Infertility and Assisted Conception Flashcards by Joanna Mitchell

What is ACT?

Any treatment which involved gametes outside the body

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How many couples in the UK will require ACT to fall pregnant?

One in six

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Why is the demand for ACT rising?

Increasing parental age
Increased chlamydia
Male factor infertility
Increasing range of ACT
Improved success rates

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What is the current access for ACT treatment in the UK?

Less than 12 months
Eligible patients (under 40) can be offered 3 cycles of IVF/ICSI where there is a reasonable expectation of a live birth
One partner has no biological child

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What are other indications for ACT aside from heterosexual couples unable to conceive?

Same sex or single people
Fertility preservation in cancer, transgender patients and social reasons
Treatment to avoid transmission of BBV between patients
Pre-implantation diagnosis of inherited disorders
Treatment with surrogacy when absent/ abnormal uterus

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What are some things that women should do before treatment begins for assisted conception?

Limit alcohol to 4 units a week
Weight; BMI between 19-29 
Stop smoking
Folic acid; 400 mcg or 5mg if specific risk factors
Rubella immunisation 
Cervical smears up to date
Occupational factors
Drugs
Screen for BBV
Assess ovarian reserve; antral follicle count or AMH
Counselling

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Who should receive the higher 5mg dose of folic acid preconception?

If increased risk of NTD
Diabetes
Obese 
Antiepileptic drugs 
Folate antagonists 
Smokers

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What different treatments are available under ACT?

Donor insemination 
IUI
IVF
ICSI
Fertility preservation 
Surrogacy

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What are the indications for IUI?

Sexual problems
Same sex relationship
Discordant BBV
Abandoned IVF

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What are the methods for IUI?

Natural or stimulated cycle

Prepared semen inserted into uterine cavity at time of ovulation

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What size should the follicle be to insert sperm for IUI?

17-18mm

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What are the indications for IVF?

Unexplained (>2 years duration) 
Pelvic disease (endometriosis, tubal disease, fibroids) 
Anovulatory infertility (after failed ovulation induction) 
Failed IUI (after 6 cycles)

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How many couples will get pregnant within 2 years of trying?

Around 95/100

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What is the tonic phase of ovarian follicular development?

Primary and secondary follicles to antral follicles

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What is the growth phase of ovarian follicular development?

Antral follicles (3-5mm) to preovulatory follicle (20mm), dependent on gonadotrophin

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What is down regulation?

Synthetic GnRH agonist to reduce ovarian production of follicles
Allows precise timing of oocyte recover by using hCG trigger

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What are side effects to downregulation?

Mini menopause; hot flushes, mood swings, nasal irritation, headaches

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What should you seen on down regulation scans of the ovary and endometrium?

No follicular development in ovary

Thin endometrium

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What is ovarian stimulation?

Gonadotropin hormone containing synthetic or urinary gonadotrophins (FSH +/- LH)
Self administered SC injection
Results in follicular development

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What should the stimulation scan of the ovary and endometrium look like?

Ovary should see follicular development

Endometrium thickening

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When should you plan the hCG injection?

36 hours before oocyte recovery to help release the follicles from the follicular wall

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How long should men be abstinent before providing semen?

72 hours

What are the semen assessed for?

Volume
Density
Motility
Progression

What are the risks to oocyte collection?

Bleeding
Pelvic infection
Failure to obtain oocytes

What will the embryologist do when they receive the follicular fluid from the oocyte collection?

Search through the follicular fluid Identify eggs and surrounding mass of cells Collect them into medium culture Incubate at 37 degrees

What will the egg do once fertilised?

Two pro-nuclei | Will continue to cleave

When will a blastocyst form?

Day 5

When is the transfer performed?

Usually day 5 of the mature blastocyst

How many blastocysts are transferred?

1 (max 3 in exceptional circumstances)

What hormones are given in the embryo transfer?

Luteal support; as the corpus luteum won't form, need to produce progesterone for 2 weeks

When is a pregnancy test performed?

16 days after oocyte recovery

What are the indications for ICSI?

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

What is required if the man has azoospermia?

Surgical sperm aspiration; extracted from epididymis or testicular tissue

When is surgical sperm aspiration from the epididymis?

Obstructive azoospermia

When is surgical sperm aspiration from the testicular tissue?

Non-obstructive azoospermia

What is the method for ICSI?

Each egg is stripped Sperm immobilised Single sperm injected Incubate at 37 degrees overnight

What are the complications for ICSI?

``` Hypospadias Chromosomal abnormalities (Klinefelter's) ```

What is the most serious side effect of ART?

Ovarian Hyper-stimulation Syndrome

What is mild OHSS?

Abdominal pain Abdominal bloating Ovarian size usually <8cm

What is moderate OHSS?

Mod abdo pain N+V USS ascites Ovarian size usually 8-12 cm

What is severe OHSS?

``` Clinical ascites Oliguria (<300 ml/day <30 ml/hr) Haematocrit >0.45 Hyponatraemia <135 Hypo-osmolality <282 mOsm/kg Hyperkalaemia >5 Hypoproteinemia <35 g/l Ovarian size >12 cm ```

What is critical OHSS?

``` Tense ascites Haematocrit >0.55 WCC > 25,000/ml Oliguria/ anuria Thromboembolism ARDS ```

How many patients will develop OHSS?

1% will develop severe OHSS

How can OHSS be prevented?

Low dose protocols | Use of antagonists for supression

Should you treat OHSS before embryo transfer?

Yes; freeze embryos | hCG will result in worsening of OHSS

How should OHSS be treated after the embryo transfer?

Monitor with scans and bloods Reduce risk of thrombosis; fluids, TED stockings and fragmin Analgesia Hospital admission if IV fluids required/ more intensive monitoring/ paracentesis

How can the risk of multiple pregnancies be reduced?

Move to blastocyst transfer Improved cytopreservation Increase in single embryo transfer

How many babies born fro ART are multiple pregnancies in the UK?

Approx. 10%

What is the IVF success rate?

35%

What are other problems assoc with ART aside from OHSS, multiple pregnancies and ectopic pregnancies?

``` No eggs retrieved Surgical risks of oocyte retrieval Surgical risks of surgical sperm aspiration Failed fertilisation Problems in early pregnancy Increased risk of on-going pregnancy Psychological problems Failed treatment ```

What are the surgical risks assoc with surgical sperm aspiration?

Haematoma | Infection

How does the HFEA regulate ART activities?

Regulates all treatment and research Considers welfare of child Rights of people seeking treatment to appropriate care Respect for human life at all stages of development

What are the main steps to ART?

``` Down regulation Ovarian stimulation Oocyte collection Fertilisation Transfer Luteal support ```