antenatal/before birth

Question 1

list some sections included in the redbook

Answer 1

child and family details, information and advice, immunisations, screening, the child’s firsts and growth charts.

Question 2

Give a definition of Herd immunity and the herd immunity threshold

Answer 2

Herd immunity occurs when a significant proportion of the population have been vaccinated with this providing protection for unprotected individuals.

The herd immunity threshold is the proportion of a population that need to be immune in order for an infectious disease to become stable in that community

Question 3

list negative associations linked to smoking in pregnancy

Answer 3

congenital malformations
miscarriages
premature births
perinatal death

Question 4

outline additional key health promotion roles of gp during early stages of pregnancy other than smoking cessation

Answer 4

diet management - folic acid, vitamin D
Lifestyle advise - BMI and weight, exercise
Managing mental wellbeing - assessment and support

Question 5

list initial assessments of female infertility that can be arranged within primary care

Answer 5

Examination – BMI + weight, pelvic examination, ultrasound – pcos, fibroids,

Taking history – smoking, GYNECOLOGICAL HISTORY: previous miscarriages etc, menstrual cycle (irregular cycles), length of time trying to get preg. Time scale – 1 year.

Question 6

State some causes of female infertility

Answer 6

Failure of ovulation caused by:
Blocked fallopian tubes
Endometriosis
Fibroids
Anatomical
age

Question 7

Whar is polycystic ovaries?

Answer 7

Enlarged ovary
large no. of follicles
peripherally arranged follicles
irregular cycles
hirsuitsm and acne
raised BMI

Question 8

What is PCOS?

Answer 8

Increased number of follicles in the ovary = pcos
increased ovarian androgen production
failure to ovulate

Question 9

what are some investigations for female infertility?

Answer 9

Assessment of tubal patency
 Hysterosalpingogram (HSG X-Ray)
 Hysterosalpingo Contrast Sonography 
(HYCOSY Ultrasound)
  Laparoscopy

Question 10

what are the hormonal assessments for female infertility?

Answer 10

Follicle Stimulating Hormone  FSH
 3-10 is normal 
 10-15 Low reserve
 Above 30 - Menopausal
 Anti Mullerian Hormone AMH
 Less than 3 very low reserve
 3-17 Low reserve
 17-35 average reserve
 Above 35 good reserve or PCO

Question 11

how is an ultrasound used to assess female infertility?

Answer 11

Ultrasound scan
 Antral follicle count – each ovary
 1-2 Follicles very low reserve
 3-5 Follicles Low reserve
 6-11 Average reserve 
 12 or more follicles good reserve or 
polycystic ovaries.

Question 12

what are some causes of male infertility?

Answer 12

No sperms
low sperm numbers 
-- 10-15 million low
-- < 5 million very low
poor sperm motility (<50%)
Progressive motility (<30%)
High no. of abnormal forms
Vasectomy

Question 13

What are some treatment options for infertility?

Answer 13

Lifestyle measures
 Cycle monitoring/Ovulation induction - PCO
 Intra-uterine insemination- IUI (placing live sperm into uterus)
 – Low sperm count and motility and single or
same sex couples( donor sperms)
 In-vitro fertilisation- IVF – Unexplained, tubal
factor or low ovarian reserve.
 Intra cytoplasmic sperm injection-ICSI male factor
or failed fertilisation following IVF

• Egg donation
• PGS/PGD
• Surrogacy
• Fertility preservation - Egg/embryo freezing
• Ovarian tissue freezing

Question 14

what are the problems with resource allocation in infertility?

Answer 14

Health Authority
 Funding for all treatments is limited
 Funding varies from place to place with some health
authority no treatment is funded (eg Croydon) and
others three cycles are provided on the NHS.
 The criteria for Providing treatment and Refusing
treatment also varies within regions

Question 15

Why do some people get refused treatment for infertility?

Answer 15

Either partner has children
 Short relationship( duration the couple have been
trying to conceive before treatment is offered – 2
years)
 Obesity and Raised BMI. The criteria for providing
treatment and
 Smoking – cessation for 6 months
 Age – 40 and some centres 42 no treatment is
provided

Question 16

Why might someone who smoked be denied treatment (female)?

Answer 16

Good evidence that smoking in the female is
• associated with impaired fecundity and
increased risks of spontaneous abortion and
ectopic pregnancy. ? Fetal ovarian reserve.
• Smoking appears to accelerate the loss of
reproductive function and may advance the
time of menopause by 1-4 years.
• There is good evidence that smoking is
negatively associated with ART outcomes such
that smokers require nearly twice the number of
IVF attempts to conceive as nonsmokers.
Concept

Question 17

why might someone who smokes be denied treatment (male)?

Answer 17

Semen parameters and sperm function tests are
lower in smokers than in nonsmokers and the
effects are dose-dependent, but smoking has
not yet been conclusively shown to reduce
male fertility.
• Passive smoking side effects are now
established, and there is good evidence that
nonsmokers with excessive exposure to tobacco
smoke may have reproductive consequences
as great as those observed in smokers.

Question 18

What is the correlation between obesity and fertility?

Answer 18

Many obese women and men are fertile.
• Obesity in women is associated with ovulatory
dysfunction, reduced ovarian responsiveness to
stimulation tx, altered oocyte, endometrial functions,
and lower birth rates.
• Obese women are at increased risk of developing
maternal and fetal complications during pregnancy.
• Obesity in men may be associated with impaired
reproductive function.
• Lifestyle modification in women and men is the first-
line treatment for obesity, followed by adjunctive
medical therapy.
• Bariatric surgery in women and men is an important
adjuvant to lifestyle modification and medical
therapy for weight loss, but pregnancy in women
should be deferred for 1 year postoperatively.

Question 19

what is the embryoselection criteria?

Answer 19

Embryo selection criteria are currently based on the rate of
embryo development and embryo morphology

Question 20

what are some advantages of next generation IVF?

Answer 20

improving Clinical Outcomes by PGS:
Avoid transfer + storage of aneuploid embryos
• Mitigates the effect of maternal age1
• Increase Implantation Rates 2,3
• Increase pregnancy & live birth rates/embryo transfer 3,4
• Reduce miscarriage rate 2,4,5,6
• Select euploid blastocysts to support single-embryo transfer 2,3,4,5
• Reduce time to live birth & costs 6

Question 21

Why do some people choose to freeze their eggs?

Answer 21

single
not planning pregnancy at present.
couples can choose to freeze their embryos

Question 22

Why do some people opt for egg donation?

Answer 22

Options for women with low ovarian reserve

• premature ovarian failure
• Poor ovarian reserve

Question 23

Critically discuss why obesity is a big factor in consideration of provision of fertility treatment

Answer 23

Differential treatments. Explain, evidence. Etc

Risk – obesity comes in association with plenty of risks: Hormonal changes, gestational problems etc effects rate of success in ivf.
Obesity associated with reduced response to stimulation – physiological evidence based – reduce success rate. Birth rate

Technically more difficult

Resources are finite – choosing allocation of resources based on evidence.

Counter argument:
Discrimination against people who are unable to lose weight. Also a lot of people against target weight do become pregnant so obesity is not necessarily unlikely to not give birth.

Eligibility for treatment – sociodemographic changes. Are obesity rates the same in each population? Should you be discriminated according to your population. Ccg Set critetia lowe

Question 24

What is the role of primary care in the

management of subfertility?

Answer 24

First point of contact
 History & examination: cycle / PCOS features / other diagnostic 
patterns / information for referral
 Lifestyle factors and advice
 Blood tests / scans
 Liaison / Shared NHS and private care
 Male semen analysis
 Referral – NHS and Private
 Prescribing
 Psychological support

Question 25

What are some issues to consider in fertility cases?

Answer 25

Ethical: Right to fertility treatment.
Resources: - Allocation
- Commissioning; who is paying?
- Limited and finite
Local vs National guidance: inequality
Psychological impact: - Dr/Pt relationship
- Direct for pt and partner
- Inequality /sense of injustice
- cost  to NHS
Societal issues: -Demographic changes
- social change
Evidence base: Evidence behind guidelines

Question 26

What are the nice guidelines on fertility treatment?

Answer 26

he updated NICE Clinical Fertility Guideline published on the 20th February 2013 recommends that women aged up to and including 39 should access three full cycles of IVF treatment; it also recommends that women aged between 40 and 42 who have never had IVF treatment and who do not have a low ovarian reserve should be able to access one full cycle of IVF. However in reality this is only a guideline and is not mandatory in England.
Research has shown that over 80% of CCGs fail to provide the recommended cycles.

Question 27

What is antenatal care?

Answer 27

This is the care you receive while you’re pregnant to make sure you and your baby are as well as possible.

The midwife or doctor providing your antenatal care will:

check the health of you and your baby
give you useful information to help you have a healthy pregnancy, including advice about healthy eating and exercise
discuss your options and choices for your care during pregnancy, labour and birth
answer any questions you may have