Fertility

Question 1

What is infertility

Answer 1

Inability to conceive after 12 months of unprotected sex OR 6 months of unprotected sex after the age of 35

Question 2

What is the Hypothalmus-Pituitary-Testes axis that causes and inhibts spermatogenesis

Answer 2

Pituitary hormone effects: LH and FSH stimulate spermatogenesis and testosterone by the testes

Testes hormone effects: Testosterone and inhibin inhibit the secretion of GnRH by the hypothalmus thus inhibiting LH and FSH release from the pitutary

Question 3

Which drugs affect the HPT axis

Answer 3

Anabolic steroids, testosterone

Question 4

T/F: Giving someone testosterone will make them more likely to be fertile

Answer 4

False: Giving more testosterone will lead to more inhibition thus no more spermatogenesis

Question 5

If there is problem with spermatogenesis due to the testes (primary), Pituitary (secondary), hypothalamic (secondary), hyperprolactinemia (secondary)

Answer 5

None, LH or FSH replacement therapy, pulsatile GnRH, dopamine agonists

Question 6

How do dopamine agonists aid in hyperprolactinemia

Answer 6

Since prolactin is a potent inhibitor dopamine inhibits the inhibitor allowing for normal function

Question 7

T/F: A male may be on a SERM because it allows estrogen to not inhibt the release of GnRH, aromatase does a similar way method of reducing an inhibitor

Answer 7

True

Question 8

Which mechanisms of female infertility may not be changed by medications

Answer 8

Fallopian tube are absent or blocked, uterine tube has fibroids or polyps, endometriosis or history of PID

Question 9

What are the four types of female infertility

Answer 9

Hypogonadotropic (low FSH, low, LH, low estradiol). Normogonadotropic (normal FSH, HIGH LH, normal estradiol), Hypergonadotropic (HIGH FSH, normal LH and low estradiol), other

Question 10

Which SERM is used to induce ovulation BUT decrease the cervical mucus aiding sperm traversing the cervix

Answer 10

Clomiphene citrate

Question 11

What group of infertility is Polycystic Ovarian syndrome apart of

Answer 11

Nornoganadotropic (normal FSH, HIGH LH, normal estradiol

Question 12

What is the pathophysiology of PCOS

Answer 12

1) Rapid pulsing of GnRH causes hypersecretion of LH,
2) Large amount of LH and only normal levels of FSH leads to follicle that are stimulated but are leading to no ovulation (no second half of the menstrual cycle)
3) LH and insulin can also be converted to androgens

Question 13

What are symptoms of PCOS

Answer 13

Infertility,Hyperandrogenism (hirsutism, acne, alopecia, menstrual distrubances, Endometrial hyperplasia and cancer, glucose intolerance

Question 14

What are the non-pharmacological treatments of PCOS

Answer 14

Weight loss, Diet, Exercise

Question 15

What is the first line pharmacological treatment for PCOS for patients who do not want to get pregnant, what are the other options

Answer 15

CHCs, Medroxyprogesterone (only reduces the endometrial hyperplasia), Spironolactione (antiandrogen)

Question 16

What are the options for PCOS if the patient wants to become pregnant

Answer 16

Metformin (ovulation induction, lowers insulin), pioglitazone (falling out of favor; edema and weight gain)

Question 17

What are is the goal of ovulation induction

Answer 17

Monofollicular development (one egg) while minimizing the risk of ovarian hyperstimulation syndrome

Question 18

Which oral medications are used to induce ovulation, how do they work

Answer 18

Clomiphene citrate: SERM that down regulates estrogen receptors (dose increases by 50 mg per cycle if ineffective)
Letrozole: aromatase inhibitor that reduces the amount of estrogen to cause inhibiton (anastrazole)

Question 19

What injectables are used to induce ovulation

Answer 19

LH/FSH combination, FSH, hCG (creates the LH surge mid cycle)

Question 20

When does follicular development happen in hCG

Answer 20

Ovulation expected within 24 hours

Question 21

What are potential adverse effects of any ovulation induction medications, how is this prevented

Answer 21

Multiple gestations, ovarian hyperstimulation syndrome (edema, ascites, pleural effusion, hemodynamic instability)/ low doses, step up therapy, close monitoring and withholding hCG trigger dose

Question 22

What happens in assisted reproductive technology (ART)

Answer 22

Manipulation of oocytes and sperm through stimulating multiple follicles for oocyte retrieval and optimize implantation after in vitro fertilization

Question 23

What are the steps for in vitro fertilization (IVF)

Answer 23

1) Controlled ovarian stimulation
2) Oocyte retrieval
3) Fertilization in vitro
4) Embryo transfer

Question 24

For the ovarial stimulation needed for IVF what medications are used in conjunction and why

Answer 24

GnRH agonists and antagonists: suppress LH to allow for follicle development,FSH OR FSH/LH: stimulate development of multiple ovarian follicles hCG: LH surge, progesterone for 8 weeks: usually medications deplete progestetone plus endometrium is maintained for embryo transfer and implantation

Question 25

T/F: If a patient needs Controlled oocyte hyperstimulation and IVF they would not take oral contraceptives because this would cause them to not get pregnant

Answer 25

False: CHCs are used to regulate cycle and know exactly when the menses starts allowing for the start of COHS to planned

Question 26

What is the order of medications used for COHS/IVF

Answer 26

1) CHCs
2) GnRH agonists
3) Gonadotropins
4) hCG
5) Progesterone

Question 27

What are treatment options for unsuccesful pregnancy based on type

Answer 27

Spontaneous abortion: Mirepristone followed by misoprostol. misoprostol
Ectopic Pregnancy: Surgical intervention, Methotrexate (IM or PO)