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Endo, Cardio and Neuro > Infertility & reproductive treatments > Flashcards

Infertility & reproductive treatments Flashcards

1
Q

what is infertility?

A

a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12+ months of regular unprotected sexual intercourse

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2
Q

what is primary infertility?

A

infertility with no previous live birth

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3
Q

what is secondary infertility?

A

infertility with a live birth 12+ months previously

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4
Q

what is the prevalence of infertility?

A

affects 1 in 7 couples

55% seek help - positive association with socioeconomic status

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5
Q

what are the psychological impacts of infertility?

A

no biological child, impact on wellbeing, larger family, investigations and treatments (often failing)

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6
Q

what are the societal costs of infertility?

A

less births, less tax income, investigation and treatment costs

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7
Q

what are the male pre-testicular causes of infertility?

A

congenital and acquired endocrinopathies e.g Klinefelters, Y chromosome deletion, HPG, T, PRL

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8
Q

what are the testicular causes of male infertility?

A 
congenital
cryptorchidism
infection - STDs
immunological - antisperm ABs
vascular - varicocoele
trauma/surgery
toxins - chemo, dxt, drugs, smoking
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9
Q

what are the post testicular causes of male infertility?

A

congenital - abscence of vas deferens in CF
obstructive azoospermia
erectile dysfunction - retrograde ejaculation, mechanical impairment, psychological
latrogenic - vasectomy

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10
Q

what is cryptorchidism?

A

undescended testes - 90% in inguinal canal

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11
Q

what are the types of causes of female infertility?

A 
pelvic, 
tubal, 
ovarian, 
uterine, 
cervical 
and unexplained
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12
Q

what is endometriosis?

A

presence of functioning endometrial tissue outside the uterus

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13
Q

what is the prevalence of endometriosis in women?

A

5%

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14
Q

what are the symptoms of endometriosis?

A

menstrual pain and irregularity, deep dyspareunia, infertility

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15
Q

what are the treatments available for endometriosis?

A

hormonal (e.g continuous oral con. pill, prog)
laparascopic ablation
hysterectomy
bilateral salpingo-oophorectomy

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16
Q

what are fibroids?

A

benign tumours of the myometrium

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17
Q

what is the prevalence of fibroids in women?

A

1-20% pre-menopausal women

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18
Q

are fibroids or endometriosis responsive to oestrogen?

A

both

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19
Q

what are the symptoms of fibroids?

A

usually asymptomatic
menstrual pain, irregularities
deep dyspareunia
infertility

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20
Q

what are the treatments for fibroids?

A

hormonal (continuous OCP, prog, cont. GnRH agonists)

hysterectomy

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21
Q

what are the blood results for a hypothalamic cause of endocrine male infertility?

A

low LH/FSH
low testosterone

low GnRH (not measurable)

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22
Q

what are the blood results for pituitary causes of endocrine male infertility?

A

low LH/FSH

low testosterone

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23
Q

what are the blood results for gonad causes for endocrine male infertility?

A

high LH/FSH

low testosterone

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24
Q

what is Kallman’s syndrome?

A

failure of migration of GnRH neurons to hypothalamus from olfactory placode (during first 10wks of development)

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25
Q

what are the reproductive features of Kallmann’s?

A 
cryptorchidism
failure of puberty
micropenis
lack of testicle development
primary amenorrhoea
infertility
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26
Q

what are the blood test results for someone with Kallmann’s?

A

low LH/FSH

low testosterone

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27
Q

how is hyperprolactinemia treated?

A

cabergoline

or pit surgery/radiotherapy

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28
Q

what is a normal male/female karyotype?

A

46XY male

46XX female

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29
Q

what is the karyotype for Klinefelter syndrome?

A

47XXY

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30
Q

what is the karyotype for Turner syndrome?

A

45X0

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31
Q

what is Klinefelters syndrome?

A

47XXY chromosomal abnormality

male but with some female characteristics

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32
Q

what are the features of Klinefelters syndrome?

A 
tall stature
decreased facial/chest hair
mildly impaired IQ
narrow shoulders
female pattern pubic hair
wide hips
small penis/testes
low bone density
slight breast development
INFERTILITY
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33
Q

how would you approach a male history for infertility?

A 
duration
previous children
pubertal milestones
associated symptoms
medical/surgical history
medications/drugs
FH/SH
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34
Q

how would you approach examining a male presenting with infertility?

A 
BMI
sexual characteristics
testicular volume
epididymis hardness
presence of vas deferens
syndromic features
anosmia?
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35
Q

what are the 4 main investigations for males presenting with infertility?

A

semen analysis
blood tests
microbiology
imaging

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36
Q

what is semen analysis?

A

measures volume (1.5ml normal), sperm concentration and total mobility of a sperm sample

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37
Q

what are the main blood tests for a male presenting with infertility?

A 
LH/FSH/PRL
morning fasting testosterone
sex hormone binding globulin
albumin
iron studies
pituitary/thyroid profile
karyotyping
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38
Q

what are the main microbiology tests for a male presenting with infertility?

A

urine test

chlamydia swab

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39
Q

what are the imaging methods used for males presenting with infertility?

A 
scrotal ultrasound/doppler (varicocoele/obstruction, testicular volume)
MRI pituitary (for low LH/FSH or high PRL)
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40
Q

what are the typical treatments for general male inferility?

A

optimise BMI
smoking cessation
alcohol cessation

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41
Q

what are specific treatments for male hyperPRL?

A

dopamine agonist - cabergoline

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42
Q

how is testosterone prescribed to males not desiring fertility?

A

daily gel
3 weekly IM injections
3 monthly IM injections
implants/oral preparations less common

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43
Q

what to prescribe to males desiring fertility?

A 
hCG injections (act on LH receptors)
if no response after 6mnth, add FSH injections
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44
Q

what treatments are used for males wanting fertility?

A

gonadotrophin treatment

NO TESTOSTERONE - -ve feedback on LH/FSH

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45
Q

when is testosterone prescribed to males presenting with infertility?

A

if fertility is not desired, only for symptomatic relief

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46
Q

what is primary amenorrhoea?

A

menses not started after 16 years old

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47
Q

what is secondary amenorrhoea?

A

periods start at puberty but stop for at least 3-6mnths

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48
Q

what is amenorrhoea?

A

no periods for at least 3-6mnths

or up to 3 periods/yr

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49
Q

what is oligomenorrhoea?

A

irregular/infrequent periods, >35day cycles

or 4/9 cycles/yr

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50
Q

what is early menopause?

A

menopause occurring in a female under 45

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51
Q

how is early menopause diagnosed?

A

high FSH (>25iU/L) twice at least 4wk apart

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52
Q

what are the odds for conception in a female with early menopause?

A

20%

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53
Q

what are the causes of early menopause?

A

autoimmune
genetic - fragile X, turner’s syndrome
cancer therapy - radio/chemo in past

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54
Q

how does hypothalamic causes of infertility in women show in a blood test?

A

low LH/FSH
low E2
hypogonadotrophic hypogonadism

55
Q

what are the female congenital causes of hypogonadotropic hypogonadism?

A

anosmic (kallmann’s syndrome) or normosmic

56
Q

what are the acquired female causes of hypogonadotrophic hypogonadism?

A

low BMI
stress
excessive exercise
hyperprolactinemia

57
Q

what are the blood results for pituitary causes of female infertility?

A

low LH/FSH

low E2

58
Q

what are the causes of female hypogonadotropic infertility? (pituitary causes)

A 
hypopituitarism-
tumour
infiltration
apoplexy
surgery
radiation
59
Q

what are the acquired gonadal causes of female primary hypogonadism?

A 
early menopause/primary ovarian insufficiency
surgery
trauma
chemo
radiation
polycystic ovarian syndrome (PCOS)
60
Q

what are the congenital causes of female primary hypogonadism?

A

turners syndrome

early menopause/premature ovarian insufficiency

61
Q

what are the blood results for PCOS?

A

high LH/FSH

low or normal E2

62
Q

what are the blood results for female primary hypogonadism?

A

high LH/FSH

low E2

63
Q

what are other endocrine causes of female infertility outside the HPG axis?

A

hyper/hypothyroidism - reduced bioavailability of oestradiol

64
Q

what is PCOS?

A

polycystic ovarian syndrome

65
Q

what is PCOS’ burden of disease?

A

affects 5-15% women of reproductive age

most common endocrine disorder in women, most common cause of infertility

66
Q

how is PCOS diagnosed?

A

exclude other reproductive disorders

Rotterdam criteria - 2/3

67
Q

what is the Rotterdam PCOS diagnostic criteria?

A

oligo or anovulation
clinical+/- biochemical hyperandrogenism
polycystic ovaries on utrasound

68
Q

how is oligo/anovulation assessed for the rotterdam criteria of PCOS?

A

by menstrual frequency - oligomenorrhoea

or proven by lack of progesterone or on ultrasound

69
Q

how is clinical hyperandrogenism for the rotterdam PCOS criteria assessed?

A

clinical - acne, hirsutism, alopecia

70
Q

how is biochemical hyperandrogenism for the rotterdam PCOS criteria assessed?

A

raised androgens on blood test (e.g testosterone)

71
Q

how is polycystic ovaries assessed for the rotterdam PCOS criteria?

A

must have >20 follicles
OR
>10ml either ovary on TVUS (8MHz)

72
Q

why are polycystic ovaries on ultrasound not diagnostic for PCOS?

A

30% of women have polycystic ovaries so isn’t confirmational

73
Q

how does Clomiphene act for female fertility?

A

oestradiol receptor antagonist
reduces negative feedback of oestrogen on hypothalamus/pituitary gland
therefore increases LH/FSH
FSH stimulates follicle growth

74
Q

what treatments for PCOS aim to restore ovulation?

A

weight loss
letrozole (aromatase inhibitor)
clomiphene (oestradiol receptor modulator)
FSH stimulation

75
Q

how does letrozole act for female infertility?

A

inhibits aromatase (test-oest)
therefore reduces negative feedback of oestrogen on LH/FSH
therefore increases serum LH/FSH leading to stimulation of follicle growth

76
Q

what are the treatments for PCOS?

A

OCP
metformin
anti-androgens
progesterone courses

77
Q

what are the symptoms of PCOS?

A 
acne
hirsutism, excess facial hair
oligomenorrhoea
insulin resistance
infertility
weight gain
anxiety and depression
male pattern hair loss
78
Q

what does metformin do for PCOS?

A

helps reduce BMI to help with irregular menses

helps with insulin resistance/impaired glucose homeostasis

79
Q

how do anti-androgens help PCOS?

A

reduce hirsutism along with creams, waxing and laser hair removal

80
Q

what are the physical features of Turner’s syndrome?

A 
short stature
low hairline
shield chest
webbed neck
poor breast development, wide spaced nipples
elbow deformity
brown nevi
short 4th metacarpal
small fingernails
81
Q

what are the internal features of Turner’s syndrome?

A

coarctation of aorta
underdeveloped reproductive tract
amenorrhoea

82
Q

what are the main history points for a female presenting with infertility?

A 
duration
previous children
pubertal milestones
breastfeeding
menstrual history
associated symptoms
medical/surgical history
medication/DH
FH/SH
83
Q

what are the examinations to consider for females presenting with infertility?

A 
BMI
sexual characteristics
hyperandrogenism signs
pelvic examination
syndromic features
anosmia
84
Q

what are the main types of investigations for females presenting with infertility?

A

blood tests
pregnancy test
microbiology
imaging

85
Q

what are the blood tests for a female presenting with infertility?

A 
LH/FSH/PRL
oestradiol, androgens
follicular phase 17-OHP, mid-luteal progesterone
sex hormone binding globulin
albumin, iron studies
pit/thyroid study
karyotyping
86
Q

what are the microbiology tests for a female presenting with infertility?

A

urine test

chlamydia swab

87
Q

what are the imaging methods used for a female presenting with infertility?

A

Ultrasound (transvaginal)
hysterosalpingogram
MRI pit

88
Q

simply, what is the process of IVF?

A

oocyte retrieval (after high dose FSH)
fertilisation in vitro
embryo incubation
embryo transfer

89
Q

what is ICSI and when is it used?

A

intra-cytoplasmic sperm injection

used for when sperm has mobility issues/male factor infertility

90
Q

what are the steps in inducing ovulation for IVF?

A

FSH stimulation high dose

LH surge prevented (to prevent premature ovulation) by GnRH antagonists/agonists (short/long protocol)

91
Q

what is the short protocol for preventing premature LH surge in IVF?

A

GnRH antagonist given around day 6 in conjunction with FSH

92
Q

what is the long protocol for preventing premature LH surge in IVF?

A

GnRH agonist given a week before starting FSH

93
Q

how are follicles matured during IVF?

A

exposed to LH by giving hCG or GnRH agonist

94
Q

following high dose FSH, what must be done before harvesting an oocyte?

A

LH surge triggered

95
Q

what day is the oocyte fertilised in IVF?

A

day 13 - immediately after LH surge ends (36hr)

96
Q

when is the fertilised oocyte transferred to the endometrium in IVF?

A

day 18

97
Q

when is the pregnancy tested by blood test in IVF?

A

day 30 - 11days after implantation

98
Q

when is a pregnancy ultrasound done in IVF to confirm pregnancy?

A

day 44 - 2 weeks after blood test

99
Q

what are the impermanent methods for contraception?

A 
barriers e.g condoms/diaphragms 
combined OCP
progesterone only pill (mini pill)
long acting reversible contraception
emergency contraception
100
Q

what are the permanent methods for contraception?

A

vasectomy

female sterilisation

101
Q

what are the positives for condoms?

A

protect against STIs
easy to obtain/no need to see healthcare professional
no contraindications

102
Q

what are the negatives of condoms?

A

can interrupt sex
can reduce sensation
can interfere with erections
some skill needed to use

103
Q

how does the combined oral contraceptive pill act for contraception?

A

high oest and prog negative feedback on LH/FSH
low LH/FSH cause anovulation
prog thickens cervical mucus
thinning of endometrial lining to reduce implantation

104
Q

what are the positives for the combined OCP?

A 
easy to take - one pill a day
effective
doesnt interrupt sex
can take back to back and avoid withdrawal bleeds
reduce endometrial and cervical cancer
weight neutral in 90%
105
Q

what are the negatives for the combined OCP?

A 
may not remember to take it
no protection against STIs
P450 enzyme inducers may reduce efficacy
not best choice during breastfeeding
can increase appetite, weight gain
106
Q

what are some possible side effects of the combined OCP?

A 
spotting
nausea
sore breasts
mood/libido changes
hunger
blood clots in legs/lungs
107
Q

what are the non-contraceptive uses of the combined OCP?

A

makes periods lighter/less painful
regular withdrawal bleeds
help reduce LH and hyperadrogenism in PCOS

108
Q

what are the positives of the mini pill?

A

suitable if can’t take oestrogen (blood clot risk)
easy to take
doesnt interrupt sex
periods may stop temporarily
can be used when breastfeeding
works same as OCP but a bit less reliable

109
Q

what are the negatives of the mini pill?

A

can be hard to remember
no protection against STIs
shorter acting so needs to be taken same time each day

110
Q

what are long acting reversible contraceptives? (LARC)

A

intra-uterine devices, coils, subdermal implants, progesterone only injections

111
Q

what is an IUD?

A

a LARC mechanically preventing implantation, decreasing sperm egg survival
lasts 5-10 years
e.g copper coil

112
Q

what is an IUS?

A

intra uterine system (LARC) secreting progesterone to thin endometrial lining and thicken cervical mucus
lasts 3-5 years
e.g mirena coil

113
Q

what are the choices for emergency contraception?

A 
copper coil (most effective)
contraceptive pill - ulipristal acetate 30mg or levonorgestrel 1.5mg
114
Q

what is the ulipristal acetate emergency contraceptive? (ellaOne)

A

stops progesterone working normally
prevents ovulation
must be taken within 5 days of unprotected intercourse

115
Q

what is the levonorgestrel emergency contraceptive pill? (levonelle)

A

synthetic progesterone prevents ovulation
doesnt cause abortion
must be taken within 3 days of intercourse

116
Q

what are the side effects of emergency contraceptive pills?

A

headache, abdo pain, nausea

117
Q

what are the contraindications for combined OCP?

A 
migraine with aura
smoking(>15/day) if over 35yo
stroke or CVD history
current breast cancer
liver cirrhosis
complicated diabetes
118
Q

what medications may interact with the combined OCP?

A

P450 liver enzyme inducing drugs (anti epileptics, antibiotics), teratogenic drugs (lithium, warfarin)
with these, would need stronger contraceptives

119
Q

what are the risks for hormone replacement therapy in menopause?

A

venous thrombo-embolism
hormone senstive cancers
increased risk of CV disease
risk of stroke

120
Q

why is venous thrombo-embolism a risk for oral oestrogen HRT?

A

oral oestrogens undergo first pass metabolism in liver
increases SHBG , triglycerides, CRP

transdermal oestrogens safer than oral

121
Q

why are hormone sensitive cancers a risk in oestrogen HRT?

A

breast cancer slight increased risk if combined w prog - related to duration of treatment, reduces after stopping
ovarian cancer small increase after long term use
endometrial cancer - must have progesterone prescribed if have an endometrium

122
Q

what is the cardiovascular disease risk of oestrogen HRT?

A

increased risk if started 10 yr after menopause

no increased risk if started before 60

123
Q

what is the risk of stroke with oestrogen HRT?

A

small increased risk
more in oral than transdermal
more in combined than oestrogen only

124
Q

what are the benefits of HRT for menopause?

A

symptomatic relief

less osteoporosis related fractures

125
Q

which transgender gender is more common?

A

transgender women 3x more common than transgender men

126
Q

what is the process for transgender treatment?

A

in prepubertal young people - GnRH agonist for pubertal suppression and then sex steroids
gender reassignment surgery after 1-2 years of hormonal treatment

127
Q

what are the masculising hormones for transgender men?

A

testosterone

progesterone given to suppress menstrual bleeding if needed

128
Q

following masculising hormones for transgender men, what effects can be seen? (1-6 months)

A 
balding
deeper voice/acne/ increased facial hair/coarser body hair
change in body fat distribution
enlargement of clitoris
menstrual cycle stops
increased muscle mass and strength
129
Q

what are the feminising hormones for transgender women?

A

oestrogen - high dose

reduce testosterone

130
Q

how is oestrogen prescribed for transgender women?

A

4-5mg daily to aim for estradiol levels 743pmol/L

131
Q

how is testosterone reduced in transgender women?

A

GnRH agonists

anti-androgen medications

132
Q

what should be monitored when giving testosterone ton males not desiring fertility?

A

haematocrit - risk of stroke/hyperviscosity

prostate specific antigen - risk of prostate cancer

133
Q

first line treatment for PCOS?

A

metformin for weight loss
letrozole - aromatase inhibitor
inhibits test-oestr

Endo, Cardio and Neuro (22 decks)

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