Reproductive treatments Flashcards
(88 cards)
1
Q
How do you treat primary hypogonadism?
A
Difficult to treat
2
Q
What is secondary hypogonadism?
A
deficiency of gonadotrophins ie hypogonadotrophic hypogonadism
3
Q
How do you treat secondary hypogonadism?
A
Treat with Gonadotrophins (ie LH and FSH) to induce Spermatogenesis
4
Q
What does LH stimulate in men?
A
Leydig cells to increases intratesticular testosterone to much higher levels than in circulation (x100)
5
Q
What does FSH stimulate in men?
A
FSH stimulates seminiferous tubule development and spermatogenesis
6
Q
What should you avoid giving to men desiring fertility?
A
Testosterone as decrease negative feedback so decrease LH and FSH even further and decrease spermatogenesis
7
Q
What happens if you give men with secondary hypogonadism testosterone?
A
lower LH / FSH further and further reduce spermatogenesis
8
Q
What treatment should you give instead?
A
- Give hCG injections (which act on LH-receptors)
* If no response after 6 months, then add FSH injections
9
Q
How do you treat Kallmann syndrome?
A
- . (not had mini puberty shortly after birth )
- FSH during mini-puberty important for growing the pool of immature spermatogonia and germ cells
- 2-4 months pretreatment with FSH before hCG treatment.
- Pretreatment Testicular size (Seminiferous tubules) ie testicular volume >6ml have better prognosis
10
Q
What do you give if the man is not desiring fertility?
A
•Daily Gel eg Tostran
-Care not to contaminate partner
•3 weekly intramuscular injection (eg Sustanon)
•3 monthly intramuscular injection (eg Nebido)
•Less Common (Implants, oral preparations)
11
Q
What are the symptoms of low testosterone?
A
loss of early morning erections, libido, decreased energy, shaving
12
Q
What is the diagnosis of low testosterone?
A
- At least 2 low measurements of serum testosterone before 11am
- Investigate the cause of low testosterone
13
Q
Why can testosterone replacement be unideal?
A
- Increased Haematocrit (risk of hyperviscosity and stroke)
* Prostate (Prostate Specific Antigen (PSA) levels) - don’t wanna overstimulate
14
Q
What happens in ovulation induction? What happens if more than one follicle is stimulated?
A
- Aim to develop one ovarian follicle
- If >1 follicle can develop, this risks multiple pregnancy (ie Twin / Triplet)
- Multiple pregnancy causes risks for mother and baby during pregnancy
15
Q
What is the aim of ovulation induction?
A
increase FSH by a small amount
16
Q
How could you restore ovulation in PCOS?
A
- Lifestyle / Weight Loss / Metformin
- Letrozole (Aromatase inhibitor)
- Clomiphene (Oestradiol receptor antagonist)
- FSH stimulation
17
Q
What is the overview process of IVF?
A
- Oocyte retrieval
- Fertilisation in vitro
- Embryo incubation
- Embryo transfer
18
Q
What percentage of pregnancies are unplanned?
A
- 19-30% of pregnancies are unplanned
2. Highest abortion rate- 2.8% in women aged22yrs
19
Q
What are methods of contraception?
A
- 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
20
Q
What are permanent methods of contraception?
A
- Vasectomy
* Female sterilisation
21
Q
What are the benefits of condoms?
A
- Easy to obtain – free from clinics
- No need to see a healthcare professional
- Protect against STI’s
- No contra-indications as with some hormonal methods
22
Q
What are the negatives of condoms?
A
• Can interrupt sex • Can reduce sensation • Can interfere with erections • Some skill to use properly eg ensure no air, not too large or small. • Two are not better than one
23
Q
What are the positive of the OCP?
A
• Easy to take – one pill a day (any time of day) • Effective • Doesn’t interrupt sex • Can take several packets back to back and avoid withdrawal bleeds • Reduce endometrial and ovarian cancer • Weight Neutral in 80% (10% gain, 10% lose)
24
Q
What are the negatives of OCP?
A
- It can be difficult to remember
- No protection against STIs
- P450 Enzyme Inducers may reduce efficacy
- Not the best choice during breast feeding
25
What are the possible side effects of OCP?
```
• Spotting (bleeding in between periods)
• Nausea
• Sore breasts
• Changes in mood or libido
• Feeling more hungry
(try different OCPs to see which suits best)
```
26
What are the rare side effects of OCP?
Blood clots in the legs or lungs (2 in 10,000)
27
What are the non-contraceptive uses for OCP?
1. Helps make periods lighter and less painful (eg endometriosis or period pain or menorrhagia)
2. Withdrawal bleeds will usually be very regular
3. PCOS: help reduce LH and hyperandrogenism
28
What are the positives of POP?
1. Works as OCP but less reliably inhibits ovulation
2. Often suitable if can't take oestrogen
3. Easy to take – one pill a day, every day with no break
4. It doesn’t interrupt sex
5. Can help heavy or painful periods
6. Periods may stop (temporarily)
7. Can be used when breastfeeding
29
What are the negatives of POP?
1. Can be difficult to remember
2. No protection against STIs
3. Shorter acting – needs to be taken at the same time each day
30
What are the possible side effects of POP?
* Irregular bleeding
* Headaches
* Sore breasts
* Changes in mood
* Changes in sex drive
31
What is an IUD?
-Intra-Uterine Device (IUD)
1. Copper Coil- mechanically prevent implantation,
decrease sperm egg survival
2. Lasts 5-10yrs.
3. Can cause heavy periods, and 5% can come out especially during first 3months with periods.
32
What is an IUS?
- secretes progesterone (eg Mirena Coil) to thin lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding)
- Last 3-5yrs
33
What are the positive and negatives of coils?
1. Coils are suitable for most women including Nulliparous (no previous children)
2. Exclude STI’s and cervical screening up to date before insertion
3. Prevent implantation of conceptus – important for some religions
4. rarely can cause ectopic pregnancy
5. Can be used as emergency contraception
34
What are implants?
Progestogen-only injectable contraceptives or subdermal implants
35
Can the IUD be used as emergency contraceptive?
- Copper intrauterine device (IUD) most effective
| - can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
36
What is ellaOne? How does it work?
-Emergency contraceptive pill, ulipristal acetate 30 mg (ellaOne)
•Ulipristal acetate stops progesterone working normally and prevents ovulation.
•Must be taken within 5 days of unprotected intercourse (earlier better).
37
What is levonelle? How does it work?
1. Emergency contraceptive pill, levonorgestrel 1.5 mg (Levonelle) least effective (esp if BMI >27 kg/m2)
2. Synthetic Progesterone prevents ovulation (don’t cause abortion).
3. Must be taken within 3 days of unprotected intercourse.
38
What are the side effects of emergency contraception?
- headache, abdominal pain, nausea.
- Liver P450 Enzyme inducer medications make it less effective.
- If vomit within 2-3hrs of taking it, may need to take another
39
What is the risk of VTE? What comorbidites need to be considered?
```
-Risk of Venous Thromboembolism (VTE) / CVD / Stroke
Comorbidities- Avoid OCP if:
•Migraine with aura (risk of stroke)
•Smoking (>15/day) + age >35yrs
•Stroke or CVD history
•Current Breast cancer
•Liver Cirrhosis
•Diabetes with retinopathy/nephropathy/neuropathy
```
40
What other things should you consider for choice of contraception?
1. Other conditions that may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids
2. Need for prevention of Sexually Transmitted Infections (STI’s)
3. Concurrent medication — P450 liver enzyme-inducing drugs (eg anti-epileptics, some antibiotics)
-Teratogenic drugs (eg lithium or warfarin), more effective methods of contraception needed
(eg progestogen-only implant, or intrauterine contraception).
41
What are the risks of HRT?
1. Venous Thrombo-embolism eg Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
2. Hormone sensitive cancers
3. Increased risk of cardiovascular disease
4. Risk of stroke
42
How do you reduce the risk of DVT or Pe with HRT?
Transdermal estrogens are safer for VTE risk than oral
43
Why is breast cancer a risk with HRT?
1. Slight increase only in women on Combined HRT (ie oestrogen AND progesterone)
2. Risk related to duration of treatment and reduces after stopping
3. Continuous worse than Sequential
4. Assess Background risk in the individual woman before prescribing
44
What is ovarian cancer a risk with HRT?
Small increase in risk after long-term use
45
When should you avoid oral oestrogens?
BMI > 30 kg/m2
46
How do you start HRT?
1. start with 0.025 mg estradiol transdermal preparation or oral estrogen (0.5 mg estradiol daily) depending on the patient's preference
2. If required, dose is increased at monthly intervals to 0.05 mg transdermal estradiol or 1 mg oral estradiol
3. For severe HFs, 0.05 mg transdermal estradiol can be used from the beginning.
47
Why are oral oestrogen not as safe in HRT?
* Oral oestrogens undergo first pass metabolism in liver
| * Oral >> Increase SHBG, Triglycerides, CRP
48
Why do you prescribe progesterone to people in HRT for women with an endometrium?
synthetic progestins
| and the natural hormone progesterone, for endometrial cancer prevention
49
What could post menopausal bleeding indicate?
endometrial cancer
50
Is it important to asses HRT?
- Assess HRT Safety / Efficacy at 3 months and then annually
| - Unscheduled bleeding is common within first 3 months.
51
What is the risk of cardiovascular disease with HRT?
1. No increased risk if started before age 60 yrs
2. Increased risk if started 10 years after menopause
3. Possible benefits of oestrogen supplementation in young women e.g. Premature Ovarian Insufficiency (POI)
52
What is the risk of stroke (cerebrovascular disease) with HRT?
* Small increased risk
* Oral > transdermal oestrogens
* Combined > oestrogen only
53
What are the benefits of HRT?
1. Relief of symptoms of low oestrogen
eg Flushing, disturbed sleep, decreased libido, low mood,
2. Less osteoporosis related fractures
decreased by one third
54
What is cisgender?
Same Sex and Gender
55
What is gender non-conforming?
Gender does not match assigned sex
56
What is gender dysphoria?
when that causes depression
57
What is non-binary?
Gender does not match to traditional binary gender understanding,
includes agender, bigender, pangender, gender fluid.
58
What is transgender?
Transitioning or planning to transition physical appearance from one to another
59
What is transgender male?
Female Sex at birth, but male gender (FtM is no longer used)
60
What type of transgender is more common?
Transgender women 3x more common than transgender men
61
How do you treat transgender in prepubertal young people?
1. Prepubertal Young people – GnRH agonist for pubertal suppression and then sex steroids.
2. Post-treatment regret 1-2%
3. Gender Reassignment surgery after 1-2 yrs of hormonal treatment
62
What are masculinising hormones for transgender men?
1. Testosterone (injections, gels)
- Side effects: Polycythaemia, lower HDL, Obstructive Sleep Apnoea (OSA) - no increase in CVD)
2. Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)
63
What happens in 1 to 6 months for transition to male?
* Balding (depending on your age and family pattern)
* Deeper voice / Acne / Increased and coarser facial and body hair
* Change in the distribution of your body fat
* Enlargement of the clitoris
* Menstrual cycle stops
* Increased muscle mass and strength
64
What are the feminising hormones?
- Estrogen (transdermal, oral, intramuscular)
| - High dose oestrogen eg 4-5mg per day to aim for estradiol levels of 734 pmol/L.
65
What are side effects of feminising hormones?
1. VTE dose-related at 2.6%
2. high BP
3. Cardio-Vascular Disease
4. high Triglycerides,
5. hormone sensitive cancers eg breast cancer
6. abnormal Liver Function tests 3%
66
What do you need to reduce for transgender women? and How?
1. Testosterone
•GnRH agonists (induce desensitization of HPG axis)
•Ant-Androgen medications (eg Cyproterone acetate, Spirnolactone)
67
What will not change for transgender women?
1. Height, voice and Adams apple will not change.
| 2. Consider Sperm Banking before you start hormone therapy.
68
What happens in 1 to 3 months for transgender women?
- Decrease in sexual desire
- function (including erections)
- Baldness slows
- may reverse
69
What happens in 3 to 6 months for transgender women?
- Softer skin and Change in body fat distribution
- Decrease in testicular size
- Breast development and tenderness
70
What happens in 6 to 12 months for transgender women?
Hair may become softer and finer
71
How does letrozole (aromatase inhibitor) work?
1. Inhibits aromatase in ovary and usual aromatase which catalyses the conversion of testosterone to oestradiol
2. Therefore low oestradiol level
3. Oestrodiol normally causes negative feedback on hypothalamus and pituitary gland
4. Therefore decreased negative feedback so more GnRH and therefore LH/FSH released
5. Increased FSH stimulates follicle growth
72
How does oestradiol receptor antagonist work e.g. clomiphene?
1. Blocks oestradiol receptors on hypothalamus and pituitary
2. Then reduces negative feedback from oestradiol so increase GnRH and FH and LSH
3. Increased FSH stimulates follicle growth
73
What happens in oocyte retrival?
1. Give high dose of FSH, to stimulate growth of lots of follicles
2. Then retrieve eggs from ovaries
74
What are the two different ways of fertilisation?
1. In vitro (IVF)
| 2. Intra-cytoplasmic sperm injection (ICSI) - when problem with sperm (select one sperm and inject directly into egg)
75
How long do you incubate embryo?
3-5 days
76
How do you stop premature ovulation in IVF after giving high dose of FSH?
Give medicine to prevent premature LH surge
77
What is the short protocol?
- First way of preventing LH surge
| 1. GnRH antagonist (blocks GnRH, reduce LH surge)
78
What is long protocol?
- Second way of preventing LH surge
| 1. GnRH agonist, give longer
79
How can both a GnRH agonist or a GnRH antagonist be used to block an LH surge?
1. GnRH if given pulsatile, LH stimulation
| 2. If give non-pulsatile GnRH get initial flare and then LH inhibition
80
How do you mature eggs before you collect them?
Give LH
81
What happens in egg maturation?
Metaphase I (diploid) gives to Metaphase II (haploid) - polar body rebased so can now receive sperm
82
How can you trigger egg maturation?
Give hCG acts on LH receptors
83
What is a side effect of hCG and IVF?
- Long time in body
| - Cause excessive ovarian stimulation so cause ovarian hyper stimulation syndrome (OHSS)
84
What is OHSS?
-Ovaries start to make chemicals that make blood vessels leaky
85
What can happen in OHSS?
1. Pleural effusion
2. Ascites
3. Renal failure
4. Ovarian torsion
86
What is chemical process of short IVF cycle?
1. Day 2 give high dose FSH
2. Day 6 give GnRH antagonist to stop LH going up too soon
3. Day 11: Trigger injection by hCG or GnRHa to form LH surge to mature eggs
4. Day 13: oocyte retrieval from ovary
5. Fertilise in vitro to form embryo
6. Day 18: Embryo transfer to endometrium
7. Day 30: pregnancy blood test
87
How does the OCP work?
1. Oestrogen and progesterone cause negative feedback on hypothalamus to reduces GnRH secretion
2. Decreased Lh and FSH
3. Cuasing annovulation
88
What else does progesterone do in OCP?
1. Thickening of cervical mucus
| 2. Thinning of endometrial lining to reduce implantation
