Infertility & PCOS & IVF

Question 1

Infertility epidemiology

Answer 1

30-34: 1/7
35-39: 1/5
40-44: 1/4
generally 1/6 couples

Incidence increasing

Question 2

Cumulative fertility and maternal age

Answer 2

20-24: 86% conceive within one year
25-29: 78
30-34: 63
35-39: 52

Question 3

When to investigate for infertility

Question 4

Ovarian reserve testing

Answer 4

Day 3 FSH/estradiol (FSH

Question 5

Documenting ovulation

Answer 5

regular cycles - 95% women are ovulating
basal body temperature charting
urniary LH kit
Luteal phase progesterone = gold standard
- measure 7 days before anticipating menses, since luteal phase is fixed

Question 6

Anovulation causes

Answer 6

PCOS
Hypothalamic hypogonadism (low BMI, FHS/LH/estradiol low)
Hypothyroidism (increased TRH can affect pituitary function)
Hyperprolactinemia
Premature ovarian failure
menopause

Question 7

Establishing tubal patency

Answer 7

hysterosalpingogram

laparoscopy

Question 8

Semen analysis

Answer 8

2 separate samples, >2 wks apart
volume >1.5 ml
concentration>15 mil/mL
motility >32%
normal morphology >4%

Question 9

Female work up for infertility

Answer 9

ovarian reserve testing: day 3 FSH and estradiol/AMH
Hysterosapingogram
TSH, prolactin
pelvic ultrasound
luteal phase progesterone

Question 10

PCOS incidence

Answer 10

5-10% of women

one of most common hormonal disorders

Question 11

PCOS diagnosis

Answer 11

2/3 of:
Oligo/amenorrhea (oligo >35 days)
Clinical/laboratory evidence of elevated androgens - hirsutism, acne
Polycystic ovaries on US

Question 12

PCOS diagnosis: rule out

Answer 12

CAH - 17OHP
Cushing’s: clinical signs, AM cortisol
Hyperprolactinemia: galactorrhea, elevated PRL
Hypothyroidism: TSH

Question 13

Presenting complaints of PCOS

Answer 13

infertility
hirsutism/male pattern hair loss
acne
irregular cycles

Question 14

Pathogenesis of PCOS

Answer 14

not simple!
increased LH, androgens, insulin

Hypothalamus rapid GnRH pulsatility
–> preferential release of LH over FSH
LH increases androgens from theca cells, lower FHS can’t recruit dominant follicles

Question 15

Causes of increased LH in PCOS

Answer 15

thecal cells stimulated –> preferential production of androgens
Granulosa cells have less FSH, don’t aromatise as much to estrogen
elevated local androgens - inhibit follicular development

Question 16

Increased insulin in PCOS

Answer 16

directly works synergistically with LH to increase theca cell androgen production
indirectly decreases sex-hormone binding globulin to increase circulating testosterone

Question 17

PCOS etiology

Answer 17

likely heritable
some rare single gene disorders
likely complex multigenic
intrauterine environment????

Question 18

Infertility in PCOS

Answer 18

not ovulating regularly

weight loss can improve insulin status

Question 19

tx of PCOS

Answer 19

1) clomiphene citrate

letrozole
metformin
others: FSH injections, IVF, ovarian drilling

if NOT trying to conceive - OCP to regulate cycles, reduce hirsutism/acne, protect endometrium, etc

Question 20

Clomiphene citrate MOA

Answer 20

blocks estrogen feedback at hypothalamus/pituitary, also at uterine lining
increased FSH release, possibility of ovulation
Anti-estrogen effects on uterine lining/cervica lmucous –> thin endometrial lining, thick mucus
Rate of multiples - 8%
cost - $100/mo
May need to bring on a period with Provera
10 days with progesterone to mimic luteal phase, then stop to signal beginning of another cycle
start at 50, then 100, then 150

Question 21

Letrozole MOA

Answer 21

aromatase inhibitor (decrease androgen level)
take day 3-7 of cycle

Question 22

Metformin MOA in PCOS

Answer 22

decreases hepatic glucose production
decreases intestinal glucose absorption
increases insulin sensitivity

Reducing insulin –> reduction of effect of LH on theca cells
does not work as well as clomiphene
500 mg three times a day

Question 23

FSH injection

Answer 23

expensive - need 10-20 injecitons at $50-100/day just to ovulate
chance of multiples ~30%

Question 24

Hirsutism/acne treatment

Answer 24

due to elevated androgens
Oral contraceptives:
- estrogen increases SHBG and reduces LH production
- progesterone: can be anti-androgenic

Anti-androgens: cyproterone acetate, spironolactone, flutamide

Question 25

Long-term health implications of PCOS

Answer 25

Endometrial cancer: - hyperplasia of endometrium due to chronic unopposed estrogen - OCP/cyclic progesterone q3 mo Hypertension Dyslipidemia Type II DM - 30-40% have impaired glucose intolerance; 10% will have T2DM by 40s Sleep apnea

Question 26

IVF overview

Answer 26

1) ovaries stimulated with drugs to produce multiple eggs 2) harvested when ready 3) inseminated with sperm 4) fertilized eggs matured into embryos 5) one or more embryos are replaced into uterus 6) extra embryos frozen for future use 7) pregnancy test performed 2 weeks later to confirm

Question 27

Investigations to be done prior to IVF

Answer 27

Ovarian function and reserve - Day 3 FSH, E2, AMH Uterine cavity architecture - HSG, SHG or hysteroscopy Tubal status (rule out hydrosalpinx) - HSG, contract SHG/larparoscopy thyroid status (aim for 1-2.5, miscarriage risk increases with abnormal TSH) Semen parameters Antral follicle count - for initial FSH dosage BMI - affect treatment outcome significantly if >35 Other - prophylactic antibiotics, concomitant meds, prenatal supplements, herbs, other supplements

Question 28

IVF - oocyte recruitment and growth

Answer 28

FSH/LH administered by daily s/c injection --> promote growth of several ovarian (antral) follicles Each follicle at maturity will contain 1 oocyte Generally require between 9-12 d befoer majority of follicles reach mature size (17-18mm in mean diameter) >3 reach mature size FOllicular number and growth monitored during stimulation using ultrasound/serum estradiol Concomitant medication - prevent developing oocytes from ovulating spontaneously before retrieval (prevent own LH surge)

Question 29

IVF - Triggering of oocyte maturity

Answer 29

majority of follicles reach mature size hCG administered by s/c injection --> mimics biological effect of LH in natural menstrual cycle - oocyte undergo first meiotic division with extrusion of first polar body (haploid oocyte) oocyte to break away from follicular wall and float freely in follicular fluid

Question 30

Oocyte retrieval

Answer 30

performed 34-36 hours after the trigger shot each follicle aspirated using an aspiration needle connected to a collection tube performed vaginally with ultrasound guidance - aspiration needle passed through a needle guide attached to US probe Needle advanced through vaginal wall into ovary, then into a follicle (ovary adjacent to vaginal wall) needle then passed form one follicle to next and fluid from each drained into collection tube

Question 31

Oocyte identification

Answer 31

each follicular aspirate passed to an embryologist for immediate examination When a cumulus-oocyte complex is identified, some of excess cumulus is cut away/oocyte then placed into oocyte culture medium

Question 32

Oocyte insemination

Answer 32

Semen sample obtained/thawed from bank Preparation process of sperm Depending on quality/quantity of semen, oocytes are then exposed to sperm by either: - adding a number of sperm to culture medium containing each egg (IVF) - single sperm is selected and injected into each egg (ICSI) ICSI is employed when sperm quality/quantity is less than ideal, and fertilization could potentially be impaired if IVF was used

Question 33

Oocyte culture

Answer 33

Inseminated sperm placed into an incubator which is strictly controlled for temperature as well as CO2, O2 and nitrogen concentration Fertilization confirmed by examining each oocyte after 18 h of incubation Presence of 2 pronuclei = fertilization Replaced into incubator, grown to 3rd or 5th day of development - on day 3, genetics of embryo must be functional, so sperm genetics must be working at this time Embryo development monitored by various means - daily examination (appearance/morphology) or by a continuous method (morphokinetics/embryoscope)

Question 34

Morphokinetics

Answer 34

quantifying dynamics of morphological changes correlates with embryo's sustained implanatation potential ``` Time of pronuclei appearance TIming of cell divisions Synchrony of cell divisions Duration of cell cycles Aneuploidy prediction strategies based on morphokinetic algorithms ```

Question 35

Embryo replacement/transfer

Answer 35

Not all embryos have potential to develop to 5th day (blastocyst stage) If an embryo reaches day 5 --> best chance of implantation Many factors influence decision regarding # of embryos to replace/timing of transfer Always best to balance chance of pregnancy against risk of a multiple pregnancy since multiple pregnancy considered a complication of IVF Choice of transfer catheter personal embryos deposited between 1-1.5 cm from top of endometrial cavity Woman receives progesterone either vaginally/im for support of luteal phase, and for a variable length of time afterward depending on pregnancy status Extra embryos frozen by vitrification

Question 36

Elimination of disease in IVF

Answer 36

pre-implantation genetic diagnosis (PGD) - single gene defects, chromosomal abnormalities Pre-implantation genetic screening (PGS, CCS) recurrent pregnancy loss, recurrent failed implantations of embryos, women over 40 oocyte rejuvenation - ovarian stem cells embryonic stem cell research gene therapy