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Phase 2: Reproduction, Nephrology and Urology > Lecture 6: Assisted Reproductive Technology > Flashcards

Lecture 6: Assisted Reproductive Technology Flashcards

1
Q

What is the epidemiology of inferility?

A

1 in 7 heterosexual couples

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2
Q

What is infertility?

A

It is when a couple has not achieved pregnancy after one year of unprotected vaginal intercourse in the absence of known causes of infertility in women of reproductive age

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3
Q

What is the “holy triad” of reproductive physiology in the female?

A

Refers to the:

  1. Ovaries- ability to produce viable oocytes
  2. Uterine tubes- to be patent (open and unobstructed)
  3. Uterus- to be receptive to the embryo
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4
Q

What is the major factor that increases the risk inferility?

A

Maternal age

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5
Q

What is the first thing to do when managing a patient with fertility issues?

A

Take a history

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6
Q

What questions do you need to ask a women when taking a history for fertility issues?

A
  • AGE!!
  • Parity- how many times has she been pregnancy before.
  • Date of last menstrual cycle
  • Regular periods
  • Last smear test
  • Past medical history
  • Family history

And many more

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7
Q

What questions do you need to ask a men when taking a history for fertility issues?

A
  • Age
    • Not as significant
  • Previous injuries to the genitals.
  • Occupation
    • Driving long distances is thought to increase risk of infertility as the temperature rises the temperature of the testes.
  • Any other children
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8
Q

In regards to fertility, at what age does the chances of a female becoming naturally or IVF pregnancy dramatically reduce?

A

35 years old

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9
Q

Name some life factors that can reduce fertility in both males and females?

A
  • Weight
  • Smoking
  • Alcohol
  • Recreational drugs
  • STIs
  • Toxins/radiation exposure e.g. previous cancer (even in childhood)
  • Tight garments
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10
Q

What investigations would the GP conduct to manage patients with fertility issues?

A
  • Rubella status
  • Chlamydia/Gonorrhoea swabs
  • BMI
  • Cervical smear (if required)

Refer to specialist if none of these are a problem

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11
Q

Which other bodily systems (except the reproductive tract) can have an impact of fertility (in both males and females)

A

Multiple other systems

  • Hypothalamus- part of the HPG axis
  • Pituitary- part of the HPG axis
  • Thyroid- endocrine function that influences of body homeostasis
  • Parathyroid- endocrine function
  • Thymus- endocrine function
  • Adrenals- produces androegns and oestrogens
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12
Q

What must we assess for in the ovary for a women with fertility issues?

A

We assess:

  1. Ability of the ovaries are releasing eggs.
  2. Measure number of follicles
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13
Q

How can we tell if an ovary is releasing an egg?

A
  1. Determine if the women is having normal menstrual cycles
  2. Assess if there is a progesterone peak at day 21
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14
Q

The World Health Organization (WHO) classifies ovulation disorders into 3 group. Describe the 3 groups?

A

Group I: hypothalamic pituitary failure. Associated with low levels of FSH, LH and oestrogen activity.

Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome). The hormones are being produced but the process is dysfunctioning

Group III: ovarian failure. In this group, the women are not producing any oocytes

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15
Q

What are the treatment options for WHO Group I ovulation disorders?

A
  • They can improve their chance of regular ovulation, conception and an uncomplicated pregnancy
  • Treatment:
    • Lifestyle changes- e.g. increase weight is BM < 19.
    • Pulsatile administration of GnRH or gonadotrophins with LH activity to induce ovulation.
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16
Q

What are the treatment options for WHO Group II ovulation disorders?

A
  • Depends on the underlying causes of the dysfunction
      • They can improve their chance of regular ovulation, conception and an uncomplicated pregnancy.
  • Treatment:
    • Clomifene citrate- useful in patients with polycystic ovarian syndrome (PCOS)
    • Metaformin
    • Combination of clomifene and metaformin
    • Lifestyle changes- reduce BMI >30
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17
Q

What are the treatment options for WHO Group III ovulation disorders?

A

As the ovaries are no longer producing oocytes, the only treatment option is oocyte donation.

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18
Q

Define primary infertility?

A

Refers to a couple who have not become pregnant after one year of unprotected vaginal intercourse in the absence of known causes of infertility in women of reproductive age

19
Q

Define secondary infertility?

A

Refers to a couple who have been able to get pregnant previous (at least once), but now have not become pregnant after one year of unprotected vaginal intercourse in the absence of known causes of infertility in women of reproductive age

20
Q

What is the use of testing for anti-Mullerian hormone?

A
  • Measured in a blood sample
  • Produced by the granulosa cells
  • Good indicator of the ovarian reserve
    • Low levels suggest a low ovarian reserve
    • In menopause women, the levels are undetectable
21
Q

Low levels of anti-Mullerian hormone indicates which process is not occuring?

A

Ovulation is not likely to happen as there is a low level of oocyte reserve

Indicate premature ovarian failure (in women below the age of menopause)

22
Q

How can we measure the number of follciles in an ovary?

A

Ultrasound is used, which can image the secondary and dominant follicles.

Can see if the patient has polycystic ovarian syndrome

23
Q

What must we assess for in the uterine tubes for a women with fertility issues?

A

Assess if an occyte is able to pass through the tube.

The uterine tube must be patent (open and unobstructed)

24
Q

Name some clinical conditions that can effect the uterine tubes, causing fertility issues?

A
  • Hydrosalpinx- blockage of the uterine tube with watery fluid.
    • Potential cause is chlamidya
  • Pelvic inflammatory disease- sign of infection
  • Endometritis
25
Q

How do we assess the uterine tube ability?

A
  • Hysterosalpingogram (HSG)
    • X-ray procedure- contrast material is injected, which moves into the uterine tube. X-ray is used, which by imaging the contrast material, can tell the ability of the uterine tube to allow material to pass.
  • HyCoSy
    • Similar mechanism however using ultrasound instead.
  • Laparoscopy and dye test
    • Tube with a camera goes into the uterus. The de will be injecteed, which you can see if it can see if the uterine tubes are blocked
26
Q

In specialised clinics, what is the three stages of assess a women with fertility issues?

A

Stage 1: Assess the ovary ability

If stage 1 is clear, move onto stage 2

Stage 2: Assess uterine tube

If stage 2 is clear, move onto stage 3

Stage 3: Assess the uterus

If stage 3 is clear, then the fertility may be due to the male or the cause is unknown.

27
Q

What must we assess for in the uterus for a women with fertility issues?

A

How receptive the uterus is to the embryo

If there is significant progesterone to support the endometrium

28
Q

What is the treatment options if the uterus is not receptive due to lack of progesterone support?

A

Offer extra progesterone at the window of implantation (around day 21) to induce implantation

29
Q

Why can endometriosis have a significant effect on the receptiveness of the uterus?

A

With endometriosis, adhesions can form on the surface of the uterus.

These adhesions can reduce the receptiveness of the uterus to the embryo

30
Q

When assess sperm, what are the 3 things we are looking for in regards to fertility?

A
  1. Is sperm being ejaculated
  2. Number/concentration of sperm
  3. Quality of the sperm
31
Q

What is the reference value for normal sperm morphology?

A

4%

Normally only 4% are normal looking

32
Q

What are the 3 classifications in regards to outcome of sperm analysis? which treatments are recommended for each

A
  1. Normal motility
    • Good number of normal sperm
    • Treatment: Suitable for IVF
  2. Oligospermia
    • Olgio- means few
    • Few normal sperm
    • Treatment: IVF with ICSI
  3. Azoospermia
    • ​No normal sperm present
    • Treatment: depends on underlying cause e.g. testis might be producing normal sperm but they are deformed during ejaculation
33
Q

Describe why cystic fibrosis males sometimes have fertility issues?

A
  • Cystic fibrosis is highly associated with bilateral absence of the duct deferens.
  • Absence of the duct deferens means that they are able to produce normal sperm but they sperm is not able to leave the body (via the duct deferens)
34
Q

If assessing semen anaylsis indicates azoospermia or aligospermia, what investigations must occur?

A

Genetic investigations

Assess other factors such as drug use

35
Q

Name the assisted reproductive technologies available for patients with fertility issues?

A
  • Intrauterine insemination (IUI)
  • In vitro fertilisation (IVF)
  • In vitro fertilisation with intracytoplasmic sperm injection (IVF with ICSI)
  • IVF with/without ICSI using donor gamete(s)
36
Q

If one uterine tube is blocked, what are the possible treatment options?

A
  • Cure underlying condition if possible e.g. infection
  • Selecive salpingography
    • Blockage of the effected tube
    • Can improve chances of natural conception
  • Assisted reproductive technology
37
Q

Describe the intra-uterine insemination (IUI)?

A
  • This involves injecting, via catheter, the sperm into the uterus at the correct time for fertilisation.
    • Sperm from the partner or donor is washed and prepared
    • Pregnancy test after 2 weeks to assess if successful.
  • Requires careful monitoring of the menstrual cycle to assess when ovulation has occured
  • Can involved ovulation induction
38
Q

Describe the steps of in vitro fertilisation (IVF)?

A

Step 1- Ovarian stimulation hormone therapy, inducing the ovary to produce more than 1 dominant follicle.

Step 2- Ultrasound through the vagina to image the follicles. Push a hollow needle through the ovary to collect the oocytes.

Step 3- Sperm is washed and prepared

Step 4- Occytes and sperms are introduced- fertilisation occurs.

Step 5- Embryo develops outside the uterus

Step 6- Embryo is transferred into the uterus, via a catheter. The stage of development in which the embryo is transferred in varies.

39
Q

Describe the process of ovarian hyperstimulation?

A
  • In order for a women to undergo IVF, her natural cycle must be suppressed in order to take control of it.
  • Suppress the natural cycle by either GnRH agonist or antagonist.
  • After the cycle has been suppressed, FSH injections are administered into the women
    • FSH stimulates the follicles to develop
    • High levels of FSH so more than one dominant follicle is formed
40
Q

When is IVF with ICSI used?

A

When there is a problem with the sperm

41
Q

What is the difference between IVF with and without ICSI?

A
  • Change in step 4 of IVF
  • Instead of the oocytes and the sperm meeting, a single sperm is injected directly into the oocyte. The sperm is released- causing the fertilisation.
  • The needle causes no damage to the oocyte.
42
Q

What risks are associated with IVF?

A

Ovarian hyperstimulating syndrome

43
Q

Describe ovarian hyperstimulating syndrome?

A
  • Possible complication of fertility treatment
  • The ovaries become overstimulated by the FSH injection
  • As a result, the ovaries become large and painful.
  • Can lead to an increased risk of pre-eclampsia
44
Q

What are grade bands of ovarian hyperstimulating syndrome?

A

Mild, moderate and severe

Phase 2: Reproduction, Nephrology and Urology (25 decks)

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