Infertility

Question 1

What’s the definition of Infertility?

How many couples are affected?

Answer 1

“Failure to conceive after 12months of unprotected intercourse.

1/4 couples.

Question 2

How many kids are we expected to have on average in NZ

Answer 2

2.2

Question 3

___% of women are childless by choice at midpoint of childbearing years

Answer 3

17%

Question 4

What is done to assess Male Fertility?

Done before woman

Answer 4

A semen Analysis!

Lower Reference Points to Infertility:

• S.Count: <15mill/ml
• Motility: <40% progressive and non-progressive
• Volume <1.5ml
• Total # Sperm <39mill in ejaculate (should be 100-300M)

Question 5

What is done to Assess female fertility?

Answer 5

1. Ovulation: to see she’s ovulating and has a functioning corpus Luteum
   
   • Check E₂ day 12
   • Check P₄ day 21
   • FSH day 2-4 <10IU/I
   • AMH anti-mullerian hormone (only done last 5-10y via age related graph)
2. Timing (not frequency) of Intercourse: Only 16% population and 27% clients know when they are ovulating. Be careful with wording! “do you have it at least 2 times around the women’s fertile period?”
   ​​

Question 6

Causes of infertility in %

Answer 6

Unexplained 20%

Male 30%

Female 30%

Both 20%

Question 7

What are the 6 causes of Female Infertility?

Treatment for each?

Answer 7

1. Anovulation
   
   • Weight gain/loss
   • Drugs
2. PCOS
   
   • metformin, clomiphene citrate or FSH
   • IVF
3. Tubal disease
   
   • Surgery
   • IVF
4. Cervical problems
   
   • IUI
5. Endometriosis
   
   • IVF
   • Ablation or hormone contraceptives
6. Premature menopause (rising FSH and decr AMH with age)
   
   • donor egg
7. No uterus
   
   • surrogacy

Question 8

What drugs are used to treat Anovulation?

Answer 8

• GnRH
• Clomiphene citrate: used to be 1^st line treatment, now outdated and SERM (non-steroidal) used
• FSH
• Letrazole: Aromatase inhibitor → decreases amount of estrogen. Better for a single not multiple ovulation

Question 9

What is PCOS

Answer 9

• Multiple cysts/follicles on ovary cortex
• Often infrequent/no period
• Weight gain is common as it’s a metabolic syndrome

First line treatment = WEIGHT LOSS
then metformin (insulin sensitiser), CC, FSHn or IVF

Question 10

What can cause tubal Defects

Answer 10

1. Blocked tubes: often by infection or STI; (clamhydia)
2. Also Fibroids, cysts/tumours, endometriosis, tubal pregnancy

Question 11

Describe the Steps involved in IVF

Answer 11

1. Ovarian Stimulation
   
   • Stimulation: FSH
   • Control: prevent ovulation via GnRH antagonist
   • Trigger: stimulate Ovulation via HCG or GnRH agonist (whilst trying to avoid fatal overactive ovaries)
   • Luteal support: progesterone (to balance the system)
2. ​Egg Retrival: 36h post stimuli
3. Sperm preperation and Fertilisation
4. Embryo Culture
5. Embryo Transfer: day 3-5
6. Embryo Freezing: day 5 is the earliest you can do this!

Question 12

How does age affect the cumulative pregnancy rate of IVF

(chance of success with every embryo picked from one lot)

Answer 12

<35 is 51%

35-39 is 45%

40+ is 25%

So once in your 40’s it’s a massive failure rate!

Question 13

IVF cycle tracking

Answer 13

Scans: day 1, 5 and 9

Daily injection of ovarian stimulation drugs: Days 1-10

Daily injections of antagonist: Days 5-10

Egg +sperm implanted Day 12

Blood tests look at Estrogen (~1000m/follile) and progesterone (<6pmol/L)

Question 14

Fertilised embryo becomes unique embryo when ___

Answer 14

8cell.

Question 15

What are the pro’s of the recent innovation of ‘Time Lapse Photography and single step media”

Answer 15

• Undisturbed culture from external environ.
• Individual embryo tracking of cell division: can see hidden abnormalities
• Algorithms predict those with best potential
• Provides full info instead of snapshiot selection

Question 16

The four main causes of Male infertility?

Answer 16

1. Oligospermia (decr. sperm conc)
   
   • ICSI
   • Donor Sperm (cheaper)
2. OATS (oligoasthenoteratospermia; low Sperm conc, and slow, no much you can do!)
   
   • ICSI
   • Donor Sperm
3. CAVD congenital absence of the Vas Deferens
   
   • ICSI
4. Azoospermia (no sperm)
   
   • Treatment dependent on type

Question 17

What are the differing types and therefore treatments for Azoospermia (NO sperm)

Answer 17

1. Kallman’s Syndrome (no GnRH) → FSH/LH replacement
   delayed puberty and impaired sense of smell
2. No spermatogenesis → Donor insemination
3. Obstuctive or Vasectomy → reversal, PESA or TESA + ICSI
4. Non-Obstuctive → TESE + ICSI

PESA: percutaneous epididymal sperm aspiration
TESA: Testicular sperm aspiration
TESE: testicular sperm extraction

Question 18

What is ICSI

Answer 18

in vitro fertilization (IVF) procedure in which a single sperm is injected directly into an egg.

Via a big microscope

Question 19

Steps involved in ICSI in sperm vs egg

Answer 19

Sperm:

1. Select motile sperm with normal morphology
2. Immobilize sperm
3. aspirate sperm tail first
4. Position sperm in needle

Egg:

1. Position PB at 12o’clock
2. suction pipette
3. insert needle into egg
4. rupture egg membrane by aspirating
5. expel the sperm
6. culture overnight

Question 20

What do you do about unexplained infertility?

Answer 20

Mild stimulation with IUI or IVF and hope for the best!

Question 21

Whats the impact of Age on fertility?

Answer 21

Leading underlying cause of infertility

>40year eggs have more mitochondrial issues and chromosome defects (Pre-implantation Genetic Screening (PGS))

Age of first child is increasing; ~30year in NZ

Due to pressure: social, financial, career and lack of knowledge

Education is key; do the AMH testing

Question 22

What’s PGS

Answer 22

Pre-implantation Genetic Screening

1. Trophoectoderm biopsy day 5/6
2. Freeze ALL biopsied embryos
3. tube the 8-10 cells
4. amplify
5. Next generation sequencing
6. Analysis results
7. Thaw and transfer unaffected euploid embryo

Question 23

Describe in more depth the day 5/6 trophectoderm biopsy for PGS

Answer 23

Page 54

Question 24

What’s the pros/cons of EGG FREEZING

Answer 24

• Less succesful then embryo freezing
• Vitrification more successful then slow freezing
• Need ~10 eggs frozen to achieve pregnancy
• Chemo and radiation
• Social egg freezing

Question 25

What are some final alternative solutions

Answer 25

Surrogacy Donor embryo Adoption Moving on