Assisted Reproduction

Question 1

What is important to understand for ART?

Answer 1

Menstrual physiology and fertilisation implantation

Question 2

What surges during ovulation and what are the results?

Answer 2

FSH and LH surge. LH surge stimulates the release of the oocyte into the fallopian tube.

Question 3

What is left over after ovulation and what does it mainly produce?

Answer 3

The corpus luteum is left over and it mainly produces progesterone.

Question 4

What does progesterone do?

Answer 4

Progesterone causes secretory changes to the endometrium, allowing for implantation of a fertilised oocyte.

Question 5

What happens at the end of the 14 days after ovulation?

Answer 5

Progesterone and oestrogen levels are reduced, leading to the breakdown of the endometrium and menstruation.

Question 6

What does the fall of progesterone and oestrogen do to the HPG axis?

Answer 6

It causes a reciprocal increase in FSH from the anterior pituitary.

Question 7

What does FSH and LH stimulate?

Answer 7

FSH stimulates granulosa cells, and LH stimulates theca cells, leading to the growth of follicles.

Question 8

What happens to the dominant follicle?

Answer 8

The dominant graphene follicle produces high levels of oestrogen and progesterone, leading to a positive feedback loop and LH surge.

Question 9

What hormone does the hypothalamus produce and how frequently?

Answer 9

The hypothalamus produces GnRH in a pulsatile manner, causing the release of FSH and LH from the anterior pituitary.

Question 10

What is the concentration of LH and FSH secreted dependent on?

Answer 10

It is dependent on feedback from oestrogen and progesterone levels.

Question 11

What do regular periods indicate?

Answer 11

Regular periods indicate that a woman is ovulating.

Question 12

What changes occur to the endometrium during the menstrual cycle?

Answer 12

In the first half, the endometrium proliferates. At ovulation, the corpus luteum produces progesterone, causing secretory changes.

Question 13

What can happen in unprotected sex?

Answer 13

It is possible for sperm to meet the secondary oocyte at the ampulla to produce an embryo.

Question 14

Where does the embryo remain for the first few days?

Answer 14

The embryo remains in the fallopian tube for the first 4-5 days and is wafted down towards the uterine cavity via peristalsis.

Question 15

What is the embryo once reaching the endometrial cavity?

Answer 15

Once it reaches the endometrial cavity, it is already a blastocyst (day 5).

Question 16

Why does the endometrium need to be secretory?

Answer 16

The endometrium needs to be secretory to be receptive to the blastocyst.

Question 17

Describe the process of IUI.

Answer 17

A sperm sample is collected, placed in a catheter, and injected into the uterine cavity.

Question 18

What is important for IUI?

Answer 18

Timing is crucial; LH surge can be tested using urinary kits to time the injection of sperm.

Question 19

What are the NICE indications for IUI?

Answer 19

Inability to have sexual intercourse, need for sperm washing, and same-sex couples using donor sperm.

Question 20

What are the 4 steps of IUI?

Answer 20

1. IUI can be done with or without ovarian stimulation. 2. With or without HCG triggering. 3. Sperm preparation and insemination. 4. Pregnancy test 2 weeks later.

Question 21

What are the problems involved with IUI?

Answer 21

Low success rate, risk of multiple pregnancy, cost, and invasiveness.

Question 22

When is IVF done?

Answer 22

Indications include anovulatory conditions, tubal disease, endometriosis, unexplained infertility, male factor infertility, and other failed treatments.

Question 23

What are the steps of IVF?

Answer 23

1. Counselling and consenting. 2. Pituitary suppression. 3. Ovarian stimulation. 4. HCG triggering. 5. Oocyte retrieval.

Question 24

How is insemination done in IVF?

Answer 24

Insemination can be done using IVF or ICSI.

Question 25

How long are embryos cultured for?

Answer 25

Embryos are usually cultured for 2, 3, or 5 days.

Question 26

What is luteal support and why is it important?

Answer 26

Luteal support mimics corpus luteal function by providing progesterone to prepare the endometrium for embryo implantation.

Question 27

What is the final stage of IVF?

Answer 27

A pregnancy test is done 2 weeks after embryo transfer to check for implantation.

Question 28

What are the problems in IVF?

Answer 28

Multiple pregnancies, ovarian hyperstimulation syndrome, risks during oocyte collection, long-term maternal risks, cost, chances of live birth, and invasiveness.

Question 29

When is ICSI used?

Answer 29

ICSI is used in cases of sperm dysfunction or failure of fertilisation in IVF.

Question 30

How is sperm retrieved for ICSI?

Answer 30

Surgical sperm retrieval is required if there is obstruction of the vas deferens.

Question 31

What is perm dysfunction?

Answer 31

Problems with sperm concentration, morphology or motility.

Question 32

How is sperm retrieved?

Answer 32

Surgical sperm retrieval is required e.g. if there is obstruction of vas deferens.

Question 33

Where is sperm collected from?

Answer 33

Sperm is collected from epididymis or testicle itself.

Question 34

What are the benefits of ICSI if sperm are normal?

Answer 34

There is no demonstrable benefit to using ICSI if sperm parameters are normal – so IVF is default as it allows for natural selection.

Question 35

When are embryos cultured?

Answer 35

Culture of embryos occurs 5-6 days post oocyte collection.

Question 36

What significant hurdles does the development of the blastocyst pass through?

Answer 36

1. Switching on of embryonic genome 2. Past stages of totipotency to first differentiation.

Question 37

What does the switching on of embryonic genome allow for?

Answer 37

This allows for non-invasive embryo selection.

Question 38

How are embryos transferred?

Answer 38

Select best embryo, then use a speculum inside vagina and thread catheter to inject embryo inside the uterine cavity.

Question 39

How can oocytes and sperm be preserved?

Answer 39

Oocytes and sperm can be preserved using liquid nitrogen and cryoprotectant.

Question 40

Why is cryopreservation useful?

Answer 40

This is useful to continue having embryo transfer without needing further ovarian stimulation.

Question 41

When is cryopreservation also done?

Answer 41

This is also done if men or women are diagnosed with cancer or any other medical condition affecting future fertility.

Question 42

How successful is sperm + oocyte cryopreservation?

Answer 42

Sperm cryopreservation is very successful. Oocyte cryopreservation is more difficult and less successful.

Question 43

When are donated oocytes used?

Answer 43

Used in women who have: 1. Ovarian failure 2. Premature menopause 3. Turner’s syndrome 4. Low egg reserves 5. Carrier of inheritable disease 6. Surgical loss of ovaries.

Question 44

When is donated sperm required?

Answer 44

1. Azoospermia 2. Male partner is a carrier of inheritable disease.

Question 45

What is Azoospermia?

Answer 45

Azoospermia includes: 1. Testicular failure 2. Obstructive/absence of vas deferens 3. Microdeletions of Y.

Question 46

What is the Human Fertilisation and Embryology Authority?

Answer 46

They are the UK's independent regulator overseeing fertility treatment and research.

Question 47

What does the HFEA do?

Answer 47

The HFEA licenses fertility clinics, performs regular inspections, and provides success rates on their website.

Question 48

What is pre-implantation genetic diagnosis?

Answer 48

Removal of one or two cells from the early embryo for genetic analysis.

Question 49

What is pre-implantation genetic diagnosis used for?

Answer 49

To check for single gene disorders & balanced translocations such as CF, Huntington’s disease, and Sickle cell disease.