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

Infertility & reproductive treatments Flashcards

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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
what are the reproductive features of Kallmann's?
``` cryptorchidism failure of puberty micropenis lack of testicle development primary amenorrhoea infertility ```
26
what are the blood test results for someone with Kallmann's?
low LH/FSH | low testosterone
27
how is hyperprolactinemia treated?
cabergoline | or pit surgery/radiotherapy
28
what is a normal male/female karyotype?
46XY male | 46XX female
29
what is the karyotype for Klinefelter syndrome?
47XXY
30
what is the karyotype for Turner syndrome?
45X0
31
what is Klinefelters syndrome?
47XXY chromosomal abnormality | male but with some female characteristics
32
what are the features of Klinefelters syndrome?
``` 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 ```
33
how would you approach a male history for infertility?
``` duration previous children pubertal milestones associated symptoms medical/surgical history medications/drugs FH/SH ```
34
how would you approach examining a male presenting with infertility?
``` BMI sexual characteristics testicular volume epididymis hardness presence of vas deferens syndromic features anosmia? ```
35
what are the 4 main investigations for males presenting with infertility?
semen analysis blood tests microbiology imaging
36
what is semen analysis?
measures volume (1.5ml normal), sperm concentration and total mobility of a sperm sample
37
what are the main blood tests for a male presenting with infertility?
``` LH/FSH/PRL morning fasting testosterone sex hormone binding globulin albumin iron studies pituitary/thyroid profile karyotyping ```
38
what are the main microbiology tests for a male presenting with infertility?
urine test | chlamydia swab
39
what are the imaging methods used for males presenting with infertility?
``` scrotal ultrasound/doppler (varicocoele/obstruction, testicular volume) MRI pituitary (for low LH/FSH or high PRL) ```
40
what are the typical treatments for general male inferility?
optimise BMI smoking cessation alcohol cessation
41
what are specific treatments for male hyperPRL?
dopamine agonist - cabergoline
42
how is testosterone prescribed to males not desiring fertility?
daily gel 3 weekly IM injections 3 monthly IM injections implants/oral preparations less common
43
what to prescribe to males desiring fertility?
``` hCG injections (act on LH receptors) if no response after 6mnth, add FSH injections ```
44
what treatments are used for males wanting fertility?
gonadotrophin treatment | NO TESTOSTERONE - -ve feedback on LH/FSH
45
when is testosterone prescribed to males presenting with infertility?
if fertility is not desired, only for symptomatic relief
46
what is primary amenorrhoea?
menses not started after 16 years old
47
what is secondary amenorrhoea?
periods start at puberty but stop for at least 3-6mnths
48
what is amenorrhoea?
no periods for at least 3-6mnths | or up to 3 periods/yr
49
what is oligomenorrhoea?
irregular/infrequent periods, >35day cycles | or 4/9 cycles/yr
50
what is early menopause?
menopause occurring in a female under 45
51
how is early menopause diagnosed?
high FSH (>25iU/L) twice at least 4wk apart
52
what are the odds for conception in a female with early menopause?
20%
53
what are the causes of early menopause?
autoimmune genetic - fragile X, turner's syndrome cancer therapy - radio/chemo in past
54
how does hypothalamic causes of infertility in women show in a blood test?
low LH/FSH low E2 hypogonadotrophic hypogonadism
55
what are the female congenital causes of hypogonadotropic hypogonadism?
anosmic (kallmann's syndrome) or normosmic
56
what are the acquired female causes of hypogonadotrophic hypogonadism?
low BMI stress excessive exercise hyperprolactinemia
57
what are the blood results for pituitary causes of female infertility?
low LH/FSH | low E2
58
what are the causes of female hypogonadotropic infertility? (pituitary causes)
``` hypopituitarism- tumour infiltration apoplexy surgery radiation ```
59
what are the acquired gonadal causes of female primary hypogonadism?
``` early menopause/primary ovarian insufficiency surgery trauma chemo radiation polycystic ovarian syndrome (PCOS) ```
60
what are the congenital causes of female primary hypogonadism?
turners syndrome | early menopause/premature ovarian insufficiency
61
what are the blood results for PCOS?
high LH/FSH | low or normal E2
62
what are the blood results for female primary hypogonadism?
high LH/FSH | low E2
63
what are other endocrine causes of female infertility outside the HPG axis?
hyper/hypothyroidism - reduced bioavailability of oestradiol
64
what is PCOS?
polycystic ovarian syndrome
65
what is PCOS' burden of disease?
affects 5-15% women of reproductive age | most common endocrine disorder in women, most common cause of infertility
66
how is PCOS diagnosed?
exclude other reproductive disorders | Rotterdam criteria - 2/3
67
what is the Rotterdam PCOS diagnostic criteria?
oligo or anovulation clinical+/- biochemical hyperandrogenism polycystic ovaries on utrasound
68
how is oligo/anovulation assessed for the rotterdam criteria of PCOS?
by menstrual frequency - oligomenorrhoea | or proven by lack of progesterone or on ultrasound
69
how is clinical hyperandrogenism for the rotterdam PCOS criteria assessed?
clinical - acne, hirsutism, alopecia
70
how is biochemical hyperandrogenism for the rotterdam PCOS criteria assessed?
raised androgens on blood test (e.g testosterone)
71
how is polycystic ovaries assessed for the rotterdam PCOS criteria?
must have >20 follicles OR >10ml either ovary on TVUS (8MHz)
72
why are polycystic ovaries on ultrasound not diagnostic for PCOS?
30% of women have polycystic ovaries so isn't confirmational
73
how does Clomiphene act for female fertility?
oestradiol receptor antagonist reduces negative feedback of oestrogen on hypothalamus/pituitary gland therefore increases LH/FSH FSH stimulates follicle growth
74
what treatments for PCOS aim to restore ovulation?
weight loss letrozole (aromatase inhibitor) clomiphene (oestradiol receptor modulator) FSH stimulation
75
how does letrozole act for female infertility?
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
what are the treatments for PCOS?
OCP metformin anti-androgens progesterone courses
77
what are the symptoms of PCOS?
``` acne hirsutism, excess facial hair oligomenorrhoea insulin resistance infertility weight gain anxiety and depression male pattern hair loss ```
78
what does metformin do for PCOS?
helps reduce BMI to help with irregular menses | helps with insulin resistance/impaired glucose homeostasis
79
how do anti-androgens help PCOS?
reduce hirsutism along with creams, waxing and laser hair removal
80
what are the physical features of Turner's syndrome?
``` short stature low hairline shield chest webbed neck poor breast development, wide spaced nipples elbow deformity brown nevi short 4th metacarpal small fingernails ```
81
what are the internal features of Turner's syndrome?
coarctation of aorta underdeveloped reproductive tract amenorrhoea
82
what are the main history points for a female presenting with infertility?
``` duration previous children pubertal milestones breastfeeding menstrual history associated symptoms medical/surgical history medication/DH FH/SH ```
83
what are the examinations to consider for females presenting with infertility?
``` BMI sexual characteristics hyperandrogenism signs pelvic examination syndromic features anosmia ```
84
what are the main types of investigations for females presenting with infertility?
blood tests pregnancy test microbiology imaging
85
what are the blood tests for a female presenting with infertility?
``` LH/FSH/PRL oestradiol, androgens follicular phase 17-OHP, mid-luteal progesterone sex hormone binding globulin albumin, iron studies pit/thyroid study karyotyping ```
86
what are the microbiology tests for a female presenting with infertility?
urine test | chlamydia swab
87
what are the imaging methods used for a female presenting with infertility?
Ultrasound (transvaginal) hysterosalpingogram MRI pit
88
simply, what is the process of IVF?
oocyte retrieval (after high dose FSH) fertilisation in vitro embryo incubation embryo transfer
89
what is ICSI and when is it used?
intra-cytoplasmic sperm injection | used for when sperm has mobility issues/male factor infertility
90
what are the steps in inducing ovulation for IVF?
FSH stimulation high dose | LH surge prevented (to prevent premature ovulation) by GnRH antagonists/agonists (short/long protocol)
91
what is the short protocol for preventing premature LH surge in IVF?
GnRH antagonist given around day 6 in conjunction with FSH
92
what is the long protocol for preventing premature LH surge in IVF?
GnRH agonist given a week before starting FSH
93
how are follicles matured during IVF?
exposed to LH by giving hCG or GnRH agonist
94
following high dose FSH, what must be done before harvesting an oocyte?
LH surge triggered
95
what day is the oocyte fertilised in IVF?
day 13 - immediately after LH surge ends (36hr)
96
when is the fertilised oocyte transferred to the endometrium in IVF?
day 18
97
when is the pregnancy tested by blood test in IVF?
day 30 - 11days after implantation
98
when is a pregnancy ultrasound done in IVF to confirm pregnancy?
day 44 - 2 weeks after blood test
99
what are the impermanent methods for contraception?
``` barriers e.g condoms/diaphragms combined OCP progesterone only pill (mini pill) long acting reversible contraception emergency contraception ```
100
what are the permanent methods for contraception?
vasectomy | female sterilisation
101
what are the positives for condoms?
protect against STIs easy to obtain/no need to see healthcare professional no contraindications
102
what are the negatives of condoms?
can interrupt sex can reduce sensation can interfere with erections some skill needed to use
103
how does the combined oral contraceptive pill act for contraception?
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
what are the positives for the combined OCP?
``` 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
what are the negatives for the combined OCP?
``` 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
what are some possible side effects of the combined OCP?
``` spotting nausea sore breasts mood/libido changes hunger blood clots in legs/lungs ```
107
what are the non-contraceptive uses of the combined OCP?
makes periods lighter/less painful regular withdrawal bleeds help reduce LH and hyperadrogenism in PCOS
108
what are the positives of the mini pill?
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
what are the negatives of the mini pill?
can be hard to remember no protection against STIs shorter acting so needs to be taken same time each day
110
what are long acting reversible contraceptives? (LARC)
intra-uterine devices, coils, subdermal implants, progesterone only injections
111
what is an IUD?
a LARC mechanically preventing implantation, decreasing sperm egg survival lasts 5-10 years e.g copper coil
112
what is an IUS?
intra uterine system (LARC) secreting progesterone to thin endometrial lining and thicken cervical mucus lasts 3-5 years e.g mirena coil
113
what are the choices for emergency contraception?
``` copper coil (most effective) contraceptive pill - ulipristal acetate 30mg or levonorgestrel 1.5mg ```
114
what is the ulipristal acetate emergency contraceptive? (ellaOne)
stops progesterone working normally prevents ovulation must be taken within 5 days of unprotected intercourse
115
what is the levonorgestrel emergency contraceptive pill? (levonelle)
synthetic progesterone prevents ovulation doesnt cause abortion must be taken within 3 days of intercourse
116
what are the side effects of emergency contraceptive pills?
headache, abdo pain, nausea
117
what are the contraindications for combined OCP?
``` migraine with aura smoking(>15/day) if over 35yo stroke or CVD history current breast cancer liver cirrhosis complicated diabetes ```
118
what medications may interact with the combined OCP?
P450 liver enzyme inducing drugs (anti epileptics, antibiotics), teratogenic drugs (lithium, warfarin) with these, would need stronger contraceptives
119
what are the risks for hormone replacement therapy in menopause?
venous thrombo-embolism hormone senstive cancers increased risk of CV disease risk of stroke
120
why is venous thrombo-embolism a risk for oral oestrogen HRT?
oral oestrogens undergo first pass metabolism in liver increases SHBG , triglycerides, CRP transdermal oestrogens safer than oral
121
why are hormone sensitive cancers a risk in oestrogen HRT?
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
what is the cardiovascular disease risk of oestrogen HRT?
increased risk if started 10 yr after menopause | no increased risk if started before 60
123
what is the risk of stroke with oestrogen HRT?
small increased risk more in oral than transdermal more in combined than oestrogen only
124
what are the benefits of HRT for menopause?
symptomatic relief | less osteoporosis related fractures
125
which transgender gender is more common?
transgender women 3x more common than transgender men
126
what is the process for transgender treatment?
in prepubertal young people - GnRH agonist for pubertal suppression and then sex steroids gender reassignment surgery after 1-2 years of hormonal treatment
127
what are the masculising hormones for transgender men?
testosterone | progesterone given to suppress menstrual bleeding if needed
128
following masculising hormones for transgender men, what effects can be seen? (1-6 months)
``` 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
what are the feminising hormones for transgender women?
oestrogen - high dose | reduce testosterone
130
how is oestrogen prescribed for transgender women?
4-5mg daily to aim for estradiol levels 743pmol/L
131
how is testosterone reduced in transgender women?
GnRH agonists | anti-androgen medications
132
what should be monitored when giving testosterone ton males not desiring fertility?
haematocrit - risk of stroke/hyperviscosity | prostate specific antigen - risk of prostate cancer
133
first line treatment for PCOS?
metformin for weight loss letrozole - aromatase inhibitor inhibits test-oestr

Endo, Cardio and Neuro (22 decks)

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