promoting their health and ensuring a healthy aging population.
What bleeding patterns may occur at the onset of menopause?
What advice would you give a woman about contraception during the peri - menopausal years?
Key points
1. Menopausal hormone therapy is not contraceptive.
2. Amenorrhoea in women using hormonal contraception is not an indicator of menopause.
3. FSH levels can be used to determine menopause in amenorrhoeic women aged >50 years using progestogen-only methods including the LNG-IUD.
4. The background risk of arterial vascular disease and venous thromboembolism increases with age.
5. Careful consideration is required when prescribing combined hormonal methods or DMPA.
6. Cu-IUDs have extended use in women aged ≥40 years at the time of insertion.
7. LNG-IUDs have extended use in women aged ≥45 years at the time of insertion.
8. The contraceptive implant and IUDs have few absolute or relatively strong contraindications in perimenopausal women.
The oral contraceptive would not be an ideal choice for HRT for the menopause - why? (8 reasons)
The COCP is not recommended for women over the age of 50 because of increased cardiovascular risk.
Pre-eclampsia
- Definition?
- Mild, Moderate, Severe?
Severity of disease is based on BP measurement alone.
- Mild: BP is 140 to 149 mmHg systolic and/or 90 to 99 mmHg diastolic.
- Moderate: BP is 150 to 159 mmHg systolic and/or 100 to 109 mmHg diastolic.
- Severe: BP is ≥160 mmHg systolic and/or ≥110 mmHg diastolic.
2 Stages of Pre-eclampsia?
Symptoms of Pre-eclampsia?
Complications of Pre-eclampsia: Maternal vs. Fetal?
Investigations?
Symptoms
- Late stage - headaches, drowsiness, visual disturbances nausea/vomiting and epigastric pain. Oedema may be present in face and hands.
Complications of Pre-eclampsia
- Maternal: Eclampsia, CVA’s, liver/renal failure, HELLP, pulmonary oedema, DIC
- Fetal: IUGR, placental abruption, fetal morbidity and mortality
Outline 4 Criteria for mother’s admission in pre-eclampsia or suspected pre-eclampsia?
- How would you treat her?
Criteria for mother’s admission in pre-eclampsia or suspected pre-eclampsia:
1. Physical Symptoms
2. Proteinuria (2+ on dipstick)
3. BP ≥ 160/110mmHg
4. Suspected fetal compromise
Outline the importance of delivery as a treatment for pre-eclampsia?
What is the Preconceptual Visit about? Who should have this visit?
Who should have this vist?
- All women who have any medical disease that may need to be stabilised such as diabetes, thyroid disease, epilepsy, hypertension.
- All couples who have a family history of genetic disease so that an opportunity to have appropriate genetic counselling and discussion of antenatal diagnosis to prevent disease in offspring.
- All women who are on any medication as the medication may need to be changed such that the risk of teratogenesis is limited.
What are the broad objectives of the Preconceptual Visit?
- History? Physical Examination? Investigations?
Broad objectives of the Preconceptual Visit
* To stabilise any disease and maximise the effect of any intervention such that the woman enters pregnancy in the best condition possible.
* To ensure that a woman and her partner are healthy and practising healthy lifestyles before pregnancy
* To ensure that couples have the opportunity to address risky behaviours that might result in poor pregnancy outcomes
* To reduce the likelihood of unwanted pregnancies.
Preterm Birth
- Definition?
- Prevalence?
- Aetiology?
- Definition: Labour occurring between 20-37/40 with progressive cervical shortening and dilatation.
- Threatened preterm labour = regular painful contractions without cervical changes.
- Prevalence: Complicates about 10% pregnancies. Prematurity accounts for 80% of neonatal ICU and 20% of perinatal mortality.
Preterm Birth
- Prevention?
- Clinical features?
- Exam findings?
- Investigations?
Prevention:
- Good prenatal care & patient education
- Identify pregnancies at risk
- Treat silent vaginal infection and UTI
Treament for Preterm Labour
- Promoting pulmonary maturity?
- Detection and prevention of infection?
- Delivery?
- Neonatal Outcomes of Preterm Labour?
- Survival rates of Preterm Labour?
- Major problems as a result of pre-term birth? (Neurological, CVS, Resp, GIT, Haem, Infection)
Neonatal Outcomes
- Long term morbidity – cerebral palsy, lung disease, blindness – common
- Fetuses delivered <28 weeks are most affected
Survival
- Born at 25 weeks – 50% survival – of the 50% who survive, 25% will have a major disability
- Born at 27 weeks – 90% survival rate – virtually no disability
Causes of Primary Post Partum Haemorrhage - 4 Ts
- Tone & Tissue?
Causes of Primary Post Partum Haemorrhage - 4 Ts
- Trauma & Thrombin?
** Thrombin - Coagulopathies acquired in pregnancy - these items are favoured to come up in an examination!!!
Outline the preventive methods for each of the Causes of Primary Post Partum Haemorrhage (4Ts)?
Prevention
- Risk assessment of mother during the antenatal and intrapartum periods.
* The third stage of labour should be actively managed to minimise the risk of PPH.
(1) Tone:
- Massage
- Compress
- Drug interventions: An oxytocic (injected into the mother’s thigh to encourage a prolonged uterine contraction).
Primary Post Partum Haemorrhage - Treatment
- 4 Non-drug interventions?
- 4 Drug interventions (for atony of uterus)?
- 2 Surgical interventions?
Treatment
Non-drug interventions:
1. Identification of a high-risk patient (Most important!): Previous PPH, Previous retained placenta, Abnormalities of coagulation acquired in pregnancy.
2. Active management of the third stage of labour (i.e. use of oxytocic and controlled cord traction)
3. Suturing of lacerations
4. Uterine massage
Management of a Primary PPH - Steps 1-4?
Step 3: If still bleeding, prepare a solution of prostaglandin F2α (PGF2α)- 1mg PGF2α mixed with 10mL normal saline (1mg/mL). Inject 1mL of this solution directly into the
myometrium via the abdomen, and rub the uterine fundus. Repeat at 1-minute intervals.
Step 4: If bleeding is not controlled, the patient requires laparotomy. Cross-match more packed cells, order platelets and fresh frozen plasma, and summon specialist help. At laparotomy repair of lacerations, hysterectomy, iliac artery ligation and the B-lynch suture compression and thereby contraction of the uterus are all possible options for controlling haemorrhage but are specialist procedures.
PUERPERIUM
- Definition?
- Discuss the Physiological changes that occur during the puerperium:
1. Hormonal Changes?
2. Genital Tract Changes?
3. Perineal Changes?
4. Lochia?
5. Breast Changes?
6. CVS Changes?
- The puerperium begins after the delivery of the placenta and lasts until the reproductive organs have returned to their pre-pregnant state. This period usually lasts approximately six weeks but is highly variable between patients.
- The puerperium is a crucial time to initiate good health practices that will have lasting effects on both the mother’s health and that of the newborn. Infant feeding and care and general emotional and physical well-being for the mother are paramount.
What can go wrong in the puerperium?
- List 10 Problems that may occur.
Some other significant problems include:
- Pain
- UTI or urinary retention
- Constipation
- Symphysis Pubis discomfort
What is involved in the six week check-up for the mother?
- History?
- 10 Common Examinations?
The research literature does not support any benefit of a 6-week check however, clinical evidence clearly indicates that the postpartum period is a time of tremendous change, increased health problems, and emotional upheaval for new parents. The check-up is commonly performed by the GP.
Specifically enquire about vaginal and rectal bleeding, perineal or caesarean wound pain, tiredness, backache, urinary symptoms, bowel movements, breast and nipple tenderness, sleep patterns and mood.
Also, ask the mother how she feels about the baby and how the baby is feeding, settling and responding.
Secondary Post Partum Haemorrhage
- Definition?
- 4 Causes?
- Presentations? (4)
- Diganosis?
- Treatments?
Definition
- Abnormal bleeding or excessive blood loss from the genital tract after 24hrs from delivery but within the first 6 weeks.
- Usually occurs 5 to 12 days after delivery
Causes:
1. Retained placental tissue or clot - inevitably leads to infection
2. Intra uterine infection with or without retained products
3. Slow involution of the uterus or inadequate drainage of the lochia sometimes leads to fresh bleeding later than expected
4. High risk patients: Long Labour, Difficult labour, Febrile Labour
What is the impact of age on female fertility?
What is infertility?
4 Treatment options for female infertility?
- What are the causes of these women’s infertility?
Treatments
1 - Ovulation induction
- Use FSH
- Aim to get one follicle
- Problem of multiple pregnancy
2 - Surgery
3 - Intrauterine insemination
4 - IVF
Which types of couples is Assisted insemination (IUI) often used for?
- Gay couples
- FIFO - man away while woman is ovulating
- Sexual dysfunction BUT only if that is treated too!
Outline the steps involved in In vitro fertilisation (IVF)?
In vitro fertilisation (IVF)
* Eggs are collected from the ovary
* The egg is fertilised in a dish in the laboratory with the sperm
* The embryo is then implanted into the uterus
* IVF is used to treat a range or reproductive problems:
How can success rates of IVF be improved?
- 2 Types of Genetic Testing?
Embryo biopsy and testing
- PGS IVF success rates by prioritising chromosomally “normal” embryos for transfer.
- Reducing the risk of a baby born with a chromosomal abnormality.
- Reducing incidence of miscarriage.
- Reducing the number of Frozen.
- Embryo Transfers necessary to achieve successful outcome.
