3.13 Reproductive Treatments

Question 1

Symptoms: loss of early morning erections, libido, decreased energy, no need to shave
Outline investigation and treatment.

Answer 1

Investigation: at least 2 low measurements of serum testosterone before 11am
Treatment: daily gel (care not to contaminate partner)
intramuscular injection (3 weekly or 3 monthly)

Question 2

What safety measure should be taken when taking testosterone?

Answer 2

increased haematocrit (risk of hyperviscosity and stroke)
prostate cancer (PSA)
= MONITOR BOTH

Question 3

How do we treat primary hypogonadism?

Answer 3

difficult

Question 4

How do we treat secondary hypogonadism?

Answer 4

treat with gonadotrophins to induce spermatogenesis
LH - stimulates Leydig cells to increase intratesticular testosterone (100x higher than circulation)
FSH - stimulates seminiferous tubule development and spermatogenesis

Question 5

What is the given treatment for secondary hypogonadism?

Answer 5

give hCG infections (which act on LH receptors)

if no response after 6 months then add FSH injections

Question 6

What is hCG?

Answer 6

Human chorionic gonadotrophin

Question 7

What is LH and FSH in PCOS?

Answer 7

LH - high

FSH - low

Question 8

What are the symptoms of PCOS?

Answer 8

irregular periods
hyperandrogenism (hirsutism/acne)
PCO morphology on ultrasound

Question 9

What is hypothalamic amenorrhea?

Answer 9

caused by not enough energy for fertility?

• low body weight
• excessive exercise
• stress
• genetic susceptibility

Question 10

How to treat fertility for PCOS?

Answer 10

ovulation induction - aim to develop one ovarian follicle

>1 follicle inc. risk of twins/triplets inc. risk for mother and baby

Question 11

How do we restore ovulation in PCOS?

Answer 11

1. Lifestyle/weight loss/metformin
2. Letrozole (aromatase inhibitor)
3. Clomiphene (oestradiol receptor modulator)
4. FSH stimulation

Question 12

How does letrozole work?

Answer 12

Letrozole is an aromatase inhibitor
= low oestrodiol
= less negative feedback
= increase GnRH
= LH+ FSH
FSH we want to stimulate follicle growth

Question 13

What does aromatase do?

Answer 13

converts testosterone to oestrodiol

Question 14

What is the role of oestrodiol?

Answer 14

provides negative feedback on hypothalamus and pituitary gland for LH/FSH function

Question 15

How does clomiphene work?

Answer 15

it is an oestrodiol receptor antagonist
= reduces negative feedback of oestrodiol
= by antagonising oestrodiol receptors
= increased GnRH
= increased LH/FsH

Question 16

What are the steps of IVF?

Answer 16

1. large dose FSH, induce folliced and collect eggs directly from ovary
2. fertilise eggs in vitro, or ICSI (sperm injection) for male factor infertility
3. embryo incubation
4. embryo transfer

Question 17

How do we trigger superovulation for IVF?

Answer 17

FSH injection

Question 18

Why do we have to prevent the premature LH surge?

Answer 18

to prevent premature ovulation so eggs can be harvested for IVF

Question 19

What are the two main protocols for prevention of premature ovulation?

Answer 19

1. GnRH antagonist protocol (short protocol)

2. GnRH agonist (long protocol)

Question 20

What does the GnRH antagonist protocol (short protocol) involve?

Answer 20

FSH from day 2 until day 10

GnRH antagonist day 6 until day 10

Question 21

What does the GnRH agonist protocol (long protocol) involve?

Answer 21

FSH from day 2 until day 10

GnRH agonist day 21 of previous period until day 10

Question 22

In the short protocol, why does GnRH agonist be used to block an LH surge?

Answer 22

GnRH is usually pulsatile and so produces LH pulses

a continuous high dose (non-pulsatile) of GnRH has an initial flare of LH production then inhibits it afterwards

Question 23

What is oocyte maturation?

Answer 23

immature eggs at metaphase I and diploid
after exposure to LH
metaphase II and haploid

Question 24

Which hormone is used to induce oocyte maturation?

Answer 24

hCG (acts on LH receptors but much longer acting)

Question 25

How long do you have to wait in between triggering oocyte maturation and retrieval?

Answer 25

36 hours

Question 26

What % of pregnancies are unplanned?

Answer 26

19-30%

Question 27

How does the oral contraceptive pill work?

Answer 27

both oestrogen and progesterone negatively feedback on the hypothalamus and pituitary
= decrease LH+ FSH
= decrease ovulation
Progesterone also
- thickens cervical mucus
3. thinning of endometrial lining to reduce implantation

Question 28

What is the difference between the progesterone only pill and the oral contraceptive pill?

Answer 28

POP more shorter acting - more important to take at same time of day

• less reliably inhibits ovulation
• suitable if can’t take oestrgen
• can be used when breastfeeding

Question 29

What are 3 types of long-acting reversible contraceptives?

Answer 29

1. Intrauterine Device (IUD) - mechanically prevent implantation
2. Intrauterine Systems (IUS) - secrete progesterone (Mirena coil)
3. Progesterone only injectable contraceptives or subdermal implants

Question 30

Who are long active reversible contraceptives appropriate for?

Answer 30

all women (incl. nulliparous)
can be used as emergency contraception
prevent implantation of conceptus - important for some religion
can cause ectopic pregnancy

Question 31

How does the copper coil work?

Answer 31

mechanically prevent implantation

prevent sperm and egg survival

Question 32

How does the mirena coil work?

Answer 32

progesterone effects and can help with heavy periods
thicken cervical mucus
thin endometrial lining

Question 33

What is the most effective form of emergency contraception?

Answer 33

Copper IUD (up to 5 days)
Ulipristal acetate 30mg (ellaOne) - stops progesterone working normally and prevents ovulation (up to 5 days)
Levonorgestrel 1.5 mg (Levonelle) least effective esp if high BMI take 2, synthetic progesterone prevents ovulation (up to 3 days)

Question 34

What are side effects of emergency contraception

Answer 34

headache abdominal pain nausea
Liver P450 enzyme inducer medications make it less effective
if vomit within 2-3 hours take another

Question 35

What comorbidities should avoid the OCP due to risk of venous thromboembolism/CVD/stroke?

Answer 35

mi