3.13 Reproductive Treatments Flashcards
Symptoms: loss of early morning erections, libido, decreased energy, no need to shave
Outline investigation and treatment.
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)
What safety measure should be taken when taking testosterone?
increased haematocrit (risk of hyperviscosity and stroke) prostate cancer (PSA) = MONITOR BOTH
How do we treat primary hypogonadism?
difficult
How do we treat secondary hypogonadism?
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
What is the given treatment for secondary hypogonadism?
give hCG infections (which act on LH receptors)
if no response after 6 months then add FSH injections
What is hCG?
Human chorionic gonadotrophin
What is LH and FSH in PCOS?
LH - high
FSH - low
What are the symptoms of PCOS?
irregular periods
hyperandrogenism (hirsutism/acne)
PCO morphology on ultrasound
What is hypothalamic amenorrhea?
caused by not enough energy for fertility?
- low body weight
- excessive exercise
- stress
- genetic susceptibility
How to treat fertility for PCOS?
ovulation induction - aim to develop one ovarian follicle
>1 follicle inc. risk of twins/triplets inc. risk for mother and baby
How do we restore ovulation in PCOS?
- Lifestyle/weight loss/metformin
- Letrozole (aromatase inhibitor)
- Clomiphene (oestradiol receptor modulator)
- FSH stimulation
How does letrozole work?
Letrozole is an aromatase inhibitor = low oestrodiol = less negative feedback = increase GnRH = LH+ FSH FSH we want to stimulate follicle growth
What does aromatase do?
converts testosterone to oestrodiol
What is the role of oestrodiol?
provides negative feedback on hypothalamus and pituitary gland for LH/FSH function
How does clomiphene work?
it is an oestrodiol receptor antagonist = reduces negative feedback of oestrodiol = by antagonising oestrodiol receptors = increased GnRH = increased LH/FsH
What are the steps of IVF?
- large dose FSH, induce folliced and collect eggs directly from ovary
- fertilise eggs in vitro, or ICSI (sperm injection) for male factor infertility
- embryo incubation
- embryo transfer
How do we trigger superovulation for IVF?
FSH injection
Why do we have to prevent the premature LH surge?
to prevent premature ovulation so eggs can be harvested for IVF
What are the two main protocols for prevention of premature ovulation?
- GnRH antagonist protocol (short protocol)
2. GnRH agonist (long protocol)
What does the GnRH antagonist protocol (short protocol) involve?
FSH from day 2 until day 10
GnRH antagonist day 6 until day 10
What does the GnRH agonist protocol (long protocol) involve?
FSH from day 2 until day 10
GnRH agonist day 21 of previous period until day 10
In the short protocol, why does GnRH agonist be used to block an LH surge?
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
What is oocyte maturation?
immature eggs at metaphase I and diploid
after exposure to LH
metaphase II and haploid
Which hormone is used to induce oocyte maturation?
hCG (acts on LH receptors but much longer acting)
How long do you have to wait in between triggering oocyte maturation and retrieval?
36 hours
What % of pregnancies are unplanned?
19-30%
How does the oral contraceptive pill work?
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
What is the difference between the progesterone only pill and the oral contraceptive pill?
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
What are 3 types of long-acting reversible contraceptives?
- Intrauterine Device (IUD) - mechanically prevent implantation
- Intrauterine Systems (IUS) - secrete progesterone (Mirena coil)
- Progesterone only injectable contraceptives or subdermal implants
Who are long active reversible contraceptives appropriate for?
all women (incl. nulliparous)
can be used as emergency contraception
prevent implantation of conceptus - important for some religion
can cause ectopic pregnancy
How does the copper coil work?
mechanically prevent implantation
prevent sperm and egg survival
How does the mirena coil work?
progesterone effects and can help with heavy periods
thicken cervical mucus
thin endometrial lining
What is the most effective form of emergency contraception?
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)
What are side effects of emergency contraception
headache abdominal pain nausea
Liver P450 enzyme inducer medications make it less effective
if vomit within 2-3 hours take another
What comorbidities should avoid the OCP due to risk of venous thromboembolism/CVD/stroke?
mi
