Reproductive Treatments

Question 1

How easy is primary hypogonadism in males treated?

Answer 1

Hard to treat via hormones

Question 2

How is secondary hypogonadism in males treated? How does this help? (requiring fertility)

Answer 2

Gonadotrophins (LH/FSH)

Stimulates spermatogenesis

Question 3

What hormone stimulates testosterone via what cells?

Answer 3

LH stimulates it via leydig cells

Increases intratesticular testosterone to much higher levels

Question 4

What hormone stimulates spermatogenesis in what structure?

Answer 4

FSH in seminiferous tubules

Question 5

What injections for male infertility target LH receptors?

Answer 5

hCG injections (act on LH receptors)

Question 6

Does Congenital Secondary Hypogonadism have better, same or worse prognosis than Acquired Secondary Hypogonadism in males and why?

Answer 6

Worse- he has not gone through mini puberty

Question 7

When is testosterone replacement given?

Answer 7

If not desiring fertility

Testosterone lowes FSH/LH so reduces spermatogenesis

Question 8

What testosterone replacements are available?

Answer 8

Daily gel- tostran
3 weekly IM injections
3 monthly IM injection
Less common: implants, oral preparations

Question 9

What do we have to monitor when giving testosterone replacement?

Answer 9

Observe haematocrit (risk of hyperviscosity and stroke- stimulates erythropoiesis)
Prostate (PSA levels)

Question 10

How is fertility mainly improved for patients with PCOS?

Answer 10

Try to stimulate ovulation (ovulation induction) via development of one ovarian follicle (avoids multiple pregnancy as this has risks for mother and baby)
We aim to cause a small increase in FSH

Question 11

How is ovulation induction encouraged?

Answer 11

1. Lifestyle / Weight Loss / Metformin
2. Letrozole (Aromatase inhibitor)
3. Clomiphene (Oestradiol receptor antagonist)
4. FSH stimulation (injection)

Question 12

How does letrozole/ aromatase inhibitor/ oestradiol receptor antagonist work?

Answer 12

Reduces negative feedback from oestradiol
Aromatase inhibitor prevents conversion from testosterone to oestradiol
This increases FSH and stimulates follicle growth

Question 13

How does IVF work?

Answer 13

High dose of FSH to stimulate eggs
Prevent premature ovulation via GnRH agonist/antagonist
Give LH to allow egg maturation
Retrieve oocyte from ovary
Fertilisation in vitro or intracytoplasmic injection of sperm
Embryo incubation
Embryo transfer

Question 14

When is intracytoplasmic injection of sperm (ICSI) used and what is it?

Answer 14

When theres a problem with the sperm, inject one sperm into an egg

Question 15

What do we do to premature ovulation in IVF?

Answer 15

Prevent it by giving medicine to prevent premature LH surge

Question 16

How is premature LH surge prevented in IVF?

Answer 16

Via GnRH antagonist (short protocol) or GnRH agonist (long protocol) - if given GnRH in a non pulsatile way LH is inhibited

Question 17

How are eggs matured in IVF and where?

Answer 17

By giving LH (activates the oocyte maturation promoting factor, MPF and oocyte chromosome segregation) then hCG (promotes VEGF and neovascularization)

They should still be in the ovary

Question 18

What happens in egg maturation?

Answer 18

Egg goes from metaphase 1 to metaphase 2 - goes from diploid to haploid

Question 19

How does Ovarian hyperstimulation syndrome occur?

Answer 19

Due to long lasting hCG during IVF

Question 20

How does Ovarian hyperstimulation syndrome present?

Answer 20

Pleural effusion
Ascites
Renal failure
Ovarian torsion

Cause: increased renin and VEGF (vascular endothelial growth factor) so more fluid moving into interstitial space

Question 21

What are methods of contraception?

Answer 21

Barrier: male / female condom/ diaphragm or cap with spermicide
Combined Oral Contraceptive Pill (OCP)
Progestogen-only Pill (POP)
Long Acting Reversible Contraception (LARC)
Emergency Contraception

Permanent methods:
Vasectomy
Female sterilisation (hysterectomy)

Question 22

What are positives of the oral contraceptive pill (OCP)?

Answer 22

Easy to take 
 Effective
 Doesn’t interrupt sex
 Can take several packets back to back and avoid withdrawal bleeds
 Reduce endometrial and ovarian cancer

Question 23

What are negatives of the OCP?

Answer 23

It can be difficult to remember
No protection against STIs
P450 Enzyme Inducers may reduce efficacy (OCP metabolised by p450)
Not the best choice during breast feeding

Question 24

What are side effects of the OCP?

Answer 24

Spotting (bleeding in between periods)
 Nausea
 Sore breasts
 Changes in mood or libido 
 Feeling more hungry

Question 25

What are non contraceptive uses of the OCP?

Answer 25

Lighter/less painful periods | PCOS (reduces LH and hyperandrogenism)

Question 26

What is the progesterone only pill (mini pill)?

Answer 26

Works as OCP but less reliably inhibits ovulation Often suitable if cant take oestrogen Can be used when breastfeeding

Question 27

What are negatives of the mini pill?

Answer 27

Can be difficult to remember No protection against STIs Shorter acting – needs to be taken at the same time each day

Question 28

What are the common long acting reversible contraceptives (LARCs)?

Answer 28

IUD (copper coil)- decreases sperm survival and prevents implantation Intra-uterine systems- secretes progesterone which thins lining of sperm and thickens cervical lining Progestogen-only injectable contraceptives or subdermal implants

Question 29

What are the emergency contraceptives?

Answer 29

IUD Emergency contraceptive pill : Ulipristat acetate 30mg (ellaOne) within 5 days, Levenorgestrel 1.5mg (Levonelle) within 3 days- less effective

Question 30

What are side effects of emergency contraception?

Answer 30

Headache, abdominal pain, nausea Liver p450 enzyme inducer medication makes it less effective If vomit in 2-3 hours of taking need to take another

Question 31

What should we consider when chosing contraception?

Answer 31

Risk of venous thromboembolism Other conditions Need for prevention of STIs Concurrent medication e.g. P450 liver enzyme inducing medication

Question 32

What are risks of HRT?

Answer 32

1. Venous thrombo embolism- use transdermal oestrogens if this is the case (oral oestrogens go past first pass metabolism in liver so can increase clotting factors along with SHBG, triglycerides and CRP) 2. Hormone sensitive cancers: Slight increase in risk for breast cancer only on combined HRT (assess risk before prescription), small increase in ovarian cancer risk after long term use, highest risk is endometrial cancer 3. Cardiovascular disease: no inc. risk if started before 60yrs, inc. risk if started 10 years post menopause 4. Small risk of stroke: risk is higher when taking oral over transdermal oestrogens and higher when taking combined over oestrogen only.

Question 33

What must we give to women with an endometrium on HRT? Why?

Answer 33

Progesterone- to prevent endometrial cancer (sometimes presents with post menopausal bleeding) Oestrogen thickens endometrium (risk of cancer) so progesterone thins it Assess HRT safety/ efficacy at 3 months then annually

Question 34

What are benefits of HRT?

Answer 34

Relief of symptoms of low oestrogen | Less osteoporosis related fractures (decreased by 1/3)- oestrogen promotes activity of osteoblasts

Question 35

How is gender different to sex?

Answer 35

Gender- what you identify as, its a social construct | Sex- biological

Question 36

What is gender dysphoria?

Answer 36

When gender non conforming causes distress

Question 37

What are treatments for supporting transgender males/females?

Answer 37

Trans Men- Testosterone injections or gels, progesterone to suppress menstrual bleeding Trans Women- high dose oestrogen, reduce testosterone via GnRH agonists (desensitisation of HPG axis- make GnRH non-pulsatile) and anti androgen medication

Question 38

If there is no response to hCG injections for sperm induction after 6 months what should be given?

Answer 38

Add FSH injections

Question 39

What are positives of condoms?

Answer 39

Protect against STI's Easy to obtain- free from clinics Non contraindications as not hormonal

Question 40

What are negatives of condoms?

Answer 40

``` Can interrupt sex Can reduce sensation Can interfere with erection Some skill to use Two aren't better than one ```

Question 41

How does the OCP work?

Answer 41

Causes anovulation Thickens cervical mucus Thickens endometrial lining to reduce implantation

Question 42

With what conditions should you avoid OCP?

Answer 42

``` Migraine with aura Smoking Stroke or CVD Current breast cancer Liver cirrhosis Diabetes with complications ```

Question 43

What is cisgender?

Answer 43

Same sex and gender

Question 44

What is gender non-conforming?

Answer 44

Gender that doesn't match assigned sex

Question 45

What is the effect of taking masculinising hormones for transgender men?

Answer 45

``` Balding Deeper voice/ acne/ increased coarser facial and body hair Change in distribution of body fat Enlargement if clitorus Menstrual cycle stops Increased muscle mass and strength ```

Question 46

What is the effect of feminising hormones for transgender women?

Answer 46

Height, voice and adams apple will not change Consider sperm banking before taking therapy 1-3 months: decrease in sexual desire/ function / baldness slows or may reverse 3-6 months: softer skin/ change in body fat distribution/ decrease in testicular size/ breast development/ tenderness 6-12 months: hair may become softer and finer

Question 47

What are 2 causes of irregular periods?

Answer 47

PCOS | Hypothalamic amenorrhea

Question 48

What are causes of hypothalamic amenorrhea?

Answer 48

Stress Excess exercise Low body weight Genetic susceptibility

Question 49

How does the OCP work?

Answer 49

Increases progesterone which neg. feedbacks on hypothalamus to decrease GnRH which decreases LH and FSH- no LH surge so follicle is lost and ovulation prevented. Progesterone also thickens cervical mucus- hard for sperm penetration Increases Estrogen which neg. feedbacks to ant. pituitary to dec. FSH secretion

Question 50

What is a possible sign of endometrial cancer?

Answer 50

Post menopausal bleeding