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Year 3 - Reproductive and Sexual Health (DP) > Reproductive Gynaecology > Flashcards

Reproductive Gynaecology Flashcards

1
Q

Where are the ischial spines palpable on vaginal examination?

A

~A finger breadth into the vagina

~4 and 8 o’clock positions

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2
Q

What is the purpose of the sacrotuberous and sacrospinous ligaments?

A

Ensure inferior ed of sacrum isn’t pushed superiorly when weight is transferred vertically through the spine:

  • Jumping
  • Late pregnancy
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3
Q

What forms the greater sciatic foramen?

A

Sacrospinous ligament and greater sciatic notch

And sacrotuberous posteromedially

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4
Q

What forms the lesser foramen?

A

Sacrotuberous ligament and lesser sciatic notch

And sacrospinous superiorly

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5
Q

What forms the pelvic inlet?

A 
Sacral promontory (posteriorly)
Pubic symphysis (anteriorly)
Laterally (on both sides):
- Ilium
- Superior pubic ramus
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6
Q

What forms the pelvic outlet?

A 
Pubic symphysis (anteriorly)
Ischiopubic ramus (anteriorly)
Ischial tuberosities (laterally)
Sacrotuberous ligaments (posterolaterally)
Coccyx (posteriorly)
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7
Q

What forms the floor of the pelvic cavity?

A

Levator ani muscle

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8
Q

At the pelvic inlet, what is bigger:

  • Transverse diameter
  • AP diameter
A

Transverse diameter

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9
Q

At the pelvic outlet, what is bigger:

  • Transverse diameter
  • AP diameter
A

AP diameter

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10
Q

How is the female bony pelvis different to a male’s?

A 
Suprapubic angle (and pubic arch) are wider in females
Pelvic cavity is shallower in females
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11
Q

What is moulding and what does it allow?

A

Movement of 1 both over another

Allows foetal head to pass through pelvis during labour

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12
Q

What permits moulding to occur?

A

Cranial sutures and fontanelles

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13
Q

In foetal skull structure, what is the vertex?

A

An area outlined by:

  • Anterior and posterior fontanells AND
  • Parietal eminences
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14
Q

In the foetal skull, what is bigger:

  • Occipitofrontal diameter
  • Biparietal diameter
A

Occipitofrontal

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15
Q

When the foetus is entering the pelvic cavity, ideally what way should the face be orientated?

A

Facing right/left (transverse direction - pelvic inlet widest this way)

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16
Q

In regards to childbirth, what is a station?

A

Distance from foetal head to ischial spines

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17
Q

What does a negative station indicate?

A

Foetal head superior to ischial spines

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18
Q

What does a positive station indicate?

A

Foetal head inferior to ischial spines

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19
Q

When descending through the pelvic cavity, what should the foetal head do?

A

Rotate (ideally to an occipitoanterior position)

Be flexed - Chin on chest

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20
Q

During delivering, what position should the foetal head be in?

A

Extension

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21
Q

What is the alcohol limit for women seeking to undergo ACT?

A

=<4 units per week

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22
Q

What is the optimal BMI range for ACT? Who does this apply to?

A

19-29

Both the male and female

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23
Q

In what conditions may the mother be advised to take 5mg folic acid daily (instead of just 400mcg)

A

Vit B12 and folate deficiency
On AEDs
Maternal diabetes/obesity
Methotrexate (folate antagonist)

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24
Q

What immunisation status must be checked? What is done if not immune?

A

Rubella

Immunise

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25
Q

How can we assess ovarian reserve prior to ACT?

A

Antral follical count
OR
Anti-Müllerian hormone

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26
Q

What are the indications for intra-uterine insemination?

A

Unexplained infertility
Mild or moderate endometriosis
Mild male factor infertility

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27
Q

What are the indications for IVF

A 
Unexplained infertility for >2 years
Pelvic disease:
- Endometriosis
- Tubal disease
- Fibroids
Anovulatory interfility:
- Hypothalamic/Hypopituitary
- PCOS (after clomifene/metformin)
Male factor infertility:
- If >1x10^6 motile sperm
Pre-implantation genetic diagnosis
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28
Q

How is down regulation carried out prior to IVF?

A

Synthetic GnRH analogue or agonist (spray or injection)

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29
Q

How does down regulation work?

A

Reduces cancellation from ovulation
Improves success rates
Allows precise timing of oocyte recovery by using hCG trigger

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30
Q

What are side effects of the drugs used for down regulation?

A

Hot flushes
Mood swings
Nasal irritation
Headaches

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31
Q

How is ovarian stimulation carried out?

A

Gonadotropin hormone containing either:
- Synthetic or urinary gonatotropins
- FSH +/- LH
Self-administer as S/C injection

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32
Q

What does ovarian stimulation do?

A

Causes follicular development

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33
Q

What are the side effects of ovarian stimulation?

A

Mild allergic reaction

Ovarian Hyper-Stimulation Syndrome

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34
Q

if there is a slow response on the initial ‘action scan’, when can it be repeated?

A

72 hours later

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35
Q

If there has been a poor response to FSH, what can be done?

A

Abandon treatment
OR
Increase FSH dose

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36
Q

What is the purpose of the ‘action scan’?

A

Assess risk of OHSS

Plan date/timing of hCG injection

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37
Q

What does the hCG injection following the ‘action scan’ do? When is it given?

A

Mimics LH -> Resumption of meiosis in oocyte

36 hours before oocyte recovery

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38
Q

Before a sperm sample is obtained, how long should the couple abstain?

A

73 hours

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39
Q

When a sperm sample is obtained, what is it assessed for?

A

Volume
Density
Motility
Progression (how well they move)

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40
Q

What are the risks of oocyte retrieval?

A

Bleeding
Pelvic infection
Failure to retrieve oocytes

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41
Q

Once a mature oocyte has been retrieved, what must the embryologist do?

A

Search through follicular fluid
Identify eggs and surrounding mass of cells
Collect them into culture medium
Incubate at 37 degrees celcius

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42
Q

Upon fertilisation, what is the outer layer of the embryo called?

A

Zona Pellucida

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43
Q

Upon fertilisation, what is the inner layer of the embryo called?

A

Trophoblast

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44
Q

Upon fertilisation, what is the inner cell mass of the embryo called?

A

Embryoblast

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45
Q

Upon fertilisation, what is the inner space of the embryo called?

A

Blastocoele

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46
Q

What is the embryo referred to on days 1-2?

A

2-cell

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47
Q

What is the embryo referred to on day 3?

A

4-cell

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48
Q

What is the embryo referred to on days 3-4?

A

8-cell

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49
Q

What is the embryo referred to on day 4?

A

16-cell or Morula

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50
Q

What is the embryo referred to on day 5?

A

Early blastocyst

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51
Q

When does the embryo tend to implant into the uterine wall?

A

Day 7 (Ranges from days 6-12)

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52
Q

When can embryo transfer be carried out in IVF?

A 
Cleavage state (Days 2-4)
OR
Blastocyst stage (Days 5-6)
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53
Q

How many embryos are usually transferred?

A

1

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54
Q

When may more embryos be transferred?

A

If younger than 37 years and its the 3rd attempt:
- No more than 2
If aged 37-39:
- On 1st and 2nd cycles; 2 if none are top-quality
- On 3rd cycle, no more than 2
If aged 40-42:
- 2 embryos

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55
Q

After embryo transfer, what is given for luteal support and for how long?

A

Progesterone suppositories for 2 weeks

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56
Q

When is a pregnancy test carried out after embryo transfer?

A

Typically 2 weeks later

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57
Q

What are the indications for ICSI?

A

Severe male factor infertility
Previous failed IVF
Pre-implantation genetic diagnosis

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58
Q

Where is the sperm aspirated from in an obstructive severe male factory infertility?

A

Epididymis

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59
Q

Where is the sperm aspirated from in a non-obstructive severe male factory infertility?

A

Testicular tissue

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60
Q

What are symptoms of Ovarian Hyper-Stimulation Syndrome?

A

Abdominal pain/bloating
Nausea/Diarrhoea
Breathlessness

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61
Q

What treatment of OHSS can be used before embryo transfer?

A 
'Coasting':
- Withdraw gonadotropin gherapy
- Check No. and size of follicles daily
- Check [oestradiol] daily
- Determine when hCG can be given safely
Elective freeze
Single embryo transfer
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62
Q

How can OHSS be treated following embryo-transfer?

A

Antithrombotic (Fluids, TED stockings, Fragmin)
Analgesia
Hospital admission -> ?Termination

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63
Q

When does FSH start to rise in the menstrual cycle?

A

Immediately before menstruation (ie. ~day 25 of previous cycle)
ie. Near the end of the luteal phase

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64
Q

What day of the menstrual cycle is the beginning of menstruation?

A

Day 1

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65
Q

When do FSH levels typically reach their peak?

A

Day 3 of menstruation

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66
Q

When else does FSH exhibit a small peak?

A

Mid-cycle LH surge (~day 12)

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67
Q

What does FSH do?

A

Stimulates:

  • Ovarian follicle development
  • Granulosa cells to produce oestrogens
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68
Q

Why do FSH levels start to fall throughout the follicular phase?

A

Increased oestrogen and inhibin production (both stimulated by FSH) by the dominant follicle

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69
Q

What does the falling FSH level trigger?

A

Atresia of non-dominant follicles

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70
Q

What does LH do?

A

Triggers ovulation and follicular rupture

Formation of the corpus luteum from the granulosa cells left behind from secondary oocyte release

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71
Q

When does LH peak?

A

~Day 12

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72
Q

When does ovulation occur?

A

~Day 14 (~36-48 hours after LH surge)

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73
Q

What is the luteal phase?

A

Formation of corpus luteum:

  • Produces progesterone
  • Maintains pregnancy (initially)
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74
Q

What is luteolysis, when does it occur and what is formed?

A

Degradation of the corpus luteum
~14 days post-ovulation (if no pregnancy)
Corpus albicans produced

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75
Q

What is the proliferative endometrial phase? What causes it and when does it begin and end?

A

Growth of endometrial glands and strome
Oestrogen
~Days 5-14

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76
Q

What is the luteal endometrial phase? What causes it and when does it begin and end?

A

Glandular secretory activity
Progesterone
~Days 14-28

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77
Q

What happens in the late endometrial secretory phase?

A

Decidualisation (preparation for pregnancy)

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78
Q

What happens to the endometrium at the end of the luteal phase if no pregnancy occurs?

A

Endometrial apoptosis

Subsequent menstruation

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79
Q

How does menstruation occur?

A

Arteriolar constriction

Shedding of functional endometrial layer

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80
Q

How is scarring prevented in menstruation?

A

Fibrinolysis

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81
Q

How long does menstruation typically last?

A

4-6 days

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82
Q

When is menstrual flow at its peak?

A

Days 1-2

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83
Q

What is a normal menstrual volume and characteristic?

A

<80ml

No clots

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84
Q

How long is the average menstrual cycle?

A

28 days

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85
Q

What is the normal range of menstrual cycle length?

A

21-35 days

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86
Q

What else defines a normal menstrual cycle?

A

No inter-menstrual bleeding

No post-coital bleeding

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87
Q

What is menorrhagia?

A

Prolonged and increased menstrual flow

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88
Q

What is metrorrhagia?

A

Regular inter-menstrual bleeding

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89
Q

What is polymenorrhoea?

A

Menses occurring at <21 day intervals

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90
Q

What is polymenorrhagia?

A

Increased bleeding and more frequent cycles

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91
Q

What is menometrorrhagia?

A

Prolonged menses and inter-menstrual bleeding

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92
Q

What is amenorrhoea?

A

Absence of menstruation >6 months

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93
Q

What is oligomenorrhoea?

A

Menses at intervals >35 days

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94
Q

What is non-organic menorrhagia also called?

A

Dysfunctional uterine bleeding

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95
Q

What systemic endocrine disorders can result in organic menorrhagia?

A

Hyper-/Hypothyroidism
Diabetes
Adrenal disease
Prolactin disorders

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96
Q

What homeostasis disorders can result in organic menorrhagia?

A

Von Willebrand’s disease
ITP
Factor II, V, VII and XI deficiency

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97
Q

What percentage of women with abnormal uterine bleeding have dysfunction uterine bleeding (ie. non-organic)?

A

50%

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98
Q

What is the most common subtype of dysfunctional uterine bleeding? When does it occur? In who is most common? How does it present

A

Anovulatory:

  • At extremes of reproductive life
  • More common in obesity
  • Irregular bleeding
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99
Q

What is the other subtype of dysfunctional uterine bleeding? In who is it more common and how does it present? What causes it?

A

Ovulatory:

  • Women aged 35-45
  • Regular heavy periods
  • Inadequate progesterone by corpus luteum
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100
Q

What are the initial investigations into dysfunctional uterine bleeding?

A 
FBC
Cervical smear
TSH
Coagulation scnree
Renal/LFTs
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101
Q

What can a transvaginal USS detect in dysfunctional uterine bleeding?

A

Endometrial thickness

Presence of fibroids/other pelvic masses

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102
Q

How can an endometrial sample be obtained (in context of dysfunctional uterine bleeding)?

A

Pipell biopsies
Hysteroscopy
Dilatation and curettage

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103
Q

What is the first line treatment of dysfunctional uterine bleeding?

A

Progestogens

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104
Q

What is the second line treatment of dysfunctional uterine bleeding?

A

COC

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105
Q

What is the first line treatment of dysfunctional uterine bleeding if progestogens and oestrogens are contraindicated?

A 
NSAIDs:
- Mefenamic acid
- Ibuprofen
Anti-fibrinolytics:
- Tranexamic acid
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106
Q

When would GnRH analogues be considered in treating dysfunctional uterine bleeding?

A

If progestogens, oestrogens, NSAIDs and surgery are all contraindicated

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107
Q

What surgical treatments for dysfunctional uterine bleeding (ie. due to fibroids) may allow the woman to maintain fertility?

A

Uterine artery embolisation

Myomectomy

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108
Q

What surgical treatments for dysfunctional uterine bleeding should be considered if there is significant impact on QoL and the woman does not want to retain fertility?

A 
Endometrial ablation:
- Rollerball (REA)
- Bipolar mesh (Novasure)
- Thermal balloon (Thermachoice)
- Thermal hydroablation (Hydroblate)
Transcervical endometrial resection
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109
Q

What are the advantages of a hysterectomy over endometrial ablation?

A

No cervical smears required

Oestrogen-only HRT required

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110
Q

When may a hysterectomy be requested?

A

If woman wishes for amenorrhoea

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111
Q

When does the first trimester end?

A

~13 weeks

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112
Q

When does the second trimester end?

A

~28 weeks

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113
Q

When does the third trimester end?

A

40 weeks

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114
Q

How is bleeding in early pregnancy defined?

A

Bleeding before 12 weeks of pregnancy

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115
Q

How common is early pregnancy bleeding?

A

In 20% of pregnancies

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116
Q

How early can a urine pregnancy test detect pregnancy?

A

As early as 10 days after fertilisation

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117
Q

What does a urine pregnancy test detect?

A

Beta-hCG

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118
Q

What are some other potential symptoms alongside bleeding in early pregnancy?

A

Pain
Hyperemesis
Dizziness/Fainting

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119
Q

A woman presents with a positive urinary pregnancy test - this result was 6 weeks ago. There is some bleeding and minor cramping. She likens the cramps to those during her periods. On USS there is an empty uterus and products are sited in the vagina.

A

Complete miscarriage

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120
Q

A woman presents with a positive urinary pregnancy test - this result was 6 weeks ago. There is some bleeding and minor cramping. She likens the cramps to those during her periods. On USS there is evidence of an embryo and the cervical os is closed on examination

A

Threatened miscarriage

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121
Q

A woman presents with a positive urinary pregnancy test - this result was 6 weeks ago. There is some bleeding and minor cramping. She likens the cramps to those during her periods. The cervical os is open and products are sited there.

A

Inevitable miscarriage

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122
Q

On USS there is a mean sac diameter of 26mm. There is no foetal pole. There is no visible heartbeat activity.

A

Early foetal demise

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123
Q

On USS there is no foetal hear activity and the foetal pole is 8mm.

A

Early foetal demise

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124
Q

Where is the most common site of ectopic pregnancy?

A

Ampulla (78%)

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125
Q

What are the three locations of ectopic pregnancies that fall under the fallopian ectopics heading?

A

Ampulla
Isthmus
Fimbria

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126
Q

How does an ectopic pregnancy present?

A

Pain > Bleeding
Dizziness/Collapse
Shoulder pain
Breathlessness

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127
Q

What are some signs of ectopic pregnancy?

A 
Pallor
Haemodynambic instability
Peritonism:
- Guarding
- Tenderness
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128
Q

What blood test can be carried out if a patient with a suspected ectopic pregnancy is stable?

A

Beta-hCG
Comparative assessment:
- 48 hours apart to assess doubling (<53% increase in ectopic)
OR
- Well above discriminatory levels for normal pregnancy
OR
- Steady decrease

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129
Q

What examination is often needed alongside blood tests to diagnose an ectopic?

A

USS:

  • Empty uterus/Pseudosac
  • +/- Mass in adnexa
  • Free fluid in Pouch of Douglas
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130
Q

What is the management of an acutely unwell ectopic pregnancy?

A

Surgical management - Laparoscopy with either:
- Salpingostomy
OR
- Salpingectomy

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131
Q

When is medical management of an ectopic pregnancy used?

A

If patient is haemodynamically stable AND
If beta-hCG levels are low AND
Ectopic is small and unruptured on USS

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132
Q

What is the medical management of an ectopic pregnancy?

A

Single-dose IM Methotrexate (50mg/m^2 body area)

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133
Q

When would expectant management of an ectopic pregnancy be appropriate?

A

Beta-hCG <200 and declining
Ectopic mass <3cm diametet
No foetal cardiac activity
Willing to have close surveillance

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134
Q

What is a molar pregnancy?

A

Gestational trophoblastic disease

Non-viable fertilised egg

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135
Q

What are the pathognomonic ‘grape-like’ clusters seen in molar pregnancy?

A

Overgrowth of placental tissue with fluid-swollen chorionic villi

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136
Q

What is a complete mole?

A 
Egg without DNA
1 or 2 sperms fertilise:
- Diploidy with PATERNAL DNA only
No foetus
Overgrowth of placental tissue
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137
Q

What are the possible genotypes for a complete mole?

A

46, XX

46, XY

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138
Q

What is a partial mole?

A 
Haploid egg
1 sperm (reduplicates DNA material) 
OR
2 sperms fertilise egg
May have foetus
Overgrowth of placental tissue
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139
Q

What are the possible genotypes for a partial mole?

A

69, XXY

92, XXXY

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140
Q

What are important signs/symptoms at presentation that may indicate a molar pregnancy?

A

Hyperemesis
Varied bleeding - Passage of ‘grape-like’ tissue
Fundus large for dates
Occasional breathlessness

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141
Q

What does an USS show in molar pregnancies?

A

‘Snow storm’ appearance

+/- Foetus

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142
Q

What is a useful screening blood test for molar pregnancy?

A

Hugely raised beta-hCG for gestational age (often >100,000)

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143
Q

When does implantation bleeding occur?

A

At ~10 days post-ovulation

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144
Q

What is the bleeding like upon implantation?

A

Light-brownish

Limited

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145
Q

When may implantation bleeding be mistaken as a period?

A

2 weeks post-ovulation
Heavier bleed
Bright red

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146
Q

What percentage of complete moles become choriocarcinomas?

A

2.5%

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147
Q

What percentage of choriocarinomas develop from complete moles?

A

~50%

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148
Q

What is the pooling of blood between endometrium and embryo due to separation (ie. subchorionic) called? How can it present?

A

Chorionic haematoma:

  • Bleeding
  • Cramping
  • Threatened miscarriage
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149
Q

How is a chorionic haematoma managed?

A

Self-limited

Supportive

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150
Q

A patient presents with post-coital bleeding. She also complains of a clear, watery discharge from her vagina. A urine pregnancy test is positive. On cervical examination, there is visible evidence of some squamous metaplasia.

A

Cervical ectropion

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151
Q

What cervical infections can cause bleeding in early pregnancy?

A

Chlamydia

Gonorrhoea

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152
Q

A patient presents with a green, offensive discharge from her vagina. There is some bleeding. A urine pregnancy test is positive. On examination she has a ‘strawberry’ vagina.

A

Trichomoniasis

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153
Q

What other vaginal infections can cause bleeding in early pregnancy?

A

Bacterial vaginosis

Chlamydia

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154
Q

What hormones are secreted by the foetal testes that result in the development of male external genitalia?

A

Testosterone

Mullerian-inhibiting factor

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155
Q

What chromosome has the sex-determining region? What does this cause?

A

Y chromosome

Causes testis development from bipotential gonad

156
Q

What are the 2 primitive genital tracts?

A 
Wolffian duct (males)
Mullerian duct (females)
157
Q

In males, what does dihydrotestosterone stimulate the genital tubercle to develop into?

A

Developing penis -> Glans penis

158
Q

In males, what does dihydrotestosterone stimulate the urethral folds to develop into?

A

Partial fusion:

- Anus

159
Q

In males, what does dihydrotestosterone stimulate the genital swellings to develop into?

A

Prepuce
Shaft of penis
Scrotum

160
Q

In females, what does the absence dihydrotestosterone stimulate the genital tubercle to develop into?

A

Developing clitoris -> Clitoris

161
Q

In females, what does the absence dihydrotestosterone stimulate the urethral folds to develop into?

A

Remains unfused:

  • Labia minora
  • Urethral opening
  • Vagina
  • Anus
162
Q

In females, what does the absence dihydrotestosterone stimulate the genital swellings to develop into?

A

Labia majora

163
Q

What does the absence of Mullerian-Inhibiting Factor do?

A

Produces the female reproductive tract:

  • Oviducts
  • Uterus
164
Q

What is Androgen Insensitivity Syndrome? What is it also known as?

A

Congenital insensitivity to androgens

Testicular feminisation

165
Q

How is Androgen Insensitivity Syndrome inherited?

A

X-linked recessive (46, XY)

166
Q

What happens to the testes in Androgen Insensitivity Syndrome?

A

They develop but do not descend

167
Q

What is the pathophysiology of Androgen Insensitivity Syndrome?

A

Androgen induction of Wolffian ducts does NOT occur

Mullerian-inhibition does occur

168
Q

What is the phenotype of a person with Androgen Insensitivity Syndrome?

A

Female external genitalia
Absence of uterus and vagina
Short vagina

169
Q

How and when does Androgen Insensitivity Syndrome commonly present?

A

Primary amennorhoea and lack of pubic hair

At puberty

170
Q

Why is testis descent important?

A

Reduces temperature to that necessary for spermatogenesis

171
Q

What muscles raise/lower testes according to external temperature?

A

Dartos muscle

172
Q

What is cryptorchidism?

A

Individual reaching adulthood and testes are undescended

173
Q

When might an individual with crytorchidism still be fertile?

A

If unilateral

174
Q

What can be used to treat cryporchidism and before what age? What does this reduce the risk?

A

Orchidopexy
Below age 14
Reduces risk of testicular germ cell cancer

175
Q

What is the cancer risk of cryptorchidism in adults?

A

6x

176
Q

Where does spermatogenesis occur?

A

Seminiferous tubules

177
Q

What hormone stimulates what cells to start spermatogenesis?

A

FSH

Sertoli cells

178
Q

What cells produce testosterone and via the action of what hormone?

A

Leydig cells

LH

179
Q

What is the acrosome?

A

A part of the head of a sperm containing enzymes for penetrating ovum

180
Q

What do the sperm centrioles do?

A

Form the sperm flagellum (allowing movement)

Assist in production of embryo after fertilisation

181
Q

Where are mitochondria mainly found in the sperm?

A

Midpiece

182
Q

Apart from spermatogenesis, what other functions do the sertoli cells serve?

A 
Form a blood-testes barrier:
- Protects sperm from Ab attack
Provides nutrients for developing cells
Phagocytosis:
- Remove surplus cytoplasm
- Destroy defective cells
Secrete seminiferous tubule fluid
183
Q

What protein do sertoli cells secrete and what does it do?

A

Androgen Binding Globulin:

  • Binds testosterone (keeps conc. high in lumen)
  • Essential for sperm production
184
Q

What hormones do sertoli cells secrete and what do they do?

A

Inhibin and activin:

  • Regulate FSH secretion
  • Control spermatogenesis
185
Q

What sort of peptides are GnRHs?

A

Decapeptides

186
Q

How are GnRHs released? Where from?

A

From hypothalamus in bursts every 2-3 hours

187
Q

When does GnRH release begin?

A

Aged 8-12 years

188
Q

What does GnRH stimulate?

A

Anterior pituitary to release:

  • FSH
  • LH
189
Q

What is GnRH under negative feedback control from?

A

Testosterone

190
Q

Apart from activin and inhibin, what other hormone has a negative feedback control effect on both FSH and LH?

A

Testosterone

191
Q

What is the production of FSH and LH like in:

  1. Men
  2. Women
A
  1. Non-cyclical

2. Cyclical

192
Q

What is testosterone derived from?

A

Cholesterol

193
Q

What functions does testosterone have before birth?

A

Masculinises reproductive tract

Promotes descent of testes

194
Q

What functions does testosterone have during puberty?

A

Promotes puberty
Promotes male characteristics:
- Growth and maturation of male repro. system

195
Q

What functions does testosterone have during adulthood?

A 
Controls spermatogenesis
Secondary sexual characteristics:
- Male body shape
- Deep voice
- Thickens skin
Libido
Penile erection
196
Q

What is capacitation?

A

Biochemical and electrical events before fertilisation

197
Q

What is the fertilisation process (in regards to sperm)?

A
  1. Chemoattraction to oocyte
  2. Binding to Zona Pelludica
  3. Acrosomal reaction
  4. Hyperactivated motility
  5. Penetration and fusion with oocyte membrane
  6. Zonal reaction (Prevents more sperm fusing)
198
Q

Where does semen drain into from the seminal vesicles?

A

Ejaculatory duct:

  • Vesicle excretory duct PLUS
  • Vas deferens
199
Q

What do the seminal vesicles do?

A

Supplies fructose
Secretes prostaglandins (increasing motility)
Secrete fibrinogen

200
Q

What fluid does the prostate produce and what is this for?

A

Alkaline

Neutralises vaginal acidity

201
Q

What do the bulbourethral glands do?

A

Secrete mucous to act as lubricant

202
Q

What happens during erection?

A

Blood fills the corpora cavernosa (PNS)

203
Q

What can cause retrograde ejaculation?

A

Neuropathy
Prostate surgery
Anticholingergics

204
Q

What are some obstructive causes of male infertility?

A

CF
Vasectomy
Infection (eg. Prostatitis)

205
Q

What infection can cause a non-obstructive male infertility?

A

Mumps orchitis

206
Q

What pathology can cause a non-obstructive male infertility?

A

Testicular tumour

207
Q

What genetic disorders can cause a non-obstructive male infertility?

A

Chromosomal (Klinefelter’s)
Y microdeletions
Robertsonian translocation

208
Q

What are some other causes of a non-obstructive male infertility?

A

Iatrogenic (chemo/radiotherapy)
Specific semen abnormalities
Systemic disorder
Endocrine

209
Q

What is globozoospermia?

A

“Round-headed sperm syndrome”:

  • No acrosome
  • Abnormal nuclear membrane
  • Abnormal midpiece
  • 85% have same abnormalities
210
Q

How do pituitary tumours and hypothalamic disorders cause male infertility?

A

Reduction in:

  • LH
  • FSH
  • Testosterone
211
Q

What pituitary tumour disorders are associated with male infertility?

A

Acromegaly (Pituitary adenoma -> GH)
Cushing’s Disease (Pituitary adenoma -> ACTH)
Hyperprolactinoma

212
Q

What hypothalamic disorders are associated with male infertility?

A

Idiopathic
Tumours
Kallman’s syndrome (Failure to release GnRH)
Anorexia

213
Q

How do thyroid disorders cause male infertility?

A

Reduce sexual function

Increase prolactin

214
Q

How can diabetes cause male infertility?

A

Reduce sexual function

Reduce testosterone

215
Q

How can CAH cause male infertility?

A

Increased testosterone

216
Q

How can androgen insensivity cause male infertility?

A

Normal/Increased LH and testosterone

217
Q

How can steroid cause male infertility?

A

Reduce:

  • LH
  • FSH
  • Testosterone
218
Q

What is the normal testicular volume pre-puberty?

A

1-3mls

219
Q

What is the normal testicular volume in adults?

A

12-25mls

220
Q

Below what testicular volume is an adult unlikely to be fertile?

A

<5ml

221
Q

How is testicular volume measured?

A

Orchidometer

222
Q

What is sperm motility?

A

What proportion are moving

223
Q

What is hypospermia?

A

Low sperm volume

224
Q

What is oligozoospermia/oligospermia?

A

Very low sperm count

225
Q

What is asthenozoospermia/asthenospermia?

A

Poor sperm motility

226
Q

What is teratozoospermia/teratospermia?

A

More morphological defects than usual

227
Q

What is necrozoospermia?

A

All sperm in ejaculate are dead

228
Q

What is the lower reference limit for sperm volume?

A

1.5ml

229
Q

What is the lower reference limit for semen pH?

A

> =7.2

230
Q

What is the lower reference limit for sperm concentration?

A

15x10^6/ml

231
Q

What is the lower reference limit for total sperm number?

A

39x10^6

232
Q

What is the lower reference limit for total sperm motility?

A

40

233
Q

What is the lower reference limit for progressive sperm motility?

A

32

234
Q

What is the lower reference limit for strict morphology?

A

4% are normal forms

235
Q

What are the clinical features of an obstructive infertility?

A

Normal testicular volume
Normal secondary sexual characteristics
Vas deferens may be absent

236
Q

What are the endocrine features of an obstructive infertility?

A

Normal:

  • LH
  • FSH
  • Testosterone
237
Q

What are the clinical features of a non-obstructive infertility?

A

Low testicular volume
Reduced secondary sexual characteristics
Vas deferens present

238
Q

What are the endocrine features of a non-obstructive infertility?

A

High:
- LH
- FSH
Low testosterone

239
Q

What lifestyle factors can help with male infertility?

A 
Frequency of sexual intercourse:
- 2-3 times/week
- Avoid lubricants toxic to sperm
Alcohol <4 units/day
Stop smoking
BMI <30
Avoid tight underwear and prolonged hot baths
Antioxidants (Vit. C or Zinc may be good)
240
Q

What is the pregnancy rate per cycle of intra-uterine insemination?

A

15%

241
Q

What is the pregnancy rate per cycle of ICSI?

A

30%

242
Q

What is the indication for surgical sperm retrieval?

A

Azoospermia

243
Q

What is the success rate of retrieving sperm by surgical sperm retrieval in both kinds of infertility (obstructive and non-obstructive)?

A

Obstruction - 95%

Non-obstructive - 50%

244
Q

What are the indications for donor sperm insemination?

A

Azoospermia/Oligozoospermia
Genetic conditions
Infectious conditions

245
Q

What is the pregnancy rate per cycle of donor sperm insemination?

A

15%

246
Q

What article of the European Convention on Human Rights states “Everyone has a right to respect for his private and family life, home and correspondance?” What implications does this have in reproductive medicine?

A

Article 8:

  • Sperm/Egg donation
  • Seeking biological parent(s)
247
Q

When is embryo research permitted until and why?

A

Up to 14 days

Primitive streak appears

248
Q

When is abortion permitted until? When is it permitted beyond this?

A

24 weeks
Permitted after if:
- Child would be severely mentally/physically handicapped
- Significant risk to physical/mental health of mother or family members

249
Q

When might mitochondrial transfer be used?

A

Same sex couples

Single parent

250
Q

What are the Scottish Guidelines for NHS-Funded Infertility Treatment?

A 
Unexplained infertility for >=2 years
Female partner younger than 40
Female partner's BMI between 18.5 and 30
Both partners non-smokers
Both partners do not take illicit drugs
Neither partner to drink before or during treatment
Parents must not have a genetic child
251
Q

When is sex selection permitted under the Human Fertilisation and Embryological Authority?

A

If risk of serious gender-linked condition

252
Q

When is pre-implantation tissue testing permitted under the Human Fertilisation and Embryological Authority?

A

If an existing child has a serious or life-threatening condition

253
Q

What arteries supply the ovary and where do they enter from?

A

Helicine arteries

Enter hilum from the broad ligament

254
Q

What are the structures from superficial to deep of an ovary?

A
  1. Simple cuboidal epithelium
  2. Dense connective tissue:
    - Tunica albuginea (collagen blue when stained)
  3. Connective tissue with:
    - Stromal cells
    - Scattered smooth muscle fibres
  4. Ovarian follicles
255
Q

During development, what occurs in week 6 in regards to the future ovary?

A

Germ cells from yolk sac invade ovaries and proliferate by mitosis to form oogonia

256
Q

How are mature oocytes/ova formed? What is this process called?

A

Development and meiosis of oogonia

Oogenesis

257
Q

What is folliculogenesis? What does the formed structure consist of?

A

Growth of the follicle consisting of:

  • The oocyte
  • Any supporting cells
258
Q

What is atresia?

A

Loss of oogonia and oocytes:

  • Apoptosis based
  • Cell reabsorbed following cell death
259
Q

What happens to oocytes before birth?

A

Meiosis begins and halts at prophase 1

260
Q

What happens to an oocyte if it fails to associate with pregranulosa cells (follicle cells)?

A

It dies

261
Q

What shape are the pregranulosa cells initially?

A

Squamous

262
Q

What are primary follicles defined by?

A

Cuboidal granulosa cells surround oocyte:

- Zona granulosa

263
Q

After the zona granulosa surrounds the oocyte, what happens to the primary follicle?

A

Oocyte enlarges

Zona pellucida forms between oocyte and ZG

264
Q

What cells form the theca of the primary follicle and where do they associate?

A

Stromal cells

Associate with outside of follicle

265
Q

From superficial to deep, what is the general structure of a primary follicle?

A

Theca cells
Zona granulosa
Zona pellucida
Oocyte

266
Q

What is the approximate size of a primary oocyte?

A

45 micrometers

267
Q

What is the inner layer of the stromal cells surrounding the follicle known as? What does it do?

A

Theca interna:

- Secretes oestrogen precursors (converted to oestrogen by granulosa

268
Q

What is the outer layer of the stromal cells surrounding the follicle known as? What does it do?

A

Theca externa:

- Fibroblast-like

269
Q

What is the antrum?

A

A space filled with follicular fluid which forms and enlarges in the zona granulosa to form the secondary follicle

270
Q

What are the largest antral follicles and what size can they reach?

A 
Graafian follicles (tertiary follicles)
~20mm diameter
271
Q

What cells are directly adjacent to the zona pelucida and what is this called?

A

Cumulus cells

Corona radiata

272
Q

What happens to the follicle after ovulation?

A

Becomes the corpus luteum

273
Q

How is the ovum propelled along the oviducts?

A

Gentle peristalsis and cilia

274
Q

What is the structure of the ampulla mucosa?

A

Folded
Lined by simple columnar epithelium
With ciliated and secretory cells
Surrounded by smooth muscle

275
Q

How many layers of smooth muscle are there in the:

  1. Ampulla
  2. Isthmus
A
  1. Two layers

2. Three layers

276
Q

What is the endometrium composed of?

A

Tubular secretory glands in a connective tissue strome

277
Q

What is the myometrium composed of?

A

3 layers of smooth muscle

Combined with collagen and elastic tissue

278
Q

What is the perimetrium composed of?

A

Loose connective tissue

Cover by mesothelium

279
Q

What is the endometrium divided into and what are their functions?

A 
Stratum Functionalis:
- Undergoes monthly growth, degen. and loss
Stratum Basalis:
- Reserve tissue
- Regenerates Functionalis
280
Q

What happens to the endometrium during the proliferative phase?

A

Glands grow
Stroma grows
Vasculature grows

281
Q

What epithelium lines endometrial glands?

A

Pseudostratified columnar epithelium

282
Q

What cause the endometrial stroma to proliferate?

A

Oestrogens

283
Q

What happens to the endometrial glands during the secretory phase?

A

Coil (corkscrew appearance) and secret glycogen

284
Q

What is the cervix lined by on its vaginal surface?

A

Stratified squamous epithelium

285
Q

What does the cervical lining transition to more internally?

A

Mucous-secreting simply columnar

286
Q

What is the site of cervical epithelium transition called? What is it a common site for?

A

Squamocolumnar junction:

  • Dysplasia
  • Neoplastic change (most common site)
287
Q

During the proliferative phase, what are the endocervical gland secretions like and what does this allow?

A

Thing and watery

Sperm passage

288
Q

After ovulation, what are the endocervical gland secretions like and what does this prevent?

A

Thick and viscous

Prevent sperm or germ passage

289
Q

What are the four layers of the vagina?

A
  1. Non-keratinised stratified squamous epithelium
  2. Lamina propria (CT rich in elastic fibres and thin-walled blood vessels)
  3. Fibromuscular layer (inner circular sm; outer longitudinal sm)
  4. Adventitia
290
Q

Why is the epithelium of the vagina thicker during reproductive years?

A

Due to glycogen accumulation in the cells

291
Q

How is lactic acid produced in the vagina and what does this do?

A

Commensal bacteria metabolise glycogen

Prohibits pathogens growing

292
Q

What is the mons pubis?

A

Skin with highly oblique hair follicles:
- Coarse, curly hair
Overlies S/C fat pad (overlies pubic symphysis)

293
Q

What is the labia major?

A

Extension of mons pubis
Rich in apocrine sweat and sebaceous flands
Small bundles of smooth muscles
Hair follicles on outer surface only

294
Q

What is the structure of the labia minor?

A

Thin skin folds
Lacks S/C fat and hair follicles
Rich in vasculature and sebaceous glands:
- Secrete directly onto skin

295
Q

What is the epithelium of the labia minor?

A

Keratinised epithelium extending into vagina until the hymen

296
Q

How many tubes of erectile vascular tissue is in the clitoris and what are they called?

A

2 corpora cavernosa

297
Q

What bacteria predominate in the ‘healthy’ vagina and what do they produce?

A

Lactobacillus spp.:

  • Lactic acid
  • Hydrogen peroxide
298
Q

What other organisms are part of the normal vaginal flora?

A

Strep ‘viridans’
Group B beta-haemolytic Strep.
Candida spp. (in very small numbers)

299
Q

What do the following predispose to:

  • Recent antibiotic Rx
  • High oestrogen levels (Pregnancy, COC)
  • Poorly controlled diabetes
  • Immunosuppression
A

Candida infection

300
Q

How does candida infection present?

A

Intensely itchy white vaginal discharge (Non-sexually transmitted)

301
Q

How is candida diagnosed?

A

High vaginal swab for culture

302
Q

What is the most common cause of a candida infection and what is seen on a gram film?

A

Candida albicans:

  • Budding yeasts
  • Hyphae
303
Q

How is candida infection treated?

A

Topical clotrimazole pessary/cream (available OTC) 2-3 times daily
OR
Oral fluconazole 150mg single-dose

304
Q

How does Candida balanitis present?

A

‘Spotty’ rash on glans

305
Q

What can cause bacterial vaginosis?

A 
Gardnerella vaginalis (most common)
Mobiluncus
306
Q

How does bacterial vaginosis present?

A

Thin, watery, fishy-smelling vaginal discharge

307
Q

How is bacterial vaginosis diagnosed?

A

Clinical diagnosis

Also vaginal pH >4.5

308
Q

What laboratory testing can be used for bacterial vaginosis?

A

High vaginal swab for microscopy - Clue cells
Hay-Ison scoring system:
- Estimates proportions of clue cells to epithelial cells and lactobacilli

309
Q

How is bacterial vaginosis treated?

A

PO Metronidazole

310
Q

How does acute bacterial prostatitis present?

A

UTI symptoms
Pain in lower abdo./back/perineum/penis
Tender prostate on PR exam

311
Q

What organisms tend to cause acute bacterial prostatitis?

A

Same as for UTI:

  • E. coli
  • Enterococcus
  • Check for STI if <35 years (Chlamydia and gonorrhoea)
312
Q

How is acute bacterial prostatitis diagnosed?

A

Clinical signs
Mid-Stream Specimen of Urine (MSSU) for culture
+/- first pass urine for STI testing

313
Q

How is acute bacterial prostatisti treated?

A

Ciprofloxacin PO 500mg bd for 28 days

314
Q

How is acute bacterial prostatitis treated if there is a high C. diff risk?

A

Trimethoprim PO 200mg bd for 28 days

315
Q

What is the commonest bacterial STI in the UK?

A

Chlamydia

316
Q

How does Chlamydia reproduce?

A

Must be intracellular

Biphasic life cycle - “Energy parasite”

317
Q

Why does Chlamydia trachomatis not gram stain?

A

No peptidoglycan in cell wall

318
Q

What serovars of Chlamydia cause Trachoma (eye infection)?

A

A-C

319
Q

What serovars of Chlamydia cause a genital infection?

A

D-K

320
Q

What serovars of Chlamydia cause Lymphogranuloma venereum?

A

L1-L3

321
Q

What is Lymphogranuloma venereum?

A

Chronic lymphatic infection by Chlamydia

322
Q

Upon entry of Chlamydia, what does it do?

A

Attach and enter cells

323
Q

Two hours after entry of Chlamydia, what does it do?

A

Migrate to perinuclear area

Elementary body -> Reticulate body transition

324
Q

What happens 8-12 hours after Chlamydia infection?

A

Reticulate body multiplication

325
Q

What happens 12-24 hours after Chlamydia infection?

A

Inclusion biogenesis

Bacterial replication

326
Q

What happens 24-48 hours after Chlamydia?

A

Reticulate body -> Elementary body transition

Cell lysis

327
Q

What is the gram stain and shape of Neisseria gonorrhoeae?

A

Gram negative diplococcus
“Two kidney beans facing each other”
Often intracellular:
- Easily phagocytosed by polymorphs

328
Q

How can Chlamydia and Gonorrhoea be diagnosed in men?

A

First pass urine sample for NAATs

329
Q

How can Chlamydia and Gonorrhoea be diagnosed in women?

A

High-vaginal/Vulvovaginal swab for NAATs
OR
Endocervical swab if speculum exam

330
Q

What additional samples can be taken in the diagnosis of Chlamydia and Gonorrhoea?

A

Rectal
Throat
Eyes (In babies and adults)

331
Q

What are NAATs?

A

Combined Nucleic Acid Amplification Tests

332
Q

Why would Chlamydia and Gonorrhoea be cultured?

A

Antibiotic sensitivity

Epidemiology

333
Q

What samples are Chlamydia and Gonorrhoea cultured from?

A

Endocervical
Rectal
Throat

334
Q

NAATs detect dead organisms. How long should you wait to test for a ‘test of cure’?

A

5 weeks

335
Q

What is the recommended treatment for Gonorrhoea?

A

IM Ceftriazone 500mg single dose
AND
PO Azithromycin 1g single dose

336
Q

What is the recommended treatment for Chlamydia?

A

PO Azithromycin 1g single dose
OR
PO Doxycycline 100mg bd for 7 days (used if rectal chlamydia)

337
Q

Does Treponema pallidum gram stain?

A

No

338
Q

What is the primary stage of syphilis infection?

A

Chancre (painless and heals by itself)

339
Q

What is the secondary stage of syphilis infection?

A

Large number in blood:

  • “Snail-track” mouth ulcers
  • Generalised rash
  • Flu like illness
340
Q

What is the latent stage of syphilis infection?

A 
Asymptomatic
Slow multiplication in vessel intima
Divided into:
- Early latent
- Late latent
341
Q

What is the late stage of syphilis infection?

A

CVS/Neurological complications

Many years later

342
Q

What is the initial test for syphilis?

A

Serology (VDRL):

- Testing for non-specific and specific Ab to T. pallidum

343
Q

What do non-specific Abs to T. pallidum test for?

A

Disease activity

Response to therapy

344
Q

What do specific Abs to T. pallidum test for?

A

Confirm diagnosis
Ab levels decline slowly even after therapy
May remain positive for life

345
Q

If there are syphilitic lesions, what testing can be done?

A

Swab of primary/secondary lesions for PCR

346
Q

If a primary/secondary lesion is present in suspected syphilis, what other investigation can be done?

A

Dark ground microscopy to look for spirochaetes

347
Q

When may serological testing show false positives?

A

SLE
Malaria
Pregnancy

348
Q

What is the specific serological test used in Tayside for diagnosis of syphilis?

A

Treponema pallidum particle agglutination assay (TPAA)

349
Q

Why are the specific serological tests for syphilis not useful in monitoring response to therapy?

A

Remain positive for life

350
Q

What is a serological screening test for syphilis?

A

IgM and IgG ELISA on clotted blood sample

351
Q

If the screening test for syphilis is positive, what tests are done?

A

IgM ELISA

VDRL and TPPA

352
Q

What is the management of syphilis?

A

IM benzathine benzylpenicillin 1.8g single dose

353
Q

What is the structure of HPV?

A

Non-enveloped, icosohedral virus with double-stranding DNA

354
Q

What types of HPV are the most commonest causes of genital warts?

A

6

11

355
Q

What is the treatment of genital warts?

A

Cryotherapy

Podophyllotoxin cream/lotion

356
Q

What is the structure of HSV?

A

Enveloped virus with double-stranded DNA

357
Q

Where does HSV replicate?

A

Dermis and epidermis

358
Q

Why does HSV cause exquisitely painful, multiple small vesicles?

A

Gets into nerve endings causing inflammation:

  • Sensory
  • Autonomia
359
Q

How does HSV hide from the immune system?

A

Migrates to sacral root ganglion

360
Q

How can HSV be diagnosed?

A

Swab a deroofed blister:

  • Virus transport medium
  • PCR (highly sensitive and specific)
361
Q

How is HSV treated?

A

Aciclovir 200mg 5 times daily for 5 days

Pain relief

362
Q

What is Trichomonas vaginalis?

A

Single celled protozoal parasite:

  • Divides by binary fission
  • No cyst form known
  • Human host only
363
Q

How does Trichomonas vaginalis present?

A

Green, frothy, offensive-smelling vaginal discharge and vulva irritation in women

Urethritis in men?

364
Q

How is Trichomonas vaginalis diagnosed?

A

High vaginal swab for microscopy

No good test for men (as PCR not used for it in Tayside)

365
Q

How is Trichomonas vaginalis treated?

A

PO metronidazole 400 bd for 5-7 days

Or 2g single dose

366
Q

How long is the life span for pubic lice in men?

A

22 days

367
Q

How long is the life span for pubic lice in women?

A

17 days

368
Q

What is the treatment for pubic lice?

A

Malathion lotion

369
Q

On trans-vaginal ultrasound, what endometrial thickness would indicate the need for biopsy?

A

> 4mm in post-menopausal

>16mm in pre-menopausal

370
Q

How does endometrial pipelle work? What are the advantages and disadvantages

A 
3.1mm diameter (no dilatation needed)
No anaesthesia
Outpatient
Very safe
Limited sample
371
Q

What are some facts about D+C for endometrial sampling?

A

Most common operation in women
Most thorough sampling method
Can miss 5% of hyperplasias/cancers

372
Q

What part of the history is not required in assessment of abnormal uterine bleeding?

A

Number of pregnancies

Drugs without hormonal influences

373
Q

What are some organic endometrial causes of abnormal uterine bleeding?

A

Endometriosis
Polyp
Miscarriage

374
Q

What are some organic myometrial causes of abnormal uterine bleeding?

A

Adenomyosis

Leiomyoma

375
Q

How is endometritis histologically diagnosed?

A

Abnormal pattern of inflammatory cells

376
Q

What protects the endometrium from ascending infection?

A

Cervical mucous plug

Cyclical shedding

377
Q

What infections can cause endometritis?

A 
Neisseria
Chlamydia
TB
CMV
Actinomyces
HSV
378
Q

What is chronic plasmacytic endometritis associated with?

A

PID:

  • Gonorrhoea
  • Chlamydia
  • Enteric organisms
379
Q

How many endometrial polyps present?

A 
Usually asymptomatic
May present with:
- Bleeding
- Discharge
Around and after menopause
380
Q

How can adenomyosis present?

A

Menorrhagia

Dysmenorrhoea

381
Q

What is adenomyosis?

A

Endometrial glands and stroma within myometrium

382
Q

What is a leiomyoma?

A

A benign smooth muscle tumour

383
Q

What are the symptoms of a leiomyoma?

A

Menorrhagia
Infertility
Mass effect
Pain

384
Q

What is the growth of a leiomyoma dependent on?

A

Oestrogen

385
Q

How does a leiomyoma appear histologically?

A

Interlacing smooth muscle cells

Year 3 - Reproductive and Sexual Health (DP) (7 decks)

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