Infertility and Assisted Conception Flashcards by S B

what risk factors must be considered in infertility

Alcohol: females limit to 4 units per week

Weight: between 19-29 optimal both male and female

Smoking: advise to stop smoking

Folic acid: 0.4mg/day preconception-12 weeks gestation (5mg increase risk NTD)

Cervical smears: check up to date according to national screening programme

Occupational factors: exposure to hazards

Drugs: prescribed, over-the-counter, any internet remedies and recreational (steroids, opiate abuse, cannabis)

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what must be screened for when dealing with infertility

Rubella: check if female immune to rubella, if not immunise

Screen for blood born viruses: hep B/C and HIV (can still treat them but have to consider how to store the eggs or other treatment options)

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how is ovarian reserve tested

antral follicle count
or
AMH

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what is AMH

anti-mullerian hormone is a substance produced by granulosa cells in ovarian follicles.

Production is highest in preantral and small antral stages (less than 4mm diameter) of development.

Production decreases and then stops as follicles grow. There is almost no AMH made in follicles over 8mm.

Levels are fairly constant

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when can a AMH test be done

any day of a woman cycle

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how can AMH be a fertility test

Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.

Women with many small follicles, i.e. PCOS have high AMH hormone values

Women that have few remaining follicles and those that are close to menopause have low anti-mullerian hormone levels.

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what treatments are available for infertility

Donor insemination
Intra-Uterine Insemination (IUI)
In Vitro Fertilisation (IVF)
Intra-Cytoplasmic Sperm Injection (ICSI)
Fertility Preservation
Surrogacy

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what are the indications for intra-uterine insemination

unexplained infertility
mild or moderate endometriosis
mild male factor infertility

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how does IUI work

Prepared semen inserted into uterine cavity around time of ovulation

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when is IVF indicated

Unexplained (> 2 years durations)

Pelvic disease (endometriosis, tubal disease, fibriods)

Anovulatory infertility

Male factor infertility (only when its mild)

Others (pre-implantation genetic diagnosis)

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what needs to happen to women about to go under IVF

down regulation

- put women artificially into menopause so there is no spontaneous ovulation

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how does down regulation work

Synthetic Gonadotrophin releasing hormone analogue or agonist
Administered as a spray or injection

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what are side effects of down regulation

Hot flushes and mood swings
Nasal irritation
Headaches

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how is follicular development encouraged in IVF

ovarian stimualtion

Gonadotrophin Hormone containing either synthetic or urinary gonadotrophins (FSH+/- LH)
Can be self-administered sc injection

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what are side effects of ovarian stimulation

Mild allergic reactions

Ovarian Hyper Stimulation Syndrome (OHSS) (i.e. when there is too many eggs)

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what classic appearance does a thickened endometrium have on ultrasound

classic triple line seen

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what is the method for sperm sampling in IVF

Abstinence for 72 hours beforehand

Ejaculated samples

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what is assessed from a sperm sample

Volume
Density - numbers of sperm
Motility - what proportion are moving
Progression - how well they move

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how are oocytes collected

theatre

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what are the risks of oocyte collection

bleeding
pelvic infection
failure to obtain oocytes

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how can you tell an egg has been fertilised

Two pronuclei

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at what day after fertilisation does it become a blastocyst

day 5

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what stage is usual day of transfer and cryopreservation

day 5

- blastocyst stage

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what are the measures taken in embryo transfer

Normally transfer 1 embryo (max 3 in exceptional circumstances)

Luteal Support
: progesterone suppositories for 2 weeks
:pregnancy test

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when do people get there scans in IVF

Baseline scan - before FSH or hMG injection Action scan - 8/9 days later before hCG injection

what are indications for Intra Cytoplasmic Sperm Injection (ICSI)

Severe male factor infertility Previous failed fertilisation with IVF Preimplantation genetic diagnosis

what is ICSI

when you inject the sperm into the egg

how can the sperm be retrieved for ICSI

Can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)

what will be require in azoospermia

surgical sperm aspiration

what is OHSS and symptoms

Ovarian Hyper Stimulation Syndrome - Enlarged ovaries - Excess Follicles Sx - abdo pain/bloating - nausea/diarrhoea - breathless

how do we try to prevent OHSS

before embryo transfer - elective freeze - single embryo transfer after embryo transfer - monitoring [scans, bloods] - antithrombotic - analgesia - Hospital admission if required IV fluids/more intensive monitoring/paracent

what regulates all ART activities

HFEA

what is the current success rate of IVF

35%

what are the complications of ART

multiple pregnancies OHSS ectopic pregnancies

what are the parts involved in IVF treatment

``` down regulation ovarian stimulation oocyte retrieval embryo transfer luteal support ```

what chromosome has the sex determining region

Y chromosome

what are the 2 primitive genital tracts in the foetus

Wolffian ducts = becomes the male genitals Mullerian ducts = becomes the female genitals

what causes the development of the male internal genital tract

Fetal testes secretes dihydrotestosterone (and Mullerian inhibiting factors) Mullerian ducts degenerate Wolffian ducts >> repro tract

what causes the development of the female internal genital tract

Without stimulus of male testicular hormones, fetus will develop female internal genital tract Wolffian ducts degenerate Mullerian ducts >> repro tract

why are males with CF infertile

absent vas deferens

where is sperm aspirated from

epididymis

what is the testes dropping into the scrotal sac before birth dependant on

androgen

what is crytorchidism

undescended testes

what does crytorchidism cause

reduced sperm count | - if unilateral usually still fertile

why is a orchidopexy [surgically descending the testes] done

to reduce risk of testicular germ cell cancer

what cells in the testis are responsible for testosterone production

leydig cells

where does spermatogenesis happen

sertoli cells in the seminiferous tubules

what is the function of sertoli cells

``` form a blood testes barrier provide nutrients phagocytosis secrete seminiferous tubule fluid secrete androgen binding globulin secrete inhibin and activin hormones ```

what stimulates spermatogenesis

FSH + testosterone

what inhibits the secretion of FSH

inhibin

what stimulates the release of testosterone

what does testosterone decreased the release of

GnRH and LH

what does FSH act on to stimulate spermatogenesis

sertoli cells

FSH and LH are stimulated by GnRH = what cells in the anterior pituitary produce them

FSH -> Granulosa cells | LH -> Theca cells

what is testosterone protective against

osteoporosis

how does the sperm fertilise the egg - what are the stages after ejaculation

``` 1 - chemoattraction to oocyte 2 - docking to zona pellucida of oocyte 3 - acrosome reaction 4 - hyperactivitiy motility 5 - penetration and fusion with oocyte membrane 6 - zonal reaction ```

what produces semen into ejaculatory duct

seminal vesicles

what secretes mucus to act as lubricant

bulbourethral glands

what is the route of sperm

Testes ➔ epididymis ➔ vas deferens ➔ ejaculatory duct ➔ urethra

how does an erection occur

blood fills corpora cavernosa (under parasympathetic control)

under what control is ejaculation

sympathetic

how can male infertility be categorised

idiopathic - most common obstructive - CF, vasectomy, infection non-obstructive - chemo/radiotherapy, Cryoptorchadism, tumour

what genetic conditions can cause male infertility

Klinefelter’s syndrome microdeletions of Y chromosome Robertsonian translocation

what are endocrine causes of male infertility

pituitary tumours - acromegaly, cushings, prolactinoma hypothalmic cause - tumour, Kallman's syndrome thyroid disorders - hyper/hypothyroid diabetes CAH androgen insensitivity steroid abuse

why does Kallman's syndrome cause infertility

do not produce GnRH, therefore no LH, FSH or testosterone

what is the normal testicular volume in adults

12-25 mls

Ix for male infertility

Semen analysis Repeat semen analysis in 6 wks Endocrine profile [LS, FSH, testosterone, PRL, TSH] Chromosome analysis Testicular biopsy Scrotal scan

what are the clinical and endocrine features of an obstructive cause of male infertility

Clinical Features: normal testicular volume normal secondary sexual characteristics vas deferens may be absent Endocrine features: Normal LH, FSH and testosterone

what are the clinical and endocrine features of a non-obstructive cause of male infertility

Clinical Features: low testicular volume reduced secondary sexual characteristics vas deferens present Endocrine features: High LH, FSH and low testosterone

what is the assisted conception method used when male infertility is the problem

IUI ICSI Surgical Sperm Aspiration Donor sperm