Safety and Efficacy of ART

Question 1

define Assisted Reproductive Technologies (ART)

Answer 1

• all interventions that include in vitro handling of both human oocytes and sperm or of embryos for purpose of reproduction

Question 2

define In Vitro Fertilsation (IVF)

Answer 2

• example of an ART
• a sequence of procedures
• that involves fertilisation of gametes external to body (in vitro)
• includes conventional in vitro insemination (combination of sperm and eggs for natural fertilsation in dish in lab)
• includes intracytoplasmic sperm injection (ICSI) (direct injection of a single spermatozoon into oocyte; common for male factor infertility)

Question 3

what is ovulation induction

Answer 3

• requires pharmacologic treatments to induce ovulation

Question 4

what is ovulation induction and ovarian stimulated used to treat

Answer 4

infertility

Question 5

examples of ovulation induction medcaitions

Answer 5

clomiphene, letrozole

Question 6

what is ovarian stimulation

Answer 6

• administration of gonadotrophins (FSH, LH) to stimulate growth and maturation of multiple follicles / oocytes
• exogenous trigger (hCG) to stimulate ovulation

Question 7

what can be used after ovulation induction or ovarian stimulation

Answer 7

intrauterine insemination (IUI)

Question 8

what is intrauterine insemination (IUI) used for

Answer 8

• fertilisation of ovulated oocytes (single or multiple)

(ovulated oocytes due to ovulation induction or ovarian stimulation)

Question 9

what is involved with IUI

Answer 9

• sperm placement into uterus 24-36 hrs post-ovulation trigger

Question 10

what cases is fertility treatment of ovulation induction commonly used for

Answer 10

• anovulation cases
• to specifically induce ovulation alone

Question 11

chance of patient having a live birth within 3 cycles on clomiphene for ovulation induction if they have unexplained infertility

Answer 11

24-31%

Question 12

chance of patient with PCOS having a live birth within 5 cycles on clomiphene for ovulation induction if they have unexplained infertility

Answer 12

19.1%

Question 13

chance of patient with PCOS having a live birth within 5 cycles on letrozole for ovulation induction if they have unexplained infertility

Answer 13

27.5%
ie/ letrozole may have a higher success rate for live births for people with PCOS

Question 14

chance of patient having a live birth within 4 cycles using ovarian stimulation if they have unexplained infertility

Answer 14

32-33%

Question 15

what is ovarian stimulation simple

Answer 15

• production of multiple follicles and oocytes
• followed by ovulation induction

Question 16

is % cumulative live birth rate higher in ovulation induction methods or ovarian stimulation methods

Answer 16

ovarian stimulation

Question 17

[safety of ovulation induction] adverse effects of clomiphene

Answer 17

• hot flushes
• headache
• fatigue
• dizziness
• irritability
• thin endometrium (can impact success of implantation -> resultant embryo)
• visual disturbances
• multiple pregnancy (up to 12.5%) - steps to try to avoid

Question 18

what are the complications to the foetus from multiple pregnancy

Answer 18

higher risk of:
- premature birth
- intrauterine growth restriction
- prenatal death

Question 19

what are the complications to maternal from multiple pregnancy

Answer 19

increased risk of developing pregnancy complications such as:
- preeclampsia
- gestational diabetes
- haemorrhage during delivery

Question 20

[safety of ovulation induction] adverse effects of letrozole

Answer 20

• hot flushes
• headache
• fatigue
• dizziness
• irritability
• multiple pregnancy (up to 14.3%) - steps to try to avoid

Question 21

[safety of ovulation induction] is chance of multiple pregnancy higher in letrozole or clomiphene & then compare with gonadotropins with ovarian stimulation

Answer 21

• letrozole in ovulation induction
• between all, gonadotropins

Question 22

[safety of ovulation induction] what are differences in adverse effects between clomiphene and letrozole

Answer 22

same except letrozole:
- does not adversely affect endometrial thickness
- no visual disturbances

Question 23

[safety of ovarian stimulation] adverse effects of gonadotrophins:

Answer 23

• injection site reaction
• abdominal bloating / discomfort
• ovarian hyperstimulation syndrome (chance 1%-5% in each cycle)
• multiple pregnancy (up to 36%)

Question 24

[safety of ovarian stimulation] what can ovarian hyperstimulation syndrome lead to

Answer 24

• serious complication
• can lead to: ascites, electrolyte imbalance, hypercoagulability (-> risks)

Question 25

what is the trade off regarding ovarian stimulation

Answer 25

- ovarian stimulation gives you higher rate of live birth rate - but higher chance of multiple pregnancy due to potential for producing multiple oocytes

Question 26

overview of an IVF cycle

Answer 26

- ovarian stimulation (administration gonadotropins to produce multiple follicles and oocytes + ovulatory trigger hCG) - collection of mature oocytes using US guided needle aspiration - oocytes can be fertilised in vitro with collected sperm: either by conventional in vitro (combination) or intracytoplasmic sperm injection (direct) - result embryos cultured in vitro until blastocyst stage - embryo can be transferred back into uterus - hopefully establish pregnancy and live birth

Question 27

what are the conditions like in vitro and why

Answer 27

- optimised conditions and temperature to mimic maternal env

Question 28

efficacy of IVF in A&NZ

Answer 28

- 18% success - chance of taking home baby from an initiated ART cycle in A&NZ is ~1 in 5 cycles - despite continual increase demand of assisted reproductive cycles in A&NZ, success rate of IVF has not changed

Question 29

many ARTs added which can improve success of

Answer 29

IVF

Question 30

[safety of ovarian stimulation with IVF] compared to ovarian stimulation with intrauterine insemination, what are risks with IVF

Answer 30

- IVF reduces chance of multiple pregnancy as able to transfer single embryo back into uterus

Question 31

success of (different) fertility treatments relative to age

Answer 31

decreases as age increases guides clinical decision making - which treatment use

Question 32

which has higher live birth rates - ovulation induction / ovarian stimulation with IUI or ovarian stimulation w IVF

Answer 32

- ovarian stimulation w IVF

Question 33

if have very diminished ovarian reserve, what should be considered to do

Answer 33

- oocyte donation

Question 34

if older, patient may need to consider doing ___ as first course based on success rates

Answer 34

IVF

Question 35

is there risk of birth defects with use of IVF

Answer 35

- significant increased risk of birth defects in children conceived w IVF

Question 36

was the risk of birth defects in the use of IVF different for whether conventional in vitro insemination and intracytoplasmic sperm injection (ICSI)

Answer 36

no

Question 37

when adjusted for parental factors, what was the change in findings for risk of birth defects with IVF use

Answer 37

- that IVF with conventional in vitro insemination did not increase risk of birth defects - but that IVF with intracytoplasmic sperm injection (ICSI) did significantly increase birth defects even after adjusting for parental factors

Question 38

children born via natural conception vs ovulation induction show differences in congenital malformations - T or F

Answer 38

F

Question 39

multiple pregnancies resulting from ART are associated with what risk of congenital malformation

Answer 39

small but increased risk

Question 40

success rates for (different) fertility treatments vary depending on the

Answer 40

infertility diagnosis helps guide clinical decision making - which treatment should be used

Question 41

risk of multiple births following ART vs natural conception

Answer 41

increased -> lead to risk of adverse outcomes (neonate / maternal)