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L1 – Case Launch
SBA – Describe the current recommended antenatal care schedule and tests
SBA – Describe the cause of and screening for sub-fertility in males and females
SAP – Describe the clinical investigations used to assess female and male infertility
SBA – Describe techniques that can be adopted to assist pregnancy in sub-fertility
SAP – Describe techniques that can be adopted to assist pregnancy in mitochondrial disease
SAP – Describe the emotional issues associated with assisted conception
The timeline of an uncomplicated pregnancy is as followed: 1. 31 weeks
7. Booking >> with midwife ideally before 10 weeks - Review, discuss and record the results of screening tests
- BMI undertaken at 28 weeks
- Urine, bloods and BP recording 2. 34 weeks
- Identify women who may need additional care - Review, discuss and record results of screening tests
- Identify women with risk factors for pre-eclampsia undertaken at 28 weeks
- Arrange testing for gestational diabetes for women with risk - Offer second dose of antigen-D treatment to women who
factors are rhesus D-negative
- Discuss all antenatal screening tests and ultrasound 3. 36 weeks
- Offer influenza vaccination - Check position of baby
- Give information and support - Offer specific information for breast feeding, care for new-
- Discuss mental health issues borns, new-born screening tests
- Identify women who have had genital mutilation 4. 38 weeks
- Discuss vitamins for pregnancy - Offer specific information for risk of pregnancies and
- Antenatal screening and source support options
- Screening for Down’s syndrome 5. 40 weeks
- Ultrasound scans - Offer specific information about risk of pregnancies
8. 16 weeks - Offer a membrane sweep
- Review, discuss and record the results of all screening tests 6. 41 weeks
undertaken - Offer a membrane sweep
- Warn re-symptoms pre-eclampsia - Offer induction of labour between 41-42 weeks
- Offer pertussis vaccine
- Discuss foetal anomaly scan
9. 18-20 weeks Sub-fertility is a delay in conceiving. The causes of subfertility are outlined
- Ultra sound scan for structural abnormalities below:
10. 25 weeks 1. Causes in males
- Measure and plot symphysis-fundal height - Cown’s syndrome
11. 28 weeks - Undescended testes
- Offer a second screening for anaemia and atypical red-cell - Steroid abuse
alloantibodies - Use of protein shakes associated with lower sperm count
- Adyspermia which is a production of sperm problem or
12. 31 weeks
blockage
- Review, discuss and record the results of screening tests 2. Causes in females
undertaken at 28 weeks - Female age >> risk of miscarriage
- Hormone levels
, - Poly cystic ovary syndrome 3. Male/female factor
- Stress >> hypothalamus cause - IUI >> intrauterine insemination – tertiary care
- Over exercise >> hypothalamus cause a. Requires patent fallopian tubes and reasonable
- Anorexia >> hypothalamus cause sperm
- Tumour >> pituitary cause a. Sperm sample is prepared and is inserted into
- Women without a uterus uterus via a catheter
- Blocked fallopian tubes - IVF >> in vitro fertilisation
a. Used to treat a wide rage of fertility issues e.g.
tubal, ovulatory, male or a combination
Investigations for male and female infertility depends on circumstances, e.g. older b. Sperm and egg will fertilise in a dish and is
women should investigate at 6 months, healthy couples should investigate after 12 inserted via a soft catheter into the uterus
months c. Success rates are strongly associated with female
age
Initial investigations for men and women are described below: - ICSI >> intracytoplasmic sperm injection
1. Female a. Useful for male factor infertility
- Progesterone level b. Prepared sperm sample is viewed under a
- Anti-müllerian hormone microscope and a single sperm is selected and
- FSH LH injected into the centre of each mature egg
- Oestrogen c. More invasive
- Testosterone level - FET >> Frozen embryo transfer
- Uterus ultrasound scan >> Tubal patency testing a. Super-numery embryos of goof quality can be
- cryopreserved either by slow freezing or
2. Male vitrification and stored in LN2
- Testosterone level b. Good survival rates and gives comparable success
- Semen analysis rates to treatments using fresh embryos
- Sperm test >> concentration, motility and morphology - Embryo selection
The techniques that can be adopted to assist pregnancy in sub-fertility is outline 4. Tailored treatments
below: - Surgical sperm retrieval
1. Male factor infertility - Donor eggs, sperm and embryos
- Obstructive Azode >> surgical correction of epididymal blockage - Single women, same sex couples
can restore normal sperm counts - Shared motherhood, surrogacy
- Hypogonadotropic hypogonadism >> drugs - Genetic testing of embryos
- Ejaculatory or Erectile problems can be improved by medication - Fertility preservation
of psychological therapy - Posthumous reproduction
2. Female factor The assisted pregnancy techniques adopted in mitochondrial disease are
- Ovulation induction >> give clomiphene citrate and outlined below:
gonadotrophins to restore hormone levels 1. Mitochondrial donation
- Clomiphene citrate is an anti-oestrogen and corrects by producing - Three parent embryos
FSH and LH which stimulates the ovaries - Take the mothers egg and father’s sperm and a donor
- Clomiphene acts in the hypothalamus where it depletes the egg and transfer the mitochondrial DNA into the faulty
hypothalamic oestrogen receptors and blocs the negative feedback mother’s egg
effect of circulating endogenous oestradiol which results in and - Highly regulated process
increase in hypothalamic gonadotrophin releasing hormone pulse 2. IVF based techniques
frequency and circulating concentrations of FSH and LH 3. Voluntary childlessness
, 4. Adoption
5. Egg donation
- Egg from donor and use a sperm from partner
- Embryo inserted into mother
6. Pre-implantation diagnosis
- Egg with mitochondriol disease and sperm form embryo
- Fertilise multiple eggs
- Select egg with the lowest chance of mutation
7. Pronuclear transfer
- 3 parent babies
Fertility as a journey creates many emotional challenges prior to medical advice.
The following describes the journey:
- Waiting
- Loss
- Investigations: blood, semen, transvaginal scans and these are
invasive
- Preparation: health, diet and alcohol
- Anxiety
- Funding
The journey of infertility is physically and emotionally challenging and patients do
not know how long it will take to resolve their issues.
The following can cause emotional issues with infertility and assisted conception:
1. Individuals or couples
- Isolation or lack of support
- Past grief and loss memories may be triggered
- Past abuse
- Mood and emotional reactions e.g. depression and anxiety
disorders
- Anticipating future loss
2. Relationship
- Power balance
- Communication may fail
- Identity and self esteem
- Lack of intimacy
- Sex as a chore/no sex
- Psychosexual issues
- Sexual dysfunctions
Patient experiences are described below:
- Depression and suicidality
- Detrimental impact on relationships with partner
- Feeling frustrated and out of control
- Post-traumatic stress
- Anxiety
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