Infertility and Assisted Conception Flashcards
What is assisted conception treatment (ACT)?
Any treatment inv. gametes outside the body
Occurrence of infertility and use of ACT?
1/6 couples require infertility assessment in the UK; ~1/2 of these couples will require ACT
Demand for ACT is rising due to: • Increasing parental age • Increasing chlamydia • Male factor infertility • Increasing range of ACT • Improved success rates
Indications for ACT, other than infertility?
Preservation of fertility in cancer patients
Treatment to avoid transmission of blood-borne viruses between patients
Pre-implantation diagnosis of inherited disorders
Treatment of single parents or same sex couples
Cryopreservation of gametes for social reasons
Treatment when the uterus is absent / abnormal
Requirements before ACT commences?
Alcohol - females must limit to 4 units per week
Weight - BMI 19-29 is optimal for both males and females
Smoking - advise cessation
Folic acid (decreases risk of neural tube defects): • 0.4 mg/day from pre-conception to 12 week gestation • 5mg if increased risk of neural tube defects or if the patient is obese
Rubella - check if female is immune; if not, immunise, as it is teratogenic
Cervical smears - check up to date
Occupation factors - consider exposure to hazards
Drugs - prescribed, OTC and recreational
Screening for blood-borne viruses:
• Hepatitis B/C
• HIV
Assess ovarian reserve - combine age with AMH test, which is produce by antral follicles, to determine how many eggs the patient is likely to produce:
• Antral follicle count
• AMH (anti-mullerian hormone test)
Counselling - offer supportive counselling
Treatments available for ACT
- Donor insemination
- Intra-Uterine Insemination (IUI) - for couple that are unable to have penetrative sexual intercourse but who have no other issues
- In Vitro Fertilisation (IVF)
- Intra-Cytoplasmic Sperm Injection (ICSI)
- Fertility preservation
- Surrogacy
Indications for IUI?
Sexual problems
Unexplained infertility
Mild / moderate endometriosis
Mild male factor infertility
Method of IUI?
Can be done in a natural / stimulated cycle; the prepared semen is inserted into the uterine cavity around the time of ovulation
Indications for IVF?
Unexplained infertility (>2 years duration)
Pelvic disease:
• Endometriosis
• Tubal disease
• Fibroids
Anovulatory infertility (after failed induction of ovulation, e.g: in PCOS)
Male factor infertility, if >1x10 to 6 motile sperm)
Others, e.g: pre-implantation genetic diagnosis
Steps in IVF?
- Down-regulation
- Ovarian stimulation followed by a stimulation scan)
- Oocyte collection
- Embryology lab procedure
- Fertilisation
- Embryo transfer
What is down regulation?
Synthetic gonadotrophin release hormone analogue or agonist is administered, to stop LH/FSH production; this stops egg production by the ovaries and later, when gonadotrophins are administered, the ovaries are more receptive and more likely to produce eggs
i.e: improves success rates as more than 1 egg is produced at a time
It also allows precise timing of oocyte recovery, by using a HCG trigger
Side effects of down-regulation?
Hot flushes and mood swings
Nasal irritation
Headaches
NOTE - the patient is essentially being put into artificial menopause
Ix after down-regulation?
Perform an USS to check the ovaries and endometrium
Explain the process of ovarian stimulation
A gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/- LH); this causes follicular development
It can be self-administered via a subcutaneous injection
Use of the stimulation scan following ovarian stimulation?
Checks how the ovaries are responding and also for ovarian hyperstimulation syndrome
How long after the HCG injection can oocyte recovery be done?
The date/timing of the HCG injection is planned (mimics LH, leading to resumption of meiosis in the oocyte)
It is done 36 hours before oocyte recovery
Collection of semen from the male during IVF?
Requires abstinence for 72 hours beforehand; it is produced within in the ward bathroom or at home (within 1 hour)
Assessment of semen?
Assess volume, density, motility (what proportion are moving) and progression (how well they move)
Sample is prepared by removing seminal plasma and then being concentrated
How is oocyte collection done?
In theatre; there are risks of bleeding, pelvic infection and there may be a failure to obtain oocytes
How is the embryology stage of IVF completed?
Follicular fluid is searched to ID eggs and the surrounding mass of cells, which are collection into a cell culture medium and incubated at 37 degrees celsius
Fertilisation - 2 pro-nuclei (with male and female genetic info); ~60% of eggs fertilise normally
Day 5 is usually the day of transfer and cryopreservation (at the blastocyst stage)
Explain embryo transfer
Normally 1 embryo is transferred (maximum of 3 in exceptional circumstances)
LUTEAL SUPPORT is provided, with progesterone suppositories for 2 weeks???????
A pregnancy test is done 16 days after oocyte recovery
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Indications for Intra-Cytoplasmis Sperm Injection (ICSI)?
Severe male factor infertility
Previous failed fertilisation with IVF
Pre-implantation genetic diagnosis
What must be done is the patient has azoospermia?
Requires surgical sperm aspiration; this can be extracted from the:
• Epididymis (if obstructive)
• Testicular tissue (if non-obstructive)
Describe the process of ICSI
Each egg is stripped and the sperm is immobilised; a single sperm is injected
Incubated at 37 degrees celsius overnight
