Infertility and Assisted Conception

Question 1

How many couples in the UK require assessment for infertility? How many of these go on to require fertility treatment?

Answer 1

1/6 require assessment, half of these go on to require treatment

Question 2

The demand for ACT is rising because of what?

Answer 2

Increasing parental age, chlamydia infection, male factor infertility and increased successes of ACT

Question 3

3 chlamydia infections gives what risk of infertility?

Answer 3

50% chance of blocked tubes or vas deferens

Question 4

Treatment of ‘infertility’ for who is not provided on the NHS?

Answer 4

Single parents

Question 5

Who is surrogacy used as a treatment option for?

Answer 5

Same sex male couples and women with an absent or abnormal uterus

Question 6

What advice should you give to couples who are trying to conceive about sex?

Answer 6

Have sex 2-3 times a week and avoid lubricants which are toxic to sperm

Question 7

Females should limit their alcohol consumption to what?

Answer 7

< 4 units per week

Question 8

What is the advice about weight for couples before starting IVF?

Answer 8

Both male and female partners should have a BMI between 19 and 29

Question 9

Are individuals eligible for IVF is they smoke?

Answer 9

No (male and female)

Question 10

What is folic acid used for? How and when should it be given?

Answer 10

It reduces the risk of neural tube defects. 0.4mg/day should be taken pre-conception to 12 weeks gestation and this should be increased to 5mg if there is any increased risk of neural tube defects or if the mother is obese

Question 11

Before starting IVF treatment, you should check that the mother is immunised against what?

Answer 11

Rubella

Question 12

What are couples going through IVF screened for before starting?

Answer 12

Blood borne viruses

Question 13

The type of fertility treatment that is used depends on what?

Answer 13

The cause of the infertility

Question 14

Describe what happens in intra-uterine insemination?

Answer 14

Fast moving sperm are isolated from sluggish ones and are injected directly into the uterus shortly after ovulation

Question 15

What are the indications for intra-uterine insemination?

Answer 15

Sexual problems, same sex relationships, BBV, abandoned IVF

Question 16

What fertility treatment is used to inject donor sperm or into a surrogate?

Answer 16

Intra-uterine insemination

Question 17

IVF can be used if there has been unexplained infertility for how long?

Answer 17

> 2 years

Question 18

What are some examples of pelvic diseases that may require the use of IVF?

Answer 18

Endometriosis, tubal disease, fibroids

Question 19

IVF can be used if intra-uterine insemination has failed how many times?

Answer 19

6 cycles

Question 20

What is the single biggest predictor of IVF success?

Answer 20

A woman’s age

Question 21

What is ICSI?

Answer 21

Essentially the same process as IVF except fertilisation is achieved by injecting a single sperm into each mature oocyte rather than mixing multiple sperm with each oocyte

Question 22

What are the 3 main indications for ICSI?

Answer 22

Severe male factor infertility, previously failed IVF, preimplantation genetic diagnosis

Question 23

If a couple are having ICSI and there is azoospermia, what must be done?

Answer 23

Surgical aspiration of sperm

Question 24

Where is sperm aspirated from in ICSI if there is a) obstructive b) non-obstructive male infertility?

Answer 24

a) epididymis b) testicular tissue

Question 25

After the sperm has been injected into the egg during ICSI, it should be incubated overnight at what temperature?

Answer 25

37 degrees

Question 26

How long does ovarian follicular development take?

Answer 26

85 days

Question 27

Describe the first phase of ovarian follicular development?

Answer 27

Tonic phase, takes 65 days, primary and secondary follicles develop into antral follicles

Question 28

Describe the second phase of ovarian follicular development?

Answer 28

Growth phase, takes 20 days, antral follicles develop into pre-ovulatory follicles

Question 29

In a normal menstrual cycles, during the early follicular phase, what do gonadotrophins do?

Answer 29

Result in synchronised growth of all ovarian follicles

Question 30

What is the first stage of IVF treatment and why is it done?

Answer 30

Down regulation: essentially turns off the ovaries to allow better control of ovulation and egg maturation during treatment

Question 31

What medications can be used to induce ovarian down regulation?

Answer 31

GnRH agonists/antagonists

Question 32

How do GnRH agonists cause ovarian down regulation?

Answer 32

They flood the body with 'fake' GnRH causing the ovaries to become overwhelmed and shut down the production of LH/FSH after 3 weeks

Question 33

How do GnRH antagonists cause ovarian down regulation?

Answer 33

Blocks the release of GnRH so no LH/FSH is produced almost immediately

Question 34

What are the aims of ovarian downregulation in IVF?

Answer 34

To allow more than 1 follicle to develop into a mature egg, and allow the eggs to stay within the follicles so they can be easily harvested

Question 35

What are some side effects of ovarian down regulation?

Answer 35

Hot flushes, moodswings, nasal irritation, headaches

Question 36

What is the second stage of IVF? What medication is given?

Answer 36

Ovarian hyperstimulation: daily SC FSH injections are given

Question 37

What is the function of giving FSH injections in IVF?

Answer 37

To mature the follicles (hopefully more than 1 mature egg is produced)

Question 38

What monitoring is used during the ovarian hyperstimulation phase of IVF?

Answer 38

On day 8, and every 2 days after, a pelvic US is done

Question 39

In the ovarian hyperstimulation stage of IVF, once a lead follicle has reached 18mm and two more have reached 16mm, what is given to the patient?

Answer 39

hCG injection

Question 40

What is the purpose of the hCG injection given in IVF? When is it given?

Answer 40

To mimic LH and trigger ovulation, it is given 36 hours before oocyte collection

Question 41

After producing a sample, the semen has to be used within how long?

Answer 41

1 hour

Question 42

A man has to abstain from ejaculation for how long before providing a semen sample for IVP?

Answer 42

72 hours

Question 43

Oocyte collection for IVF occurs where? What are the risks?

Answer 43

In theatre - bleeding, pelvic infection, failure to obtain oocytes

Question 44

Once oocytes have been collected, they should be incubated at what temperature?

Answer 44

37 degrees

Question 45

How are the oocytes fertilised for IVF?

Answer 45

Up to 50,000 sperm are added to a Petri dish containing a single mature egg

Question 46

Approximately what proportion of oocytes obtained from IVF will fertilise normally?

Answer 46

60%

Question 47

After fertilisation in IVF, when is the pronuclei transferred into the mother?

Answer 47

After 5 days, at the blastocyst stage

Question 48

How many embryos are normally transferred in IVF?

Answer 48

Usually just one

Question 49

What is the maximum number of embryos that can be transferred into mother in IVF under exceptional circumstances?

Answer 49

Three

Question 50

How are embryos inserted into the mother in IVF?

Answer 50

Directly into the uterus via ultrasound guidance

Question 51

What is given as luteal support after the embryo has been inserted in IVF? How long for?

Answer 51

Progesterone suppositories for 2 weeks

Question 52

When should you do a pregnancy test in IVF?

Answer 52

16 days after oocyte recovery

Question 53

What are some risk factors for ovarian hyperstimulation syndrome?

Answer 53

Young age, low BMI, PCOS

Question 54

What are some mild presentations of ovarian hyperstimulation syndrome?

Answer 54

Abdominal bloating, mild pain and ovarian size < 8cm

Question 55

What are some features of more severe ovarian hyperstimulation syndrome?

Answer 55

Ascites, oliguria, hyponatraemia, hyperkalaemia, ovarian size > 12cm

Question 56

Ovarian hyperstimulation syndrome is associated with capillary leakage which can result in what?

Answer 56

Pleural effusion, pericardial effusion, ascites, intravascular volume depletion

Question 57

When does ovarian hyperstimulation syndrome normally present? What would be classed as a late presentation?

Answer 57

Normal = 2-3 days after oocyte collection / late = 7-10 days after

Question 58

How can ovarian hyperstimulation syndrome be prevented?

Answer 58

Using low dose protocols and GnRH antagonists for suppression

Question 59

What are some treatment options for ovarian hyperstimulation syndrome before embryo transfer?

Answer 59

Elective freezing or a single embryo transfer

Question 60

What are some treatment options for ovarian hyperstimulation syndrome after embryo transfer?

Answer 60

Monitoring with scans and bloods, thromboprophylaxis, IV fluids, drainage of any fluid collections

Question 61

What are the 2 main risks to the foetuses associated with multiple pregnancy?

Answer 61

Foetal growth restriction and premature birth

Question 62

The risk of multiple pregnancies with IVF can be reduced how?

Answer 62

Moving to blastocyst transfer, improved cryopreservation, increased single embryo transfer

Question 63

What is the relationship between IVF and ectopic pregnancy?

Answer 63

2-3 fold increase with IVF