Infertility + Assisted Conception Flashcards by Megan McLaren

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 the ovarian follicles

production decreases and then stops as the follicles grow. There is almost no AMH made in follicles >8mm

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when can AMH be tested

any day of a woman cycle

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how can AMH be a fertility test

AMH is only produced in small follicles so blood levels can be used to measure the size of the pool of growing follicles
Women with may small follicles, e.g. PCOS will have high AMH
Women that have few remaining follicles and those that are close to menopause have low AMH

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what must BMI of both partners be to be considered for fertility treatment

between 19-29

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Indications for intra-uterine insemination (IUI)

unexplained infertility
mild/moderate endometriosis
mild male infertility

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how does IUI work

prepared semen inserted into uterine cavity around the time of ovulation

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Indications for IVF (in-vitro fertilisation)

unexplained infertility >2 years
pelvic disease (endometriosis, tubal disease, fibroids)
anovulatory infertility
mild male factor infertility

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what needs to happen to women about to under go IVF treatment

down regulation- puts women artificially into menopause so there is no spontaneous ovulation

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what is used to induce down regulation

synthetic GnRH analogue

administered as injection/spray

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how is follicular development encouraged in IVF

ovarian stimulation- gonadotrophin hormone containing either synergic or urinary gonadotrophin (FSH +/- LH)

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Side effects of ovarian stimulation

mild allergic reaction

Ovarian hyperstimulation syndrome

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sign of thickened endometrium on USS

Triple line

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what is the method for sperm collection in IVF

abstinence for 72 hours

ejaculated sample

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what factors are assessed in a sperm sample

volume
density- number of sperm
motility- what proportion are moving
progression- how well they are moving

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how are oocytes collected

in theatre

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risks of oocyte collection

bleeding, infection, failure to obtain oocytes

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how can you tell if 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 day is the embryo usually transferred to the mum

day 5

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what is given as luteal support during embryo transfer

progesterone suppositories for 2 weeks

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what are the indications for intra-cytoplasmic sperm injection (ICSI)

severe male factor infertility
previous failed IVF
preimplantation genetic diagnosis

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what is ICSI

when you inject sperm into the egg

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how are sperm retrieved for ICSI

Extraction from epididymis (if obstructive infertility) testicle (if non-obstructive)

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what will be required in azoospermia

surgical sperm aspiration

what is OHSS and its symptoms

Ovarian Hyper Stimulation Syndrome Enlarged ovaries- excess follicles Symptoms- abdo pain, bloating, nausea, diarrhoea, SOB

How is OHSS prevented

only transfer one embryo in IVF anti-thrombotic drugs monitor closely

current IVF success rate

35%

complications of assisted conception

multiple pregnancies ectopic pregnancy OHSS

which chromosome has the sex determining region

Y chromosome

what are the 2 primitive genital tracts

Wolffian ducts | Mullerian ducts

which primitive duct becomes male genitals

wolffian duct

which primitive duct becomes female genitals

mullerian duct

what causes the development of the male genital tract

testosterone + mullerian inhibiting factors cause mullerian duct to degenerate + wolffian ducts to become male tract

what causes the development of the female genital tract

without stimulus of male testicular hormones, wolffian duct degenerates + mullerian duct becomes female genital tract

why are males with CF infertile

absent vas deferens

where are sperm aspirated from

epididymis

what is dropping of the testes into the scrotum dependent on

androgens

what is cryptorchidism

undescended testes

what does cryptorchidism cause

decreased sperm count | usually still fertile if unilateral

what is orchidopexy? why is it done?

surgically descending the testes | reduces risk of germ cell cancer

what cells in the testes produce testosterone

leydig cells

where does spermatogenesis occur

Sertoli cells in seminiferous tubules

function of Sertoli cells

form a blood-testes barrier provide nutrients phagocytosis secretion of seminiferous tubule fluid, androgen binding globulin, inhibin + activin hormones

what stimulates spermatogenesis

FSH + testosterone

what inhibits FSH secretion

inhibin

what stimulates release of testosterone

what does the release of testosterone do to GnRH + LH

works by negative feedback to decrease GnRH + LH

Where is FSH released from? What is its action? how is it inhibited?

released from granulosa cells in anterior pituitary acts on Sertoli cells to stimulate spermatogenesis inhibin released from sertoli cells decreases FSH

where is LH released from? What is its action? how is it inhibited?

released from theca cells in the anterior pituitary acts on leydig cells to release tesosterone inhibited by negative feedback from testosterone

what type of hormone is testosterone? what is it derived from?

steroid hormone derived from cholesterol

what is testosterone protective against

osteoporosis

route of sperm

testes - epididymis - vas deferens - ejaculatory duct - urethra

what structure produces seem into ejaculatory duct

seminal vesicles

function of bulbourethral glands

secretion of mucus lubricant

function of the prostate gland

produces alkaline fluid + clotting enzymes

ejaculation is under what control

SYMPATHETIC | there is smooth muscle contraction

how does an erection occur

blood fills the corpora cavernosa

erection is under what control

PARASYMPATHETIC

Most common cause of male infertility

idiopathic

obstructive causes of male infertility

CF, vasectomy, infection

non-obstructive causes of male infertility

undescended testes, chemotherapy, tumour, chromosomal abnormality, endocrine problem, semen abnormality

genetic conditions that cause male infertility

Kleinfelters ( 47 XXY) | Robertsonian translocation

endocrine causes of male infertility

pituitary tumours- acromegaly, cushings, prolactinoma Hypothalmic causes- Kallmans syndrome, tumours Thyroid- hyper/hypothyroidism Diabetes Steroid abuse

why does Kallman's syndrome cause infertility

do not produce GnRh- therefore no LH, FSH or testosterone

normal testes volume in adults

12-25 mls

what is globozoospermia

round sperm

investigations for male infertility

``` semen analysis endocrine profile (LH, FSH, Testosterone, Prolactin, TSH) Chromosome analysis Testicular biopsy Scrotal Scan ```

clinical + endocrine features of an obstructive cause

Clinical: normal testicular volume, normal secondary sexual characteristics, vas deferens may be absent (CF) Endocrine: normal LH, FSH, Testosterone

clinical + endocrine features of a non-obstructive cause

Clinical: low testicular volume, reduced secondary sexual characteristics Endocrine: high LH + FSH and low testosterone (note all would be low in Kallman's)

what methods of assisted conception can be used when male infertility is the problem

IUI ICSI Surgical sperm aspiration donor sperm