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ESR > Reproduction and Fertility > Flashcards

Reproduction and Fertility Flashcards

1
Q

What are the first endocrine changes to happen when fertility develops?

A
  1. Increase in gonadotrophin secretion at night (LH and FSH start to inc. in secretion)
  2. Leptin is an endocrine marker of puberty but does NOT trigger it
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2
Q

Why is the age of menarche decreasing esp. in girls?

A
  1. Interaction between lifestyle factor and pre-existing genetic predisposition
  2. Lifestyle factors incl:
  • Eating more
  • Exercising less
  • Accumulating more body fat = sig. source of oestrogen :. speed up puberty
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3
Q

What does adrenarche signifiy?

A
  • Does not seem essential for puberty to occur but may be marker for termination of period od rapid barin growth
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4
Q

What are the key hormonal changes when undergoing puberty?

A
  1. At start/before puberty gonadtrophins secretion usually at night and v. low
  2. From puberty FSH and LH become evident and levels rise gradually to reach adult levels (secreted during the day)
  3. Once adult the baseline is higher than child but only odd pulses
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5
Q

What is the key and primary event underlying gonadal activation?

A

Activation of pulsatile hypothalamic GnRH secretion

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6
Q

What physiological and anatomic processes does menarche lead to?

A
  1. Sufficient body mass (typically 17% body fat at 1st menses, 2nd 22%)
  2. Disinhibition of the GnRH pulse generator in the arcuate nucleus of the hypothalamus
  3. Secretion of oestrogen by the ovaries in response to pituitary hormones
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7
Q

Is there a specific hormonal signal in menarche for fertility?

A

No

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8
Q

Does menses indicate that ovulation has occured?

A

No

  • In post-menarchal girls, about 80% of the cycles are anovulatory in the 1st year after menarche
  • 50% in the 3rd
  • 10% in the 6th year
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9
Q

What is regular ovulation indicated by?

A
  • predictable and consistent intervals between menses
  • predictable and consistent durations of menses
  • predictable and consistent patterns of flow (e.g., heaviness or cramping).
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10
Q

What is the male pituitary gonadal axis?

A
  1. GnRH produced from hypothalamus - going down hypophyseal vessels
  2. AP will release LH and FSH.
  3. LH and FSH will act on leying cells to produce testerone in testes or sertoli cells to produce androgen binding protein
  4. Also produce the hormone inhibin which will feedback and turn down FSH production or the feedback from the cells via testerone to turn down LH.
  5. These cells will then produce circulating testerone which can then be converted to DHT - most active form of testerone that acts to generate much of the secondary characteristics or it can be converted into estrodiol or estrogenic components in terms of maturation and development changes in bone.
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11
Q

What does DHT cause?

A
  1. Male pattern of development before birth
  2. Enlargement of male sex organs and expression of male secondary sex characteristics (starting at puberty)
  3. Anabolism (protein synthesis)
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12
Q

What is the process of sperm formation?

A

Start spermatogenesis at BM

  1. Spermatogonium (2n) - stem cell
  2. Mitosis (2n) - some used for sperm and some stored
  3. Primary spermatocyte (2n) - DNA replication, tetrad formation and crossing over
  4. Secondary spermatocyte (n) - each chromosome has two chromatids (:. technically 46 still)
  5. Spermatids (n) - one secondary spermatocyte forms two spermatids (connected through cytoplasmic bridge with tails forming)
  6. Spermatozoa (n) - with their tail sticking out from the lumen
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13
Q

Where do you find leydig cells?

A
  • Between seminferious tubules
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14
Q

What is the process of development of an ovum?

A
  1. Oogonium (2n) - then meiosis I
  2. After puberty primary oocyte complete meiosis (2n)
  3. Secondary oocyte (n) and first polar body (n) - once LH has been released to cause ovulation (this division happens just before ovulation)
  4. Secondary oocyte begins meiosis II
  5. Ovulation of secondary oocyte and first polar body
  6. Fertilisation (secondary oocyte and sperm cell) - meiosis II resumes
  7. After fertilisation ovum produced and second polar body
  8. Zygote (2n)
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15
Q

How does follicular development occur?

A
  1. Primordial follicles which differentiate into primary follicle
  2. Then to the secondary follicle
  3. Develop fluid space within the cell - multiplication of cells around the follicle to produce a large cell called the grafian follicle
  4. Follicle fuses with the outer membranes and burst it discarges the secondary oocyte and a whole set of cells around it called the corona radiata
  5. Remaining tissues generate CL — produce hormones to signal back to hypo and pit to indicate ovulation has occured - maintains uterus while oocyte goes up through the fibri, into the oviduct and down towards the uterus looking for sperm to fertilise the egg.
  6. If this doenst happen CL degenerates
  7. That releases the corpus albicans (white bodies — scar tissue ) which is involuted and brought back to the stromal tissue of ovary
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16
Q

What is follicular development?

A
  1. Follicular development means that the cell around the primary oocyte multiply. clear zone around primary oocyte called zona pellucida i.e. clear zone around the oocyte itself within follicle
  2. These cells muptily and divide until they make this fluid space around the maturing oocyte ready for this being in conact with the outer surface of the ovary, ready for this to rupture and to send the oocyte with a range of tissue cells around about it, ready to enter the outer cavities of the woman to seek fertilisation
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17
Q

What is the ovarian cycle?

A
  1. During the last stages of follicular development, we see the mature grafian folcile produces a range of oestrogen and progesterone. which is having an effect on increasing GnRH and increase LH so this is the surge in LH which is key to ovulation and this is a point where we get positive feedback
  2. The oestrogen feedbacls back, turns up GnRH and LH and FSH and brings about the LH surge
  3. So get FSH increase but not as high as LH
  4. This causes rupturing and release of the oocyte.
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18
Q

What happens to the Graafian follicle following ovulation?

A
  1. The Graafian follicle collapses and develops into corpus luteum
  2. The corpus luteum secretes progesterone and oestrogen which supports uterine endometrial changes in preparation for implantation of an embryo in the event that fertilisation will occur
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19
Q

Describe the menstrual cycle

A
  1. Oestrogens from the seconday follicle/mature graafian follicle release oestrogen and cause the proliferative phase
  2. During proliferative phase LH and FSH casuse proliferation of the endometrium (FSH v imp)
  3. Once egg has been released at day 14 progesterone and oestrogen from CL causes the secretory phase ready for implantation
  4. If no implantation then CL breaks down and there is a drop in oestrogen and progesterone and the lining breaks up
20
Q

Describe the hormones of the menstrual cycle

A
21
Q

Give a summary of the hormonal control of reproduction

A
22
Q

What can you use to measure how many follicles there are in the body?

A

AMH

23
Q

What is Kallman’s syndrome?

A
  • Lack of GnRH receptors in pituitary
24
Q

What is Sheehan’s syndrome?

A
  • Hypopituitarism caused by ischeamic necrosis due to blood loss and hypovolemic shock during childbirth
  • Reduced blood flow to the eclls that produce FSH and LH
  • Seen as secondary infertility
25
Q

What can PCOS cause?

A
  1. Hyperinsulinemia leading to inccreased ovarian androgen production but reduces sex hormone binding protein (SHBG) :. free androgen levels increase and oestrogen levels decrease
26
Q

What is Asherman’s syndrome?

A

Scar tissue formed after abortions

–> damage to endometrium and can impact implantation

27
Q

What is vaginismus?

A
  • Spasms during sexual intercourse
28
Q

What is the gold standard for tubal patency?

A
  • Laproscopy and dye test
  • Other:
  1. Hysterosalpino contrast sonography (HyCoSy) - ultrasound
  2. Hysterosalpinogram (HSG) - Xray after injecting contrast
29
Q

What is ovarian reserve testing?

A
  1. Used to guide how fast to give treatment
  2. Measures likelihood of IVF being successful
30
Q

How would you test endometrium?

A
  1. Progesterone challenge
  2. Hysteroscopy - telescope in uterus
31
Q

When would you test for serum progesterone?

A
  1. On day 21 to confirm whether a woman has ovulated
  2. Only work for women who have 28 day cycles
  3. Do 7 days before period is due
32
Q

What do serum gonadotrophins measure?

A
  • Measure day 2-5 serum gonadotrophins
  • When the follucle is starting to grow in response to LH and FSH
33
Q

How would you test for prolactinoma?

A
  1. Endocrine tests
  2. Prolactin levels > 6000mU/L = large non-functional tumour
  3. Large macroprolactinomas above 1cm = >10,000mU/
  4. CT scan
34
Q

What treament would you give to someone with a functioning prolactinoma?

A
  1. Cabergoline: long acting dopamine agonist
  2. If hormone profile for prolactin not v. hight = transphenoidal removal of tumour
  3. Treatment with long acting somatostatin analogues can also be used to see tumour shrinkage
35
Q

What hormonal imbalances would be observed in PCOS?

A
  1. LH - increased secretion
  2. Oestrogen - persistent (rather than cyclic)
  3. FSH - may be normal or low (LH:FSH ratio changes from 1:1 to 2:1 to 3:1)
  4. Progesterone - absent or low secretion
  5. Testosterone - increased
36
Q

Why is there lots of oestrogen being produced in PCOS?

A
  1. Egg is not being released
  2. Woman is not menstruating :. sufficient progesterone not being produced
  3. Leads to hormonal imbalance in which oestrogen acts unopposed
  4. Can lead to endometrial hyperplasna and increases risk of endometrial cancer
37
Q

What is given to stabilise PCOS?

A

Low dose oral contraceptives

38
Q

What can you give a woman with PCOS to help her get pregnant?

A
  1. Clomiphene citrate (clomifene, clomid) - induces ovulation
  2. Human menstrual gonadatrophins (Merional, Menopur) - increases chances of multiple pregnancies
39
Q

What is primary ammenorrhoea?

A
  • Failure to menarche by age of 16
  • May be due to structural abnormality: imperforated hymen, congenital absence of the uterus
  • Genetic disorders: XO in Turner’s syndrome or Testicular Feminisation Syndrome
40
Q

How would you test for TFM?

A
  • Chromosomal evaluation shows XY genotype, short vagina, no cervix, ovaries or uterus but testes present
  • Androgen binding studies on genital skin fibroblasts
    • Study shows no binding of T or DHT suggesting AR is absent or nonfunctional
    • Mildy elevated testerone and LH
41
Q

Treatment for TFM?

A
  • Removal of testes as they can cause neoplasia
  • Subsequent replacement with oestrogens will be required to maintain breasts due to removal of the source of oestradiol
42
Q

What is the threshold beta-hCG for intrauterine pregnancies?

A
  • 1500
  • More than 1500 and an empty uterus may indicate ectopic pregnancy
  • Or if diagnosis is uncertain and then measured again after 48 hours and repeat US and hCG droped then indicates spontaneous abortion or rupture
43
Q

Treatment for ectopic pregnancy?

A
  1. Linear salpingostomy: remove pregnancy by incising affected tube
  2. Salpingectomy: remove affected tube with pregancy

NB. Can be done via laproscopy or laparotomy (large surgical incision)

44
Q

What is premature thelarche?

A
  • Characterised by breast development under 2 years
  • Growth and bone age are normal
  • Condition is self-limiting over a few years
45
Q
A

ESR (7 decks)

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