Fertility Flashcards

1
Q

What are the 2 gonadotrophic hormones secreted by the pituitary gland?

A

FSH and LH

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2
Q

What does FSH do in males and females?

A

Males: testes to produce sperm via stimulation of sertoli cells
Females: growth of ovarian follicles and causes the ovary to secrete oestrogen

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3
Q

What is the role of LH in males and females?

A

Males: testes secrete testosterone via leydig cells
Females: ovulation and causes progesterone to be produced by the corpus luteum

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4
Q

How does testosterone act on the anterior pituitary and hypothalamus?

A

Negative feedback to reduce the production of LH and FSH

Negative feedback on hypothalamus to reduce the production of GnRH

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5
Q

How does oestrogen feedback?

A

Estrogen below 200 will exert a negative feedback

Oestrogen above 200 will exert a positive feedback of LH and FSH

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6
Q

What is GnRH?

A

Neuropeptide hormone synthesized and released from the GnHR neurones within the hypothalamus and is released in a pulsatile manner

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7
Q

Describe the relationship between GnRH pulses and release of FSH and LH

A

Oestrogen contractions above 200 will increase GnRH pulsatility driving the release of LH.
During the early menstrual cycle, GnRH frequency is spaced out so only FSH is released, once the frequency is quicker there will be subsequent release of LH

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8
Q

Explain GnRH during puberty?

A

Appropriate modulatio nof LH freuqncy is essential for puberty and reproductive function. The onset of pubertal maturation is associated with a steady acceleration in GnRH pusatility with a peak at night

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9
Q

What is considered delayed puberty?

A

In females, no period by 15
In males, no sign of testicular development by 14
Moderated by the activation of GnRH frequency

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10
Q

What are the 2 cycles of the menstrual cycle?

A

Follicular / proliferative phase

Luteal / secretory phase

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11
Q

What mediates the follicular phase?

A

FSH

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12
Q

What mediates the luteal phase?

A

Corpus luteum and therefore progesterone

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13
Q

What is day 1 of the menstrual cycle?

A

First day of menstrual bleeding

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14
Q

When is the LH surge and what does it do?

A

Day 14
Influences the follicle to produce progesterone
As progesterone increases it will shut off the production of LH

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15
Q

What is a follice?

A

An oocyte surrounded by follicular cells (granulosa and theca cells)
Growth of a follice is an increase in the number of follicular cells and the accumulation of follicular fluid

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16
Q

How does the endometrium change over the menstrual cycle?

A

Thickens under the influence of oestrogen and becomes a secretory tissue under the influence of progesterone

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17
Q

What receptors are found on theca and granulosa cells?

A

Theca cells: LH

Granulosa cells: FSH

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18
Q

What occurs in the granulosa and theca cells?

A

FSH acts on the enzyme aromatase to convert the androgen in oestrogen within the granulosa cell
Cholesterol is converted to androgen in the theca cell

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19
Q

How many oocytes are recruited within each menstrual cycle?

A

5/6
These will all grow but only the dominant follicle will be selected for ovulation. The dominant oocyte might be the one that is most vascular or has the most FSH receptors

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20
Q

How long after the LH surge does ovulation occur?

A

Approx. 34-36 hrs

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21
Q

How is the corpus luteum formed?

A

Following ovulation, release of an oocyte and follicle will convert into corpus luteum (full of cholesterol to produce progesterone).
Within the corpus luteum there are no granulosa and theca cells as under the influence of LH will transfer into luteal cells

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22
Q

What are the roles of oestrogen?

A

Increase thickness of vaginal wall
Regulate LH surge
Reduce vaginal pH through increase in lactic acid production
Decrease viscosity of cervical mucus to facilitate sperm production

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23
Q

What are the roles of progesterone?

A

Pro-gestational hormone to maintain pregnancy
Maintains thickness of endometrium
Responsible for infertile thick mucus to prevent sperm transport and help prevent infection
Relax the myometrium
Progesterone withdrawal regulates partition

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24
Q

How is sperm made?

A

Occurs within the testes
Under control of LH, FSH and testosterone
Entire spermatogenic process takes 70 days
Humans produce 1000 sperm every heart beat

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25
Q

What regulates the gate of sertoli cells?

A

Tight junctions

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26
Q

What receptors are found on sertoli cells?

A

FSH receptors

Induce spermatogenesis

27
Q

What receptors are found on leydig cells?

A

LH receptors

Causes the secretion of testosterone

28
Q

What is the function of testosterone?

A

Maintains integrity of blood testes barrier

Release of sertoli cells

29
Q

What is oligomenorrhea?

A

Cycles last more thana 35 days

30
Q

What is amenorrhoea?

A

Primary - never had a period

Secondary - had periods which then stop

31
Q

How is ovulation assessed?

A

Mid Luteal serum progesterone should be over 30 nmol/L

32
Q

How is spermatogenesis assessed?

A

Diagnostic semen analysis - oligozoospermia (sperm count), asthenozoospermia (motility), teratozoospermia (morphology)

33
Q

What is group 1 ovulatory disorder?

A

Hypothalamic pituitary failure: failure to produce GnRH which leads to lack of oestrogen and progesterone

34
Q

What are the biochemical signs of hypogonadrotrophic hypogonadism?

A

Low levels of FSH and LH
Oestrogen deficiency - negative progesterone challenge test
Normal prolactin
Amenorrhoea

35
Q

What can cause hypothalamic pituitary failure?

A
Stress
Excessive exercise 
Anorexia
Brain/ pituitary tumours
Head trauma
Kallmans syndrome 
Drugs (steroids, opioates)
36
Q

How is group 1 anovulation managed?

A
Stabilise weight 
Hormone therapy
Lifestyle modification 
Folic acid 400 mcg daily
Check prescribed drugs
Rubella immune 
Normal semen analysis
Patent fallopian tube
37
Q

What hormone is given in group 1 anovulation?

A

Pulsatily GnRH
Up to 90% ovulation rate
82% conception rate in 12 months
FSH and LH injections but has a high risk of multiple pregnancies

38
Q

What is group 2 anovulatory disorder?

A

Hypothalamic pituitary dysfunction

39
Q

What will hypothalamic pituitary dysfunction disorders show biochemically?

A

Normal gonadotropins/ excess LH
Normal oestrogen levels - progesterone challenge test
Oligo/amenorrhoea

40
Q

What is the commonest cause of type 2 anovulatory disorder?

A

PCOS

41
Q

What is the criteria for PCOS?

A

Oligo/amenorrhoea
USS appearance - 12 or more follicles, increased ovarian volume
Clinical or biochemical signs of hyperandrogenism (acne, hirsutism) - testosterone, sex hormone binding globulin (SHBG)

42
Q

What does insulin do to the SHBG levels?

A

Increased free testosterone leads to hyperandrogenism

43
Q

What symptoms and signs are associated with PCOS?

A
Subfertility: ovulation induction 
Oligo/amenorrhoea: risk of endometrial hyperplasia
Hirsutism
Obesity
Acne/ alopecia
44
Q

What is clomifene?

A

An ovulation induction drug that will cause the release of FSH and LH

45
Q

What are the 3 different ways to induce ovulation in PCOS?

A

Clomifene citrate
Gonadotropin injections - recombinant FSH
Laparoscopic ovarian diathermy

46
Q

What is the role of metformin in ovulation induction?

A

Improves insulin resistance, reduction in androgen production and increase in SHBG
Restoration of menstruation and ovulation
Does not help in weight loss

47
Q

What are the risks of ovulation induction?

A

Ovarian hyperstimulation
Multiple pregnancies
Risk of ovarian cancer

48
Q

What can severe ovarian hyperstimulation lead to?

A

Renal failure
PE
DIC
ARDS

49
Q

What are the associated maternal complications with multiple pregnancies?

A
Hyperemesis
Anaemia
Hypertension/ pre-eclampsia
Gestational diabetes (risk of intrauterine death and still birth) 
Mode of delivery 
Post natal depression
50
Q

What are the risks to the foetus in multiple pregnancies?

A
Early and late miscarriage 
Low birth weight
Prematurity
Disability
Stillbirth/ neonatal death 
TTTS
51
Q

What is diaminotic dichrionic twins?

A

Separate sacs and separate pregnancies

52
Q

What type of twins are at the highest risk of TTTS?

A

Monochorionic diamniotic

53
Q

What is TTTS?

A

Twin twin transfusion syndrome
Unbalances in vascular communications within the placental bed:
Recipient develops polyhydramnios
Donor develops oliguria, oligohydramnios and growth restriction

54
Q

How is twin-twin transfusion syndrome (TTTS) treated?

A

Laser division of placental vessels
Amnioreduction
Septostomy

55
Q

What are the symptoms of hyperprolactinemia?

A

Amenorrhoea
Galactorrhea
Always examine visual field

56
Q

What investigations should be done in suspicion of hyperprolactinemia?

A

Normal FSH/:H
Low oestrogen
Raised serum prolactin >1000 it/l on 2 or more occasions

57
Q

How is hyperprolactinemia treated?

A

Dopamine agonist

Cabergoline twice weekly

58
Q

What is type 3 anovulatory disorder?

A

Ovarian failure

59
Q

What will ovarian failure show biochemically?

A

Raised FSH and LH
Low oestrogen
Amenorrhoea
Menopausal

60
Q

What is classified as premature menopause?

A

Below 40

61
Q

What can cause premature ovarian failure?

A
Turner syndrome
XX gonadal agenesis
Fragile X syndrome 
Autoimmune ovarian failure
Bilateral oophrectomy
Pelvis radio or chemotherapy
62
Q

How is premature ovarian failure treated?

A

HRT
Egg/embryo donation
Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy

63
Q

What should be asked in a gynaecological history?

A
Details of menstrual cycle
Amenorrhoea
Hirsutism
Acne
Galactorrhea 
Headaches
Prolcatin
64
Q

What biochemical tests should be done in a gynaecological work up?

A

Mid luteal progesterone
Early follicular phase: serum FSH, LH and oestreogen. Serum testosterone/ SHG, prolactin, TSH
Progesterone challenge test