Fertility Control Flashcards
Give the 3 most common contributors to subfertility:
- ovulatory problems
- male problems
- tubal problems
- unexplained
Elevated serum levels of ____ in the mid-luteal phase can indicate ovulation has occured
-progesterone
hence this is called the mid-luteal phase serum progesterone
what are the 3 criteria of which 2 need to be present to make a diagnosis of polycystic ovarian syndrome?
- PCO on ultrasound
- irregular periods (>35 days apart)
- hirsutism clinical or biochemical (raised testosterone)
Women w PCOS have disordered LH production and insulin resistance so to compensate produce more insulin.
- what effect does raised LH and insulin have on the polycystic ovaries?
- raised insulin also leads to increased adrenal _____ production and reduced hepatic production of __ ___ __ ___ (—-) leading to increased free androgen levels
- increased ovarian androgen production from PCOs
- increased adrenal androgen production, reduced steroid-hormone binding globulin (SHBG)
What effect does high intra-ovarian androgen levels have on folliculogenesis and ovulation ?
-excess small ovarian follicles and the polycystic ovarian picture with irregular or absent ovulation
In PCOS FSH levels will be normal. What about AMH levels? Suggest 2 other investigations you may do when investigating PCOS:
AMH is high in PCOS
- TVUS
- testosterone, prolactin, TSH levels
- fasting lipids and glucose to screen for complications
What malignancy is more common in those with PCOS due to many years of amenorrhoea due to unopposed oestrogen action?
Endometrial cancer increased risk
Hypothalamic hypogonadism is when low GnRH release -> amenorrhoea (low FSH/LH and low E2 levels follow)
- give 2 environmental causes and 1 genetic cause
- suggest how to treat this
- anorexia nervosa, secondary to diets, female athletes, those under stress
- treat with restoration of body weight
- genetic = Kallman’s syndrome
- exogenous GnRH pump to induce ovulation
Pituitary damage/tumour can lead to which hormone excess that affects ovulation?
suggest 2 sx
- hyperprolactinaemia reduces GnRH
- sx: oligo/a-menorhoea, galactorrhoea, headaches and bitemporal hemianopia if tumour
Hyperprolactinaemia can be medically treated with what class of drugs, give example -this usually restores ovulation
-Dopamine agonists e.g. cabergoline, bromocriptine
Premature ovarian insufficiency: as ovary fails E2 and ____ levels fall, so reduced negative feedback leads to which hormones rising?
NB: on US scan the antral follicle count will be very low
- inhibin levels fall
- FSH and LH rise
What is the 1st line ovulation induction drug in PCOS? what hormone does it antagonise to increase gonadotrophin release?
Clomifene, an anti-oestrogen that blocks E2 receptors int he hypothalamus and pituitary, so more FSH and LH is released
What is an alternative to Clomifene in PCOS which can restore ovulation and treats hirsutism at the same time?
NB: can also be used jointly with clomifene as increases the effectiveness
Metformin
Describe briefly the process of exogenous gonadotrophin induction of ovulation:
- recombinant FSH/LH given by daily subcut injection, stimulates follicular growth
- follicular development monitored with US
- once follicle is adequate size for ovulation (~17mm) injection of hCG or LH artificially stimulates the process
what risk is associated with gonadotrophin stimulation of the follicles which leads to pain especially in attempting IVF, in younger women and in those with PCO
-how is this risk reduced?
-OHSS: ovarian hyperstimulation syndrome (follicles overstimulated -> very large and painful)
-reduce risk by using lowest effect gonadotrophin dose, US monitoring of follicular growth, if growth is excessive withdraw injections for a few days or cancel the cycle of IVF
NB: OHSS can be fatal (!).. hypovolaemia, electrolyte disturbance, VTW, pulmonary oedema….
Give 4 causes of abnormal semen analysis:
- smoking
- alcohol
- drugs
- chemical
- inadequate local cooling
- genetic factors
- antisperm antibodies
suggest 2 drugs that can effect sperm/male fertility
- sulfasalazine
- anabolic steroids
- exposure to industrial chemicals esp solvents
- alcohol
does varicocele affect fertility?
yes, usually occurs on the left, varicosities of pampiniform plexus
-surgery does not improve fertility
Antisperm antibodies are common after what surgery?
Reversal of Vasectomy
Give 4 causes of male subfertility
- infections e.g. epididymitis, mumps orchitis
- testicular abnormalities e.g. in Klinefelter’s XXY
- obstruction to delivery e.g. congenital absence of vas with CF
- hyperprolactinaemia
- retrograde ejaculation into bladder
Give 3 ways male subfertiity can be managed in a couple trying to conceive:
- lifestyle changes (drug exposure, loose clothing, testicular cooling)
- intrauterine insemination (IUI)
- if more severe oligospermia then IVF
- if v severe then intracytoplasmic sperm injection (ICSI)
- if azoospermia, can extract sperm from testes, surgical sperm retrieval (SSR)
- donor insemination
IUI can be used to bypass the cervix if it is the cause of failure to fertilise.
Suggest 1 reason cervical factors could contribute to adhesion formation
- women producing antibodies that agglutinate or kill the sperm
- infection in vagina/cervix that prevents adequate mucus production
- cone biopsy
If someone is starting contraception in the day 1-5 of the cycle (even if they have UPSI during these days) what contraceptives will be effective immediately?
Any/all hormonal contraceptives
If someone is starting contraception outside/after day 1-5 of the cycle, double protection with barrier methods are required for ____ days with hormonal contraception except ___ which you only need barrier methods for ___ days
- 7 days
- except Progesterone Only Pill (POP)
- 2 days
