Infertility and Assisted Conception Flashcards

1
Q

how long are patients waiting for treatment?

A

less than 12 months

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2
Q

how many cycles of IVF/ICSI are offered where there is reasonable expectation of a live birth?

A

three

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3
Q

what are the common indications for ART?

A
endometriosis 
male factor infertility 
tubal disease
unexplained reasons 
ovulatory disorder
multiple male and female factors
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4
Q

other than the common ones, what are the other indications for assisted conception treatment?

A

fertility preservation in cancer, transgender patients and social reasons
treatment to avoid transmission of blood born viruses between patients
pre-implantation diagnosis of inherited disorders
treatment of single parents or same sex couples
treatment with surrogacy when absent / abnormal uterus

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5
Q

before treatment begins, what lifestyle factors must be checked / put in place?

A

alcohol = females limit to 4 units per week
weight = between 19-29
smoking = stop
folic acid = 0.4mg/day preconception-12 weeks gestation
rubella = immunise
smears = up to ate
occupational factors = avoid hazards
drugs = prescribed, OTC and recreational
screen for blood born viruses
assess ovarian reserve = antral follicle count or AMH

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6
Q

what assisted conception treatments are available?

A
donor insemination 
intra-uterine insemination (IUI)
in vitro fertilisation (IVF)
intra-cytoplasmic sperm injection (ICSI)
fertility preservation 
surrogacy
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7
Q

when is intra uterine insemination indicated?

A

sexual problems
same sex relationships
discordant BBV
abandoned IVF

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8
Q

how is IUI carried out?

A

can be in natural / stimulated cycle

prepared semen inserted into uterine cavity around time of ovulation

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9
Q

what are the indications for IVF?

A
unexplained (>2 years durations)
pelvic disease (endometriosis, tubal disease, fibroids)
anovulatory infertility (after failed ovulation induction)
failed intra-uterine insemination (after 6 cycles)
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10
Q

what are the two phases of ovarian folliculogenesis?

A

tonic phase (65 days) = primary and secondary follicles to antral follicles

growth phase (20 days) = antral follicles 3-5mm to pre-ovulatory follicle (20nm), dependent on gonadotrophin

*in a stimulated cycle, gonadotropins during early follicular phase result in synchronised growth of all follicles (approx 1.5mm per day)

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11
Q

what is the first stage in IVF treatment?

A

down-regulation

  • synthetic gonadotrophin releasing hormone analogue or agonist
  • switches off egg production
  • allows precise timing of oocyte recover by using HCG trigger
  • side effects = hot flushes and mood swings, nasal irritation and headaches
  • scan performed
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12
Q

what is the second stage in IVF treatment?

A

ovarian stimulation

  • gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/- LH)
  • can be self administered sc injection
  • causes follicular development
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13
Q

what does HCG injection cause?

A

mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery

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14
Q

what is the third stage of IVF and what are the risks of this?

A

oocyte collection

risk = bleeding, pelvic infection, failure to obtain oocytes

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15
Q

what is the job of the embryologists in maturing human egg?

A

search through follicular fluid
identify eggs and surrounding mass of cells
collect them into cell culture medium
incubate at 37oc

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16
Q

what is the fourth stage in IVF?

A

sperm collection

abstinence for 72 hours beforehand, produced in mens room in ward or at home (within 1 hour)

assessed for volume, density (number of sperm), motility (what proportion are moving), progression (how well they move)

17
Q

what is the fifth stage of IVF?

A

fertilisation

*two pronuclei, male and female genetic information, approx 60% of eggs fertilise normally

18
Q

what is the sixth stage of IVF?

A

embryo transfer (usually on day 5 after fertilisation)

  • normally transfer 1 (max 3)
  • luteal support: progesterone suppositories for 2 weeks
19
Q

how long after oocyte recovery is a pregnancy test performed?

A

16 days

20
Q

what are the indications for ICSI?

A

severe male factor infertility
previous failed fertilisation with IVF
preimplantation genetic diagnosis

21
Q

what will be required for ICSI in the case of azoospermia?

A

surgical sperm aspiration

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

22
Q

what is the process of ICSI?

A

each egg is stripped
sperm immobilised
single sperm injected
incubate at 37oc overnight

23
Q

what is the biggest complication of ART?

A

ovarian hyper-stimulation syndrome

24
Q

what are the symptoms of ovarian hyper-stimulation syndrome?

A

mild = bloating, mild abdo pain, ovarian size <8cm

moderate = moderate abdo pain, nausea + vomiting, ascites on US, ovarian size 8-12cm

severe = clinical ascites, oliguria, haematocrit >0.45, hyponatraemia, hypo-osmolality, hyperkalaemia, hypoproteinaemia, ovarian size >12cm

critical = tense ascites/large hydrothorax, haematocrit >0.55, high WBC, oliguria/anuria, thromboembolism, ARDS

25
Q

how can ovarian hyper-stimulation syndrome be prevented?

A

low dose protocols

use of antagonist for suppression

26
Q

how can OHSS be treated before embryo transfer?

A

elective freeze

single embryo transfer

27
Q

how can OHSS be treated after embryo transfer?

A

monitor with scans and bloods
reduce risk of thrombosis (fluids, TED stockings and fragmin)
analgesia
hospital admission if requires IV fluids / more intense monitoring/paracentesis

28
Q

how have multiple pregnancy rates been decreased in IVF?

A

the move to blastocyst transfer
improved cryopreservation
increase in single embryo transfer

29
Q

currently, what % of babies born from ART are multiple pregnancies?

A

10%

30
Q

what is the biggest complication of ART?

A

ectopic pregnancies

*incidence increased 2-3 fold with IVF

31
Q

what are other problems associated with ART?

A
no eggs retrieved (v uncommon)
surgical risks of oocyte retrieval (bleeding, infection)
surgical risks of surgical sperm aspiration (haematoma, infection)
failed fertilisation 
problems in early pregnancy 
increase risk in on-going pregnancy 
psychological problems 
failed treatment
32
Q

what body regulates and licences all ART activities?

A

human fertilisation and embryo authority (HFEA)

  • regulate all treatment and research
  • consider welfare of child
  • rights of people seeking treatment to appropriate care
  • respect for human life at all stages of development
33
Q

what is the current success rate for IVF?

A

35%