The big picture 2

Question 1

Aims

Answer 1

• Definition of infertility
• Management of infertility
• Causes of infertility in male and female
• Treatments
• Assisted conception clinically and IVF lab
• Current advances in embryology

Question 2

What it infertility considered as?

Answer 2

No conception after 12 months of intercourse

Question 3

What is the background pregnancy rate after one year and after two years?

Answer 3

Background pregnancy rate is 80% after one year and 95% after two years

Question 4

Whats the stats for couples affected by infertility?

Answer 4

Affects 1 in 7 couples

Static prevalence for 20 years

Question 5

As more couple seek help, are they going through psychological stress?

Answer 5

Yes

Question 6

What is an effective treatment with infertility?

Answer 6

Assisted conception

Question 7

What is the management with infertility?

Answer 7

• No-one is at fault or to blame
• Deal with the infertile couple together
• Investigate with GP, infertility clinic the ACU to give prognosis, explanation, and plan
• Confirm ovulation, sperm quality and tubal patency

Question 8

If a couple present with infertility, what things is taken into account/ looked into?

Answer 8

Preconception lifestyle

• BMI, smoking, alcohol, supplements- folic acid for women, drug history, cervical smear history for women, surgical history for both

Presence of eggs/ sperm

Fallopian tube patency

Question 9

If women are having ovulation problems, what could be some main reasons for this?

Answer 9

• Hypothalamic
• Pituitary
• Endocrine
• Ovarian

Question 10

Tell me about some reasons for hypothalamic ovulation problems?

Answer 10

Stress

Excessive exercise (doesn’t produce signals to send to pituitary)

Weight change

Question 11

What are some reasons for pituitary ovulation problems?

Answer 11

Hyperprolactinaemia and Cerebral irradiation

Question 12

What are some reasons for endocrine ovulation problems?

Answer 12

Hypo- or hyper- thyroidism (want thyroid to make thyroxin as this is important for brain development in baby)

Question 13

What are some reasons for ovarian ovulation problems?

Answer 13

Failure: Ageing (>40 issues)

Genetic (eggs chromosome could affect how eggs form)

Cytotoxic treatment
Autoimmune

Surgical

Polycystic ovaries (follicles as opposed to cysts, resistant to stimulation)

Question 14

What is the main function of the fallopian tube?

Answer 14

Picks up eggs, transports eggs and sperm, sperm capacitation, egg fertilisation, early embryonic development

Has cilia which move egg and sperm in their directions

Question 15

What can cause problems with the fallopian tube?

Answer 15

Infection, miscarriage, LSCS, IUCD appendicitis, chlamydia, gonorrhea

Malformations

Ectopic pregnancies

Sterilization

Endometriosis

Question 16

What is endometriosis?

Answer 16

With endometriosis, bits of the uterine lining (endometrium) — or similar endometrial-like tissue — grow outside of the uterus on other pelvic organs. Outside the uterus, the tissue thickens and bleeds, just as typical endometrial tissue does during menstrual cycles

Question 17

Semen parameters- WHO 2021 reference ranges

Answer 17

Question 18

There can be problems with sperm, what are some reasons for reduction in the production of sperm?

Answer 18

Maldescent

Ischaemia (twisting of testis)

Trauma

Mumps

47XXY (Klinefelter’s, when baby was made the chromosome haven’t separated. This baby can have fertility problems)

Question 19

What are some other sperm and male problems that can occur?

Answer 19

Obstruction of ducts from testis

Disorders of accessory glands of genital tract

Disturbances of sexual function

High proportion of abnormal sperm i.e., no heads, 2 tails etc.

Question 20

What sorts of things cna cause an obstruction of the ducts from the testis?

Answer 20

Infection

anatomical

Cystic fibrosis (sticky secretion of mucus memrbanes which blocks the vas deferens)

vasectomy

Question 21

Sometimes there is unexplained infertility in IVF clinics, this is getting smaller in time but some research was carried out that was focussing on specific problems with what?

Answer 21

• Implantation
• Early embryonic growth
• Development

Question 22

What are the treatments for infertility and what is included under each one?

Answer 22

Lifestyle - BMI / stress/ nutrition / toxins

Ovulation treatments - anti-oestrogens (clomiphene citrate: what it does?) / Gonadotrophins

Donor sperm - no sperm/genetic/ WWM (women without men- single or female couples)

Donor eggs - genetic, age, male couples

Assisted conception - unexplained, tubal, male factor

Surrogacy - no uterus, male couples, pregnancy issues (cancer, born without a uterus, miscarriages, premature babies)

Embryo adoption - both male and female problems (means embryos aren’t thrown away as this isn’t allowed in some countries)

Child adoption - from UK and abroad

Question 23

What is the IVF protocol?

Tell me a bit about each stage as to what it entails

Answer 23

Superovulation: more FSH as an external injection to make ovaries make eggs. Calculate so too many eggs aren’t made. Can do FSH and LH in combination but not as common. FSH can be genetically engineered

Monitoring (monitor uterine lining)

Oocyte retrieval (ultrasound used and eggs obtained using a needle)

Insemination

Embryo transfer into uterus

Question 24

What are some of the main problems with IVF?

Answer 24

• Cost (roughly £6,000 as a baseline, if more complex things required then could be up to £10,000)
• Stress
• Complications of drugs
• Complications of egg recovery
• Complications of embryo transfer (can still get ectopic pregnancies, can end up with twins and triplets)
• Laboratory errors i.e., wrong sperm, wrong egg, wrong embryo
• OHSS (ovarian hyperstimulation)
• Multiple pregnancies (now focus on putting one embryo on at a time rather than multiple now)
• Normal Babies???

Question 25

On Lab day 0 what are the main processes that occur?

Answer 25

* Egg collection and sperm preparation * Insemination

Question 26

Tell me about the egg collection and sperm preparation during lab day 0

Answer 26

* need sperm and egg on this day * 36 hours after HCG trigger has been given * Can’t use neat semen as contains other things other than sperm that you don’t want in petri dish * Semen contains decapacitation factors that we need to separate sperm from * Find name of technique to get sperm * Centrifugal force used to remove supernatant, wash pellet, spin again, pellet used for insemination

Question 27

Tell me about insemination during lab day 0

Answer 27

**IVF** has egg with zona pellucida surrounding and cells and sperm **ICSI** use enzyme to remove cumulous cells to have naked egg; want to do this to be able to clamp egg when injecting sperm, ensuring egg is mature, only inject mature eggs, expect 80% of eggs to be mature

Question 28

What happens during lab day 1?

Answer 28

Fertilisation check

Question 29

During the fertilisation check what is looked for and tell me about each type

Answer 29

Question 30

What happens during lab day 1-6?

Answer 30

Embryo development

Question 31

Tell me about the stages of embryo development and the rough timeline for each

Answer 31

Morula: cells divided to such an extent they squish into each other Usually transfer embryos on 2 or 3 but this was shown not best as uterus wasn’t prepared to take them. Now put into day 5/6 so into better environment for egg to survive Embryo genome switched on by day 3, especially the sperm so contributes to embryo morphology, so if embryo doesn’t get to this stage then wont transfer as won’t make a baby

Question 32

What are the optimal culture conditions for IVF?

Answer 32

**Temperature** 37˚c (+/- 2˚c) **Gas mix** CO2 (6%)- appropriate pH of 7.3/7.4 O2 (5%)- oxygen bad for embryos, embryos can’t handle more and won’t grow and may reduce implantation rates Visible light- embryos don’t like blue spectrum light, **red is okay** **Embryo scope incubator used** Observe embryos in real time so that temp and pressure isn’t affected from having to take them out to look under microscope Creates a more stable environment for the embryo

Question 33

Culture medium for IVF contents (don't need to learn but good to be aware)

Answer 33

Question 34

What is used for the morphological assessment and selection of the embryos for IVF?

Answer 34

Question 35

What happens on lab day 5?

Answer 35

Embryo transfer

Question 36

The following graph shows the Birth rates per embryo transferred 1991-2019 Why is there an increase in birth rates %?

Answer 36

* Optimal culture conditions (incubator type, temperature, gas max and quality control) * Commercial production of culture media (pharmaceutical standards) * Toxicity testing of lab consumables

Question 37

What happens with embryo biopsies?

Answer 37

Pre-Implantation Genetic Screening- Aneuploidy (PGT-A)

Question 38

Whats Aneuploidy and how is this done?

Answer 38

Aneuploid is abnormal chromosome number in a haploid set * Test DNA amplified by PCR * Amplicon spliced & hybridised with reference DNA – * Next Generation Sequencing * * Allows quantification of chromosomes & aneuploidy detection * Mosaic has a mixture or normal and abnormal cells

Question 39

More PGT-A data

Answer 39

Question 40

Morphokinetic assessment- embryo selection algorithms

Answer 40

Question 41

What is the applications of IVF to the fertile couple?

Answer 41

* Fertility Preservation: Pre-chemotherapy (Ovarian tissue / Oocyte / Embryo cryopreservation). * Family planning: Pre-vasectomy sperm cryopreservation. * Pre-implantation Genetic Diagnosis (PGD) * Treatment of Mitochondrial disease

Question 42

With pre-implantation genetic diagnosis, what do they look for?

Answer 42

* Diagnosis of single gene disorders * Non sex linked - probes designed for specific disease mutation in PCR amplified embryo biopsies * Sex linked- aCGH & numerical chromosome assessment (as per PGS) * Currently 1346 conditions licenced for screening by the HFEA

Question 43

What are some ethical concerns with IVF?

Answer 43