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MRCOG - Part 2 > Fertility > Flashcards

Fertility Flashcards

1
Q

NICE recommended BMI of the female partner before commencing fertility treatment

A

19-30%

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2
Q

Frozen-thawed embryo replacement increases the overall cumulative pregnancy rate by approximately

A

11%

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3
Q

Oocyte retrieval is carried out _____ hours after the hCG injection

A

34-37hours

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4
Q

At the age of 40 years, the woman’s risk of miscarriage per IVF pregnancy

A

23%

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5
Q

What proportion of pregnancies following transfer of two blastocysts during IVF are twins

A

35%

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6
Q

Follicular response together with endometrial thickness is monitored by USS commencing on what days of the treatment cycle.

A

D 6-8

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7
Q

Inseminated oocytes are checked for signs of fertilisation after approximately ____ hours

A

12-21 (approximately 18)

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8
Q

Optimal endometrial thickness in millimetres for frozen–thawed embryo replacement cycles

A

7-11 mm

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9
Q

Optimal endometrial thickness in millimetres fresh embryo replacement cycles

A

10-12 mm

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10
Q

Undertaking eSET in approximately 50% of IVF patients will reduce the multiple twin birth rate to less than

A

10%

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11
Q

Up to ___ of women with moderate/severe OHSS may require admission to hospital

A

1%

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12
Q

Normal Semen Volume

A

1.5 ml (1.4–1.7)

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13
Q

Normal Progressive motility

A

32% (31–34)

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14
Q

Sperm morphology (normal forms [%])

A

4% (3.0–4.0)

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15
Q

Sperm concentration (106 per ml)

A

15 (12–16)

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16
Q

Minimal count of motile sperms per ml is suitable for IUI

A

5 million/ml

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17
Q
A
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18
Q

BMI >30 is of high risk to OHSS?

A

No

In fact, young slim women are at higher risk of developing OHSS

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19
Q

Early follicular phase FSH in determining ovarian reserve

A

In day 2 to 5

> 8.9 IU/L for a low response

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20
Q

AMH measurement in determining Ovarian Reserve

A

<5.4 pmol/l for low response
>25 pmol/l for high response

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21
Q

Total antral follicular count in determining of Ovarian reserve

A

<4 low response
>16 high response

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22
Q

Things don’t ask for when investigating for female infertility

A
  1. Post coital Cx mucus
  2. Prolactin level (unless pitutary tumor, glactorrehea, ovulatory disorder)
  3. Thyroid function test
  4. Endometrial Biopsy
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23
Q

Women who undergoing inv. for infertility should be offered serum progesteron in

A

regular cycles: midluteal phase (day 21)
irregular cycles: day 28-35 & repeated weekly until next menses

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24
Q

In case of suspected tubal occlusion, what inv. shall be taken

A

If no comorbidities: Hysterosalpingography
If expertise are available: Hysterosalpingo-contrast-ultrasound
If comorbidities: Laproscopy and dye

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25
Q

if the man is HIV positive that the risk of HIV transmission to the female partner is negligible in 3 cases:

A
  • the man is compliant with highly active antiretroviral therapy (HAART)
  • the man has had a plasma viral load of less than 50 copies/ml for more than 6 months
  • there are no other infections present
  • unprotected intercourse is limited to the time of ovulation
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26
Q

if the man is HIV +ve, and the criteria of no transmission are met, do we need to do sperm washing

A

No
sperm washing may not further reduce the risk of infection and may reduce the likelihood of pregnancy.

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27
Q

If the man is HIV +ve and he isn’t compliat to HAART or viral load >50 copies

A

offer sperm washing

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28
Q

What is sperm washing

A

separation of sperms from semen, by removing mucus, non motile sperms and chemicals

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29
Q

Does sperm washing eleminate the risk of HIV transmission

A

reducesthe risk of HIV transmission, reduces, but does not eliminate it.

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30
Q

if man is HIV +Ve and all criteria is met, does it useful if women take pre exposure prophylaxis

A

No
no sufficient evidence

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31
Q

For partners of people with hepatitis B, what shall we do before fertility ttt

A

offer vaccination before starting fertility treatment.

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32
Q

If men with HBV do we offer sperm washing

A

No

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33
Q

Risk of transmission during intercourse of HCV from a +ve male partner is

A

LOW

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34
Q

Viral Screening for the female partner before fertility TTT

A
  1. HBV
  2. HCV
  3. HIV
  4. Rubella
  5. Chlamydia Trochomatis
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35
Q

male factor infertility

Men with hypogonadotrophic hypogonadism, offer

A

gonadotrophin drugs

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36
Q

Men with idiopathic semen abnormalities should not be offered

A
  • anti- oestrogens
  • gonadotrophins
  • androgens
  • bromocriptine
  • kinin- enhancing drugs
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37
Q

significance of Anti-sperm anti-bodies in investigating male factor infertility

A

insgnificant

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38
Q

Where appropriate expertise is available, men with obstructive azoospermia should be offered —-

A

surgical correction of epididymal blockage because it is likely to restore patency of the duct and improve fertility.

Surgical correction should be considered as an alternative to surgical s

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39
Q

Varicocele surgery as infertility ttt

A

it does not improve pregnancy rates

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40
Q

Group 1 Ovulatory disorders

A

hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)

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41
Q

Group 2 Ovulatory disorders

A

hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome)

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42
Q

Group 3 Ovulatory disorders

A

ovarian failure.

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43
Q

First line ttt of group 1 ovulatory disorders (hypogonadotropic hypogonadism)

A
  • increase body weight if BMI <19
  • Do less agressive exercise
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44
Q

Medical ttt of Group 1 ovulatory disorders

A
  • pulsatile GnRH
  • Gonadotrophin containing LH

to induce ovulation

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45
Q

first line ttt of PCOs (group 2 ovulatory disorder)

A

Lower body weight if BMI >30
it may restore ovulation, improve response to ovulation induction & have a positive impact on pregnancy outcomes.

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46
Q

Medical ttt of PCOs (group 2 ovulatory disorders)

A
  • Clomifene Citrate
    or
  • Metformin
    or
  • combination of the above
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47
Q

U/S monitoring of women taking clomifene as a stimulant

A

US during at least the first cycle of treatment to ensure that they are taking a dose that minimises the risk of multiple pregnancy.

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48
Q

How long do you give clomifene for PCOs

A

no longer than 6 months

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49
Q

metformin side effects

A

nausea, vomiting and gastrointestinal disturbances

50
Q

If women has anovulation d.t. hyperprolactinemia what shall we do

A

Dopamine agonists such as bromocriptine

51
Q

Risks of ovulation induction with gonadotrophins

A
  1. Multiple Pregnancy
  2. OHSS
52
Q

What to do for women with proximal tubal obstruction

A

selective salpingography plus tubal catheterisation
or
hysteroscopic tubal cannulation

53
Q

Women with hydrosalpingex

A

Surgical ttt
- Salpingectomy (common)
- Laparoscopic tubal occlusion
- Hysteroscpoic sterilization (lacking evidence)

54
Q

invstigating for hydrosalpinx

A

TVS

55
Q

In case of amneorreah d.t. uterine adhesions

A

** hysteroscopic adhesiolysis **because this is likely to restore menstruation and improve the chance of pregnancy.

56
Q

Why we do pituitary downregulation

A
  • Suppress endogenous gonadotropin release
  • suppress premature ovulation (so ensuring Oocyte for retrival)
57
Q

GnRh agonist mode of action

A

competitively blocks the action of GnRH, preventing the release of (LH) and (FSH) from the anterior pituitary gland.

However, initially there is a release of FSH and LH, the so-called ‘flare effect’.

58
Q

GnRH antagonist mode of action

A

competitively and reversibly bind to GnRH receptors in the pituitary gland, blocking the release of LH and FSH from the pituitary, thus preventing ovulation.

They are rapid acting and do not have a flare effect.

59
Q

In case of fear pf OHSS which regimen do we use?

A

GnRH antagonists

60
Q

Characteristics of using GnRh antagonist regimen

A
  • lowe number of follicles
  • dec. risk of OHSS
  • Lower period of stimulation
  • dec. need to freeze all
61
Q

Different types of Gonadotropins

A
  • Human menopausal gonadotropin (hMG)
  • urinary FSH
  • recombinant FSH
62
Q

GnRH antagonists are used in

A
  • Patients at high risk of OHSS
  • in previous porr responders to ttt
  • those patients who require timely ttt (fertility preservation)
63
Q

In case of exaggerated ovarian resposne, we use which trigger

A

GnRH agonist trriger
Which induces endogenous LH flare instead of hCG

64
Q

hcg As trigger standard dose

A

5000-10000 IU

65
Q

do hCG increases the risk of OHSS

A

Yes

66
Q

How to avoid the risk of OHSS with hCG

A

In agonist protocol: use GnRH agonist as trigger

In antagonist protocol: dual trigger:
GnRH agonist+ hCG 1500 IU

67
Q

Rate of follicular growth after stimulation

A

2-3 mm/day + steady increase in serum estradiol level

68
Q

When to give the trigger

A

3 or more follicles >17-18 mm

Give subcutaneous

5000-10000 IU of hCG
Or
250-500 mcg of rhCG- alpha

69
Q

When to consider poor ovarian response

A

When less than 3 follicles develop after 14 days of gonadotropin ttt

Results in cancellation

70
Q

Number pf follicles developed in normal cycle

A

10-20 ovarian antral follicles
Only 1 dominant follicle

71
Q

How much time does it take for follicular recruitment

A

First 5 to 6 days to stimulation
Then continue on FSH to maintain follicular growth

72
Q

COH monitoring is done by

A

2D TVS &/or hormonal assessment

73
Q

Monitoring in GnRH AGONIST PROTOCOL

A

US before FSH stimulation
US after 1 week of stimulation
US w 12-36h of trigger

74
Q

After we got we need from COH what to do

A
  1. Stop pituitary downregulation
  2. Give LH containg trigger (hCG)
75
Q

Sperm recovery instructions

A
  • by masturbation
  • no lubricants
  • after 2-5 days abstinence
  • if at home ( keep it room temp - take it to lab in less than 60mins)
76
Q

If the man cannot masturbate;

A

Use silastic codom

77
Q

If the man has ejaculatory dysfunction, how we can collect sperm

A

Vibratory or electrical stimulation

78
Q

If the man has retrograde ejac

A

Urinary sample analyzed for vital spermatozoa

79
Q

If the man has azoospermia/ ejac failure, how do we collect sperm

A

Surgical intervention:
- aspirated from epididymis ( percutaneous epididymal sperm aspiration PESA) or ( testicular sperm aspiration TESA)
- extracted from testis ( testicular sperm extraction TESE)

80
Q

How do we determine fertilization

A

Presence of 2 pro-nuclei (2 PN)
18-20 hrs post insemination

81
Q

How much time it takes for fertilization after insemination

A

18-20 hours

82
Q

When do we do embryo transfer after fertilization

A

Day 2 , day 3 ( cleavage stage) or day 5 (blastocyst stage)

83
Q

If there is no follicle yield an oocyte, what shall we do

A

Follicle flushing
To encourage the yielding of oocytes

84
Q

Why the use of flushing is controversial

A

Fertilization rates reduced the more times the follicle is flushed to obtain the oocyte

85
Q

Oocytes in most of the antral follicles having completed maturation, will be at

A

metaphase II. (M2)

86
Q

What is cumulus complex

A

The oocytes at the time of retrieval are encased in a mass of granulosa cells called the cumulus complex.

87
Q

What is the function of the granulosa cells in the cumulus complex

A
  • possess the receptors for FSH and, therefore, gonadotrophin acts on these cells to stimulate growth and estrogen production.
    -The granulosa cells communicate with the egg as the egg develops and matures.
88
Q

Oocyte classification is based on

A
  • cumulus expansion
  • corona cell dispersion
  • coronal association with zona pellucida

These are good predictors of maturity

89
Q

How oocyte is checked for maturity

A

Presence of polar body

90
Q

ICSI is recommended for which cases

A

-Obstructive and non-obstructive azoospermia
-Poor history of fertilization
- Previous ivf failure

91
Q

Fertilization rate of ICSI

A

60-70%

92
Q

In non male sub-fertility, which is better IVF OR ICSI

A

IVF

93
Q

Time to check for fertilization (2 PN)

A

Pro nuclei are visible for finite time
12-21 hours

It is imp to check the eggs for 2 PN within this finite time, as often cannot be distinguished from abnormal 3 PN or activated 1 PN after cleavage

94
Q

Following embryonic cleavage, what does 1 pro nuclei means

A

Indicataive or spontaneous activation of oocyte without fertilization

95
Q

What does 3 pro nuclei mean

A

Abnormally fertilized eggs:
- 2 sperms fertilizing 1 egg
- failure of emission of 2nd polar body (digynic fertilization)
- rarely, injection of diploid sperm cell

96
Q

Rate of normal fertilization (2PN)

A

50-70% of insiminated eggs should form at least 2 pronuclei

97
Q

Indication of embryonic viability

A
  • Distance between 1st & 2nd polar bodies
  • orientation of PN relative to polar bodies
  • distribution of nucleoli with pronuclei
98
Q

If the indication for ICSI is severe semen quality or azoospermia, shall we do karyotyping

A

Yes

99
Q

What is assisted hatching

A

Small crack in zona pellucida

100
Q

Assisted hatching is recommended for

A
  • pts w/ hx of failed IVF/ICSI who have a good embryo quality
  • pts >38 years
  • those w/ elevated FSH
  • pts w/ thickened or abnormal zona pellucida
101
Q

Does assisted hatching increase embryo implantation potential

A

It’s hypothetical, but no strong evidence for this

102
Q

When do we do embryo transfer

A

Day 2/3 or day 4/5 after retrival

103
Q

Embryos are graded for quality on day 2/3 depending on

A
  • number of cells (D2: 4 cells, D3: 8 cells)
  • degree of fragmentation
  • cell symmetry
  • granularity
  • vacuolisation
  • membrane definition (compaction)
104
Q

Embryos are graded for quality on day 5 (blastocyst)depending on

A
  • cavitation
  • expansion
  • zona thinning
  • presence of inner cell mass and hatching
105
Q

Where in uterus do we transfer embryos

A

Midcavity (maximal implantation point MIP)
For better results

106
Q

How many embryos do we transfer

A

2 embryos

Unless there is no more than 3 to transfer so transfer 3

107
Q

Minimal endometrial thickness for embryo transfer

A

Transfer in endo <5 mm is unlikely to result in pregnancy

108
Q

Does bed rest after IVF ttt improves its outcome

A

Bed rest for more then 20 mins after IVF doesn’t improve outcome

109
Q

Number pf embryo transfer in women <37 years

A

1st full cycle: single

2nd full cycle: single (if 1 or more top quality embryos) - 2 embryos (if no top quality)

3rd full cycle: no more than 2 embryos

110
Q

Number pf embryo transfer in women 37-39 years

A

If 1st/2nd cycles: single (if 1 or more of top quality) - 2 embryos (if no top quality)

If 3rd cycle: 2 embryos

111
Q

Number pf embryo transfer in women 40-42years

A

No more than 2 embryos

112
Q

When to transfer single embryo

A

When you have a top quality embryo

113
Q

Why do women need luteal support after ET

A

D.t. desensitization of pituitary and aspiration of granulosa cells, so prevents adequate progesterone production

114
Q

How do we do luteal support

A

With Progesterone supplements during luteal phase to increase endometrial receptivity

115
Q

When to start luteal support

A

Give progesterone supplements in the luteal phase within two days of oocyte retrival

116
Q

Duration of progesterone supplementation as luteal support

A

Its given until positive or negative pregnancy test was obtained and till the end of the first trimester

NICE: not more than 8 weeks of gestation

117
Q

Use of hCG as luteal support

A

Isn’t recommended as it inc risk of OHSS

118
Q

How cryopreservation increases pregnancy rate

A

By increasing number of potential embryo replacement cycles without additional egg retrieval.

And it also decreases risk of OHSS

119
Q

What have the most significant impact on post thaw survivals of embryos

A

Embryo quality

120
Q

Live birth rates from frozen thawed embryos

A

<35 y: 31% per transfer
41-42 y: 19% per transfer

121
Q

In semen analysis, what absence of fructose may indicate?

A

It indicates obstructive azoospermia..

Most common cause of obstructive is vasectomy.

MRCOG - Part 2 (30 decks)

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