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
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
3
Q
What forms the greater sciatic foramen?
A
Sacrospinous ligament and greater sciatic notch
And sacrotuberous posteromedially
4
Q
What forms the lesser foramen?
A
Sacrotuberous ligament and lesser sciatic notch
And sacrospinous superiorly
5
Q
What forms the pelvic inlet?
A
Sacral promontory (posteriorly) Pubic symphysis (anteriorly) Laterally (on both sides): - Ilium - Superior pubic ramus
6
Q
What forms the pelvic outlet?
A
Pubic symphysis (anteriorly) Ischiopubic ramus (anteriorly) Ischial tuberosities (laterally) Sacrotuberous ligaments (posterolaterally) Coccyx (posteriorly)
7
Q
What forms the floor of the pelvic cavity?
A
Levator ani muscle
8
Q
At the pelvic inlet, what is bigger:
- Transverse diameter
- AP diameter
A
Transverse diameter
9
Q
At the pelvic outlet, what is bigger:
- Transverse diameter
- AP diameter
A
AP diameter
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
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
12
Q
What permits moulding to occur?
A
Cranial sutures and fontanelles
13
Q
In foetal skull structure, what is the vertex?
A
An area outlined by:
- Anterior and posterior fontanells AND
- Parietal eminences
14
Q
In the foetal skull, what is bigger:
- Occipitofrontal diameter
- Biparietal diameter
A
Occipitofrontal
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)
16
Q
In regards to childbirth, what is a station?
A
Distance from foetal head to ischial spines
17
Q
What does a negative station indicate?
A
Foetal head superior to ischial spines
18
Q
What does a positive station indicate?
A
Foetal head inferior to ischial spines
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
20
Q
During delivering, what position should the foetal head be in?
A
Extension
21
Q
What is the alcohol limit for women seeking to undergo ACT?
A
=<4 units per week
22
Q
What is the optimal BMI range for ACT? Who does this apply to?
A
19-29
Both the male and female
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)
24
Q
What immunisation status must be checked? What is done if not immune?
A
Rubella
Immunise
25
How can we assess ovarian reserve prior to ACT?
Antral follical count
OR
Anti-Müllerian hormone
26
What are the indications for intra-uterine insemination?
Unexplained infertility
Mild or moderate endometriosis
Mild male factor infertility
27
What are the indications for IVF
```
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
```
28
How is down regulation carried out prior to IVF?
Synthetic GnRH analogue or agonist (spray or injection)
29
How does down regulation work?
Reduces cancellation from ovulation
Improves success rates
Allows precise timing of oocyte recovery by using hCG trigger
30
What are side effects of the drugs used for down regulation?
Hot flushes
Mood swings
Nasal irritation
Headaches
31
How is ovarian stimulation carried out?
Gonadotropin hormone containing either:
- Synthetic or urinary gonatotropins
- FSH +/- LH
Self-administer as S/C injection
32
What does ovarian stimulation do?
Causes follicular development
33
What are the side effects of ovarian stimulation?
Mild allergic reaction
| Ovarian Hyper-Stimulation Syndrome
34
if there is a slow response on the initial 'action scan', when can it be repeated?
72 hours later
35
If there has been a poor response to FSH, what can be done?
Abandon treatment
OR
Increase FSH dose
36
What is the purpose of the 'action scan'?
Assess risk of OHSS
| Plan date/timing of hCG injection
37
What does the hCG injection following the 'action scan' do? When is it given?
Mimics LH -> Resumption of meiosis in oocyte
| 36 hours before oocyte recovery
38
Before a sperm sample is obtained, how long should the couple abstain?
73 hours
39
When a sperm sample is obtained, what is it assessed for?
Volume
Density
Motility
Progression (how well they move)
40
What are the risks of oocyte retrieval?
Bleeding
Pelvic infection
Failure to retrieve oocytes
41
Once a mature oocyte has been retrieved, what must the embryologist do?
Search through follicular fluid
Identify eggs and surrounding mass of cells
Collect them into culture medium
Incubate at 37 degrees celcius
42
Upon fertilisation, what is the outer layer of the embryo called?
Zona Pellucida
43
Upon fertilisation, what is the inner layer of the embryo called?
Trophoblast
44
Upon fertilisation, what is the inner cell mass of the embryo called?
Embryoblast
45
Upon fertilisation, what is the inner space of the embryo called?
Blastocoele
46
What is the embryo referred to on days 1-2?
2-cell
47
What is the embryo referred to on day 3?
4-cell
48
What is the embryo referred to on days 3-4?
8-cell
49
What is the embryo referred to on day 4?
16-cell or Morula
50
What is the embryo referred to on day 5?
Early blastocyst
51
When does the embryo tend to implant into the uterine wall?
Day 7 (Ranges from days 6-12)
52
When can embryo transfer be carried out in IVF?
```
Cleavage state (Days 2-4)
OR
Blastocyst stage (Days 5-6)
```
53
How many embryos are usually transferred?
1
54
When may more embryos be transferred?
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
55
After embryo transfer, what is given for luteal support and for how long?
Progesterone suppositories for 2 weeks
56
When is a pregnancy test carried out after embryo transfer?
Typically 2 weeks later
57
What are the indications for ICSI?
Severe male factor infertility
Previous failed IVF
Pre-implantation genetic diagnosis
58
Where is the sperm aspirated from in an obstructive severe male factory infertility?
Epididymis
59
Where is the sperm aspirated from in a non-obstructive severe male factory infertility?
Testicular tissue
60
What are symptoms of Ovarian Hyper-Stimulation Syndrome?
Abdominal pain/bloating
Nausea/Diarrhoea
Breathlessness
61
What treatment of OHSS can be used before embryo transfer?
```
'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
```
62
How can OHSS be treated following embryo-transfer?
Antithrombotic (Fluids, TED stockings, Fragmin)
Analgesia
Hospital admission -> ?Termination
63
When does FSH start to rise in the menstrual cycle?
Immediately before menstruation (ie. ~day 25 of previous cycle)
ie. Near the end of the luteal phase
64
What day of the menstrual cycle is the beginning of menstruation?
Day 1
65
When do FSH levels typically reach their peak?
Day 3 of menstruation
66
When else does FSH exhibit a small peak?
Mid-cycle LH surge (~day 12)
67
What does FSH do?
Stimulates:
- Ovarian follicle development
- Granulosa cells to produce oestrogens
68
Why do FSH levels start to fall throughout the follicular phase?
Increased oestrogen and inhibin production (both stimulated by FSH) by the dominant follicle
69
What does the falling FSH level trigger?
Atresia of non-dominant follicles
70
What does LH do?
Triggers ovulation and follicular rupture
| Formation of the corpus luteum from the granulosa cells left behind from secondary oocyte release
71
When does LH peak?
~Day 12
72
When does ovulation occur?
~Day 14 (~36-48 hours after LH surge)
73
What is the luteal phase?
Formation of corpus luteum:
- Produces progesterone
- Maintains pregnancy (initially)
74
What is luteolysis, when does it occur and what is formed?
Degradation of the corpus luteum
~14 days post-ovulation (if no pregnancy)
Corpus albicans produced
75
What is the proliferative endometrial phase? What causes it and when does it begin and end?
Growth of endometrial glands and strome
Oestrogen
~Days 5-14
76
What is the luteal endometrial phase? What causes it and when does it begin and end?
Glandular secretory activity
Progesterone
~Days 14-28
77
What happens in the late endometrial secretory phase?
Decidualisation (preparation for pregnancy)
78
What happens to the endometrium at the end of the luteal phase if no pregnancy occurs?
Endometrial apoptosis
| Subsequent menstruation
79
How does menstruation occur?
Arteriolar constriction
| Shedding of functional endometrial layer
80
How is scarring prevented in menstruation?
Fibrinolysis
81
How long does menstruation typically last?
4-6 days
82
When is menstrual flow at its peak?
Days 1-2
83
What is a normal menstrual volume and characteristic?
<80ml
| No clots
84
How long is the average menstrual cycle?
28 days
85
What is the normal range of menstrual cycle length?
21-35 days
86
What else defines a normal menstrual cycle?
No inter-menstrual bleeding
| No post-coital bleeding
87
What is menorrhagia?
Prolonged and increased menstrual flow
88
What is metrorrhagia?
Regular inter-menstrual bleeding
89
What is polymenorrhoea?
Menses occurring at <21 day intervals
90
What is polymenorrhagia?
Increased bleeding and more frequent cycles
91
What is menometrorrhagia?
Prolonged menses and inter-menstrual bleeding
92
What is amenorrhoea?
Absence of menstruation >6 months
93
What is oligomenorrhoea?
Menses at intervals >35 days
94
What is non-organic menorrhagia also called?
Dysfunctional uterine bleeding
95
What systemic endocrine disorders can result in organic menorrhagia?
Hyper-/Hypothyroidism
Diabetes
Adrenal disease
Prolactin disorders
96
What homeostasis disorders can result in organic menorrhagia?
Von Willebrand's disease
ITP
Factor II, V, VII and XI deficiency
97
What percentage of women with abnormal uterine bleeding have dysfunction uterine bleeding (ie. non-organic)?
50%
98
What is the most common subtype of dysfunctional uterine bleeding? When does it occur? In who is most common? How does it present
Anovulatory:
- At extremes of reproductive life
- More common in obesity
- Irregular bleeding
99
What is the other subtype of dysfunctional uterine bleeding? In who is it more common and how does it present? What causes it?
Ovulatory:
- Women aged 35-45
- Regular heavy periods
- Inadequate progesterone by corpus luteum
100
What are the initial investigations into dysfunctional uterine bleeding?
```
FBC
Cervical smear
TSH
Coagulation scnree
Renal/LFTs
```
101
What can a transvaginal USS detect in dysfunctional uterine bleeding?
Endometrial thickness
| Presence of fibroids/other pelvic masses
102
How can an endometrial sample be obtained (in context of dysfunctional uterine bleeding)?
Pipell biopsies
Hysteroscopy
Dilatation and curettage
103
What is the first line treatment of dysfunctional uterine bleeding?
Progestogens
104
What is the second line treatment of dysfunctional uterine bleeding?
COC
105
What is the first line treatment of dysfunctional uterine bleeding if progestogens and oestrogens are contraindicated?
```
NSAIDs:
- Mefenamic acid
- Ibuprofen
Anti-fibrinolytics:
- Tranexamic acid
```
106
When would GnRH analogues be considered in treating dysfunctional uterine bleeding?
If progestogens, oestrogens, NSAIDs and surgery are all contraindicated
107
What surgical treatments for dysfunctional uterine bleeding (ie. due to fibroids) may allow the woman to maintain fertility?
Uterine artery embolisation
| Myomectomy
108
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?
```
Endometrial ablation:
- Rollerball (REA)
- Bipolar mesh (Novasure)
- Thermal balloon (Thermachoice)
- Thermal hydroablation (Hydroblate)
Transcervical endometrial resection
```
109
What are the advantages of a hysterectomy over endometrial ablation?
No cervical smears required
| Oestrogen-only HRT required
110
When may a hysterectomy be requested?
If woman wishes for amenorrhoea
111
When does the first trimester end?
~13 weeks
112
When does the second trimester end?
~28 weeks
113
When does the third trimester end?
40 weeks
114
How is bleeding in early pregnancy defined?
Bleeding before 12 weeks of pregnancy
115
How common is early pregnancy bleeding?
In 20% of pregnancies
116
How early can a urine pregnancy test detect pregnancy?
As early as 10 days after fertilisation
117
What does a urine pregnancy test detect?
Beta-hCG
118
What are some other potential symptoms alongside bleeding in early pregnancy?
Pain
Hyperemesis
Dizziness/Fainting
119
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.
Complete miscarriage
120
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
Threatened miscarriage
121
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.
Inevitable miscarriage
122
On USS there is a mean sac diameter of 26mm. There is no foetal pole. There is no visible heartbeat activity.
Early foetal demise
123
On USS there is no foetal hear activity and the foetal pole is 8mm.
Early foetal demise
124
Where is the most common site of ectopic pregnancy?
Ampulla (78%)
125
What are the three locations of ectopic pregnancies that fall under the fallopian ectopics heading?
Ampulla
Isthmus
Fimbria
126
How does an ectopic pregnancy present?
Pain > Bleeding
Dizziness/Collapse
Shoulder pain
Breathlessness
127
What are some signs of ectopic pregnancy?
```
Pallor
Haemodynambic instability
Peritonism:
- Guarding
- Tenderness
```
128
What blood test can be carried out if a patient with a suspected ectopic pregnancy is stable?
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
129
What examination is often needed alongside blood tests to diagnose an ectopic?
USS:
- Empty uterus/Pseudosac
- +/- Mass in adnexa
- Free fluid in Pouch of Douglas
130
What is the management of an acutely unwell ectopic pregnancy?
Surgical management - Laparoscopy with either:
- Salpingostomy
OR
- Salpingectomy
131
When is medical management of an ectopic pregnancy used?
If patient is haemodynamically stable AND
If beta-hCG levels are low AND
Ectopic is small and unruptured on USS
132
What is the medical management of an ectopic pregnancy?
Single-dose IM Methotrexate (50mg/m^2 body area)
133
When would expectant management of an ectopic pregnancy be appropriate?
Beta-hCG <200 and declining
Ectopic mass <3cm diametet
No foetal cardiac activity
Willing to have close surveillance
134
What is a molar pregnancy?
Gestational trophoblastic disease
| Non-viable fertilised egg
135
What are the pathognomonic 'grape-like' clusters seen in molar pregnancy?
Overgrowth of placental tissue with fluid-swollen chorionic villi
136
What is a complete mole?
```
Egg without DNA
1 or 2 sperms fertilise:
- Diploidy with PATERNAL DNA only
No foetus
Overgrowth of placental tissue
```
137
What are the possible genotypes for a complete mole?
46, XX
| 46, XY
138
What is a partial mole?
```
Haploid egg
1 sperm (reduplicates DNA material)
OR
2 sperms fertilise egg
May have foetus
Overgrowth of placental tissue
```
139
What are the possible genotypes for a partial mole?
69, XXY
| 92, XXXY
140
What are important signs/symptoms at presentation that may indicate a molar pregnancy?
Hyperemesis
Varied bleeding - Passage of 'grape-like' tissue
Fundus large for dates
Occasional breathlessness
141
What does an USS show in molar pregnancies?
'Snow storm' appearance
| +/- Foetus
142
What is a useful screening blood test for molar pregnancy?
Hugely raised beta-hCG for gestational age (often >100,000)
143
When does implantation bleeding occur?
At ~10 days post-ovulation
144
What is the bleeding like upon implantation?
Light-brownish
| Limited
145
When may implantation bleeding be mistaken as a period?
2 weeks post-ovulation
Heavier bleed
Bright red
146
What percentage of complete moles become choriocarcinomas?
2.5%
147
What percentage of choriocarinomas develop from complete moles?
~50%
148
What is the pooling of blood between endometrium and embryo due to separation (ie. subchorionic) called? How can it present?
Chorionic haematoma:
- Bleeding
- Cramping
- Threatened miscarriage
149
How is a chorionic haematoma managed?
Self-limited
| Supportive
150
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.
Cervical ectropion
151
What cervical infections can cause bleeding in early pregnancy?
Chlamydia
| Gonorrhoea
152
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.
Trichomoniasis
153
What other vaginal infections can cause bleeding in early pregnancy?
Bacterial vaginosis
| Chlamydia
154
What hormones are secreted by the foetal testes that result in the development of male external genitalia?
Testosterone
| Mullerian-inhibiting factor
155
What chromosome has the sex-determining region? What does this cause?
Y chromosome
| Causes testis development from bipotential gonad
156
What are the 2 primitive genital tracts?
```
Wolffian duct (males)
Mullerian duct (females)
```
157
In males, what does dihydrotestosterone stimulate the genital tubercle to develop into?
Developing penis -> Glans penis
158
In males, what does dihydrotestosterone stimulate the urethral folds to develop into?
Partial fusion:
| - Anus
159
In males, what does dihydrotestosterone stimulate the genital swellings to develop into?
Prepuce
Shaft of penis
Scrotum
160
In females, what does the absence dihydrotestosterone stimulate the genital tubercle to develop into?
Developing clitoris -> Clitoris
161
In females, what does the absence dihydrotestosterone stimulate the urethral folds to develop into?
Remains unfused:
- Labia minora
- Urethral opening
- Vagina
- Anus
162
In females, what does the absence dihydrotestosterone stimulate the genital swellings to develop into?
Labia majora
163
What does the absence of Mullerian-Inhibiting Factor do?
Produces the female reproductive tract:
- Oviducts
- Uterus
164
What is Androgen Insensitivity Syndrome? What is it also known as?
Congenital insensitivity to androgens
| Testicular feminisation
165
How is Androgen Insensitivity Syndrome inherited?
X-linked recessive (46, XY)
166
What happens to the testes in Androgen Insensitivity Syndrome?
They develop but do not descend
167
What is the pathophysiology of Androgen Insensitivity Syndrome?
Androgen induction of Wolffian ducts does NOT occur
| Mullerian-inhibition does occur
168
What is the phenotype of a person with Androgen Insensitivity Syndrome?
Female external genitalia
Absence of uterus and vagina
Short vagina
169
How and when does Androgen Insensitivity Syndrome commonly present?
Primary amennorhoea and lack of pubic hair
| At puberty
170
Why is testis descent important?
Reduces temperature to that necessary for spermatogenesis
171
What muscles raise/lower testes according to external temperature?
Dartos muscle
172
What is cryptorchidism?
Individual reaching adulthood and testes are undescended
173
When might an individual with crytorchidism still be fertile?
If unilateral
174
What can be used to treat cryporchidism and before what age? What does this reduce the risk?
Orchidopexy
Below age 14
Reduces risk of testicular germ cell cancer
175
What is the cancer risk of cryptorchidism in adults?
6x
176
Where does spermatogenesis occur?
Seminiferous tubules
177
What hormone stimulates what cells to start spermatogenesis?
FSH
| Sertoli cells
178
What cells produce testosterone and via the action of what hormone?
Leydig cells
| LH
179
What is the acrosome?
A part of the head of a sperm containing enzymes for penetrating ovum
180
What do the sperm centrioles do?
Form the sperm flagellum (allowing movement)
| Assist in production of embryo after fertilisation
181
Where are mitochondria mainly found in the sperm?
Midpiece
182
Apart from spermatogenesis, what other functions do the sertoli cells serve?
```
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
What protein do sertoli cells secrete and what does it do?
Androgen Binding Globulin:
- Binds testosterone (keeps conc. high in lumen)
- Essential for sperm production
184
What hormones do sertoli cells secrete and what do they do?
Inhibin and activin:
- Regulate FSH secretion
- Control spermatogenesis
185
What sort of peptides are GnRHs?
Decapeptides
186
How are GnRHs released? Where from?
From hypothalamus in bursts every 2-3 hours
187
When does GnRH release begin?
Aged 8-12 years
188
What does GnRH stimulate?
Anterior pituitary to release:
- FSH
- LH
189
What is GnRH under negative feedback control from?
Testosterone
190
Apart from activin and inhibin, what other hormone has a negative feedback control effect on both FSH and LH?
Testosterone
191
What is the production of FSH and LH like in:
1. Men
2. Women
1. Non-cyclical
| 2. Cyclical
192
What is testosterone derived from?
Cholesterol
193
What functions does testosterone have before birth?
Masculinises reproductive tract
| Promotes descent of testes
194
What functions does testosterone have during puberty?
Promotes puberty
Promotes male characteristics:
- Growth and maturation of male repro. system
195
What functions does testosterone have during adulthood?
```
Controls spermatogenesis
Secondary sexual characteristics:
- Male body shape
- Deep voice
- Thickens skin
Libido
Penile erection
```
196
What is capacitation?
Biochemical and electrical events before fertilisation
197
What is the fertilisation process (in regards to sperm)?
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
Where does semen drain into from the seminal vesicles?
Ejaculatory duct:
- Vesicle excretory duct PLUS
- Vas deferens
199
What do the seminal vesicles do?
Supplies fructose
Secretes prostaglandins (increasing motility)
Secrete fibrinogen
200
What fluid does the prostate produce and what is this for?
Alkaline
| Neutralises vaginal acidity
201
What do the bulbourethral glands do?
Secrete mucous to act as lubricant
202
What happens during erection?
Blood fills the corpora cavernosa (PNS)
203
What can cause retrograde ejaculation?
Neuropathy
Prostate surgery
Anticholingergics
204
What are some obstructive causes of male infertility?
CF
Vasectomy
Infection (eg. Prostatitis)
205
What infection can cause a non-obstructive male infertility?
Mumps orchitis
206
What pathology can cause a non-obstructive male infertility?
Testicular tumour
207
What genetic disorders can cause a non-obstructive male infertility?
Chromosomal (Klinefelter's)
Y microdeletions
Robertsonian translocation
208
What are some other causes of a non-obstructive male infertility?
Iatrogenic (chemo/radiotherapy)
Specific semen abnormalities
Systemic disorder
Endocrine
209
What is globozoospermia?
"Round-headed sperm syndrome":
- No acrosome
- Abnormal nuclear membrane
- Abnormal midpiece
- 85% have same abnormalities
210
How do pituitary tumours and hypothalamic disorders cause male infertility?
Reduction in:
- LH
- FSH
- Testosterone
211
What pituitary tumour disorders are associated with male infertility?
Acromegaly (Pituitary adenoma -> GH)
Cushing's Disease (Pituitary adenoma -> ACTH)
Hyperprolactinoma
212
What hypothalamic disorders are associated with male infertility?
Idiopathic
Tumours
Kallman's syndrome (Failure to release GnRH)
Anorexia
213
How do thyroid disorders cause male infertility?
Reduce sexual function
| Increase prolactin
214
How can diabetes cause male infertility?
Reduce sexual function
| Reduce testosterone
215
How can CAH cause male infertility?
Increased testosterone
216
How can androgen insensivity cause male infertility?
Normal/Increased LH and testosterone
217
How can steroid cause male infertility?
Reduce:
- LH
- FSH
- Testosterone
218
What is the normal testicular volume pre-puberty?
1-3mls
219
What is the normal testicular volume in adults?
12-25mls
220
Below what testicular volume is an adult unlikely to be fertile?
<5ml
221
How is testicular volume measured?
Orchidometer
222
What is sperm motility?
What proportion are moving
223
What is hypospermia?
Low sperm volume
224
What is oligozoospermia/oligospermia?
Very low sperm count
225
What is asthenozoospermia/asthenospermia?
Poor sperm motility
226
What is teratozoospermia/teratospermia?
More morphological defects than usual
227
What is necrozoospermia?
All sperm in ejaculate are dead
228
What is the lower reference limit for sperm volume?
1.5ml
229
What is the lower reference limit for semen pH?
>=7.2
230
What is the lower reference limit for sperm concentration?
15x10^6/ml
231
What is the lower reference limit for total sperm number?
39x10^6
232
What is the lower reference limit for total sperm motility?
40
233
What is the lower reference limit for progressive sperm motility?
32
234
What is the lower reference limit for strict morphology?
4% are normal forms
235
What are the clinical features of an obstructive infertility?
Normal testicular volume
Normal secondary sexual characteristics
Vas deferens may be absent
236
What are the endocrine features of an obstructive infertility?
Normal:
- LH
- FSH
- Testosterone
237
What are the clinical features of a non-obstructive infertility?
Low testicular volume
Reduced secondary sexual characteristics
Vas deferens present
238
What are the endocrine features of a non-obstructive infertility?
High:
- LH
- FSH
Low testosterone
239
What lifestyle factors can help with male infertility?
```
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
What is the pregnancy rate per cycle of intra-uterine insemination?
15%
241
What is the pregnancy rate per cycle of ICSI?
30%
242
What is the indication for surgical sperm retrieval?
Azoospermia
243
What is the success rate of retrieving sperm by surgical sperm retrieval in both kinds of infertility (obstructive and non-obstructive)?
Obstruction - 95%
| Non-obstructive - 50%
244
What are the indications for donor sperm insemination?
Azoospermia/Oligozoospermia
Genetic conditions
Infectious conditions
245
What is the pregnancy rate per cycle of donor sperm insemination?
15%
246
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?
Article 8:
- Sperm/Egg donation
- Seeking biological parent(s)
247
When is embryo research permitted until and why?
Up to 14 days
| Primitive streak appears
248
When is abortion permitted until? When is it permitted beyond this?
24 weeks
Permitted after if:
- Child would be severely mentally/physically handicapped
- Significant risk to physical/mental health of mother or family members
249
When might mitochondrial transfer be used?
Same sex couples
| Single parent
250
What are the Scottish Guidelines for NHS-Funded Infertility Treatment?
```
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
When is sex selection permitted under the Human Fertilisation and Embryological Authority?
If risk of serious gender-linked condition
252
When is pre-implantation tissue testing permitted under the Human Fertilisation and Embryological Authority?
If an existing child has a serious or life-threatening condition
253
What arteries supply the ovary and where do they enter from?
Helicine arteries
| Enter hilum from the broad ligament
254
What are the structures from superficial to deep of an ovary?
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
During development, what occurs in week 6 in regards to the future ovary?
Germ cells from yolk sac invade ovaries and proliferate by mitosis to form oogonia
256
How are mature oocytes/ova formed? What is this process called?
Development and meiosis of oogonia
| Oogenesis
257
What is folliculogenesis? What does the formed structure consist of?
Growth of the follicle consisting of:
- The oocyte
- Any supporting cells
258
What is atresia?
Loss of oogonia and oocytes:
- Apoptosis based
- Cell reabsorbed following cell death
259
What happens to oocytes before birth?
Meiosis begins and halts at prophase 1
260
What happens to an oocyte if it fails to associate with pregranulosa cells (follicle cells)?
It dies
261
What shape are the pregranulosa cells initially?
Squamous
262
What are primary follicles defined by?
Cuboidal granulosa cells surround oocyte:
| - Zona granulosa
263
After the zona granulosa surrounds the oocyte, what happens to the primary follicle?
Oocyte enlarges
| Zona pellucida forms between oocyte and ZG
264
What cells form the theca of the primary follicle and where do they associate?
Stromal cells
| Associate with outside of follicle
265
From superficial to deep, what is the general structure of a primary follicle?
Theca cells
Zona granulosa
Zona pellucida
Oocyte
266
What is the approximate size of a primary oocyte?
45 micrometers
267
What is the inner layer of the stromal cells surrounding the follicle known as? What does it do?
Theca interna:
| - Secretes oestrogen precursors (converted to oestrogen by granulosa
268
What is the outer layer of the stromal cells surrounding the follicle known as? What does it do?
Theca externa:
| - Fibroblast-like
269
What is the antrum?
A space filled with follicular fluid which forms and enlarges in the zona granulosa to form the secondary follicle
270
What are the largest antral follicles and what size can they reach?
```
Graafian follicles (tertiary follicles)
~20mm diameter
```
271
What cells are directly adjacent to the zona pelucida and what is this called?
Cumulus cells
| Corona radiata
272
What happens to the follicle after ovulation?
Becomes the corpus luteum
273
How is the ovum propelled along the oviducts?
Gentle peristalsis and cilia
274
What is the structure of the ampulla mucosa?
Folded
Lined by simple columnar epithelium
With ciliated and secretory cells
Surrounded by smooth muscle
275
How many layers of smooth muscle are there in the:
1. Ampulla
2. Isthmus
1. Two layers
| 2. Three layers
276
What is the endometrium composed of?
Tubular secretory glands in a connective tissue strome
277
What is the myometrium composed of?
3 layers of smooth muscle
| Combined with collagen and elastic tissue
278
What is the perimetrium composed of?
Loose connective tissue
| Cover by mesothelium
279
What is the endometrium divided into and what are their functions?
```
Stratum Functionalis:
- Undergoes monthly growth, degen. and loss
Stratum Basalis:
- Reserve tissue
- Regenerates Functionalis
```
280
What happens to the endometrium during the proliferative phase?
Glands grow
Stroma grows
Vasculature grows
281
What epithelium lines endometrial glands?
Pseudostratified columnar epithelium
282
What cause the endometrial stroma to proliferate?
Oestrogens
283
What happens to the endometrial glands during the secretory phase?
Coil (corkscrew appearance) and secret glycogen
284
What is the cervix lined by on its vaginal surface?
Stratified squamous epithelium
285
What does the cervical lining transition to more internally?
Mucous-secreting simply columnar
286
What is the site of cervical epithelium transition called? What is it a common site for?
Squamocolumnar junction:
- Dysplasia
- Neoplastic change (most common site)
287
During the proliferative phase, what are the endocervical gland secretions like and what does this allow?
Thing and watery
| Sperm passage
288
After ovulation, what are the endocervical gland secretions like and what does this prevent?
Thick and viscous
| Prevent sperm or germ passage
289
What are the four layers of the vagina?
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
Why is the epithelium of the vagina thicker during reproductive years?
Due to glycogen accumulation in the cells
291
How is lactic acid produced in the vagina and what does this do?
Commensal bacteria metabolise glycogen
| Prohibits pathogens growing
292
What is the mons pubis?
Skin with highly oblique hair follicles:
- Coarse, curly hair
Overlies S/C fat pad (overlies pubic symphysis)
293
What is the labia major?
Extension of mons pubis
Rich in apocrine sweat and sebaceous flands
Small bundles of smooth muscles
Hair follicles on outer surface only
294
What is the structure of the labia minor?
Thin skin folds
Lacks S/C fat and hair follicles
Rich in vasculature and sebaceous glands:
- Secrete directly onto skin
295
What is the epithelium of the labia minor?
Keratinised epithelium extending into vagina until the hymen
296
How many tubes of erectile vascular tissue is in the clitoris and what are they called?
2 corpora cavernosa
297
What bacteria predominate in the 'healthy' vagina and what do they produce?
Lactobacillus spp.:
- Lactic acid
- Hydrogen peroxide
298
What other organisms are part of the normal vaginal flora?
Strep 'viridans'
Group B beta-haemolytic Strep.
Candida spp. (in very small numbers)
299
What do the following predispose to:
- Recent antibiotic Rx
- High oestrogen levels (Pregnancy, COC)
- Poorly controlled diabetes
- Immunosuppression
Candida infection
300
How does candida infection present?
Intensely itchy white vaginal discharge (Non-sexually transmitted)
301
How is candida diagnosed?
High vaginal swab for culture
302
What is the most common cause of a candida infection and what is seen on a gram film?
Candida albicans:
- Budding yeasts
- Hyphae
303
How is candida infection treated?
Topical clotrimazole pessary/cream (available OTC) 2-3 times daily
OR
Oral fluconazole 150mg single-dose
304
How does Candida balanitis present?
'Spotty' rash on glans
305
What can cause bacterial vaginosis?
```
Gardnerella vaginalis (most common)
Mobiluncus
```
306
How does bacterial vaginosis present?
Thin, watery, fishy-smelling vaginal discharge
307
How is bacterial vaginosis diagnosed?
Clinical diagnosis
| Also vaginal pH >4.5
308
What laboratory testing can be used for bacterial vaginosis?
High vaginal swab for microscopy - Clue cells
Hay-Ison scoring system:
- Estimates proportions of clue cells to epithelial cells and lactobacilli
309
How is bacterial vaginosis treated?
PO Metronidazole
310
How does acute bacterial prostatitis present?
UTI symptoms
Pain in lower abdo./back/perineum/penis
Tender prostate on PR exam
311
What organisms tend to cause acute bacterial prostatitis?
Same as for UTI:
- E. coli
- Enterococcus
- Check for STI if <35 years (Chlamydia and gonorrhoea)
312
How is acute bacterial prostatitis diagnosed?
Clinical signs
Mid-Stream Specimen of Urine (MSSU) for culture
+/- first pass urine for STI testing
313
How is acute bacterial prostatisti treated?
Ciprofloxacin PO 500mg bd for 28 days
314
How is acute bacterial prostatitis treated if there is a high C. diff risk?
Trimethoprim PO 200mg bd for 28 days
315
What is the commonest bacterial STI in the UK?
Chlamydia
316
How does Chlamydia reproduce?
Must be intracellular
| Biphasic life cycle - "Energy parasite"
317
Why does Chlamydia trachomatis not gram stain?
No peptidoglycan in cell wall
318
What serovars of Chlamydia cause Trachoma (eye infection)?
A-C
319
What serovars of Chlamydia cause a genital infection?
D-K
320
What serovars of Chlamydia cause Lymphogranuloma venereum?
L1-L3
321
What is Lymphogranuloma venereum?
Chronic lymphatic infection by Chlamydia
322
Upon entry of Chlamydia, what does it do?
Attach and enter cells
323
Two hours after entry of Chlamydia, what does it do?
Migrate to perinuclear area
| Elementary body -> Reticulate body transition
324
What happens 8-12 hours after Chlamydia infection?
Reticulate body multiplication
325
What happens 12-24 hours after Chlamydia infection?
Inclusion biogenesis
| Bacterial replication
326
What happens 24-48 hours after Chlamydia?
Reticulate body -> Elementary body transition
| Cell lysis
327
What is the gram stain and shape of Neisseria gonorrhoeae?
Gram negative diplococcus
"Two kidney beans facing each other"
Often intracellular:
- Easily phagocytosed by polymorphs
328
How can Chlamydia and Gonorrhoea be diagnosed in men?
First pass urine sample for NAATs
329
How can Chlamydia and Gonorrhoea be diagnosed in women?
High-vaginal/Vulvovaginal swab for NAATs
OR
Endocervical swab if speculum exam
330
What additional samples can be taken in the diagnosis of Chlamydia and Gonorrhoea?
Rectal
Throat
Eyes (In babies and adults)
331
What are NAATs?
Combined Nucleic Acid Amplification Tests
332
Why would Chlamydia and Gonorrhoea be cultured?
Antibiotic sensitivity
| Epidemiology
333
What samples are Chlamydia and Gonorrhoea cultured from?
Endocervical
Rectal
Throat
334
NAATs detect dead organisms. How long should you wait to test for a 'test of cure'?
5 weeks
335
What is the recommended treatment for Gonorrhoea?
IM Ceftriazone 500mg single dose
AND
PO Azithromycin 1g single dose
336
What is the recommended treatment for Chlamydia?
PO Azithromycin 1g single dose
OR
PO Doxycycline 100mg bd for 7 days (used if rectal chlamydia)
337
Does Treponema pallidum gram stain?
No
338
What is the primary stage of syphilis infection?
Chancre (painless and heals by itself)
339
What is the secondary stage of syphilis infection?
Large number in blood:
- "Snail-track" mouth ulcers
- Generalised rash
- Flu like illness
340
What is the latent stage of syphilis infection?
```
Asymptomatic
Slow multiplication in vessel intima
Divided into:
- Early latent
- Late latent
```
341
What is the late stage of syphilis infection?
CVS/Neurological complications
| Many years later
342
What is the initial test for syphilis?
Serology (VDRL):
| - Testing for non-specific and specific Ab to T. pallidum
343
What do non-specific Abs to T. pallidum test for?
Disease activity
| Response to therapy
344
What do specific Abs to T. pallidum test for?
Confirm diagnosis
Ab levels decline slowly even after therapy
May remain positive for life
345
If there are syphilitic lesions, what testing can be done?
Swab of primary/secondary lesions for PCR
346
If a primary/secondary lesion is present in suspected syphilis, what other investigation can be done?
Dark ground microscopy to look for spirochaetes
347
When may serological testing show false positives?
SLE
Malaria
Pregnancy
348
What is the specific serological test used in Tayside for diagnosis of syphilis?
Treponema pallidum particle agglutination assay (TPAA)
349
Why are the specific serological tests for syphilis not useful in monitoring response to therapy?
Remain positive for life
350
What is a serological screening test for syphilis?
IgM and IgG ELISA on clotted blood sample
351
If the screening test for syphilis is positive, what tests are done?
IgM ELISA
| VDRL and TPPA
352
What is the management of syphilis?
IM benzathine benzylpenicillin 1.8g single dose
353
What is the structure of HPV?
Non-enveloped, icosohedral virus with double-stranding DNA
354
What types of HPV are the most commonest causes of genital warts?
6
| 11
355
What is the treatment of genital warts?
Cryotherapy
| Podophyllotoxin cream/lotion
356
What is the structure of HSV?
Enveloped virus with double-stranded DNA
357
Where does HSV replicate?
Dermis and epidermis
358
Why does HSV cause exquisitely painful, multiple small vesicles?
Gets into nerve endings causing inflammation:
- Sensory
- Autonomia
359
How does HSV hide from the immune system?
Migrates to sacral root ganglion
360
How can HSV be diagnosed?
Swab a deroofed blister:
- Virus transport medium
- PCR (highly sensitive and specific)
361
How is HSV treated?
Aciclovir 200mg 5 times daily for 5 days
| Pain relief
362
What is Trichomonas vaginalis?
Single celled protozoal parasite:
- Divides by binary fission
- No cyst form known
- Human host only
363
How does Trichomonas vaginalis present?
Green, frothy, offensive-smelling vaginal discharge and vulva irritation in women
Urethritis in men?
364
How is Trichomonas vaginalis diagnosed?
High vaginal swab for microscopy
| No good test for men (as PCR not used for it in Tayside)
365
How is Trichomonas vaginalis treated?
PO metronidazole 400 bd for 5-7 days
| Or 2g single dose
366
How long is the life span for pubic lice in men?
22 days
367
How long is the life span for pubic lice in women?
17 days
368
What is the treatment for pubic lice?
Malathion lotion
369
On trans-vaginal ultrasound, what endometrial thickness would indicate the need for biopsy?
>4mm in post-menopausal
| >16mm in pre-menopausal
370
How does endometrial pipelle work? What are the advantages and disadvantages
```
3.1mm diameter (no dilatation needed)
No anaesthesia
Outpatient
Very safe
Limited sample
```
371
What are some facts about D+C for endometrial sampling?
Most common operation in women
Most thorough sampling method
Can miss 5% of hyperplasias/cancers
372
What part of the history is not required in assessment of abnormal uterine bleeding?
Number of pregnancies
| Drugs without hormonal influences
373
What are some organic endometrial causes of abnormal uterine bleeding?
Endometriosis
Polyp
Miscarriage
374
What are some organic myometrial causes of abnormal uterine bleeding?
Adenomyosis
| Leiomyoma
375
How is endometritis histologically diagnosed?
Abnormal pattern of inflammatory cells
376
What protects the endometrium from ascending infection?
Cervical mucous plug
| Cyclical shedding
377
What infections can cause endometritis?
```
Neisseria
Chlamydia
TB
CMV
Actinomyces
HSV
```
378
What is chronic plasmacytic endometritis associated with?
PID:
- Gonorrhoea
- Chlamydia
- Enteric organisms
379
How many endometrial polyps present?
```
Usually asymptomatic
May present with:
- Bleeding
- Discharge
Around and after menopause
```
380
How can adenomyosis present?
Menorrhagia
| Dysmenorrhoea
381
What is adenomyosis?
Endometrial glands and stroma within myometrium
382
What is a leiomyoma?
A benign smooth muscle tumour
383
What are the symptoms of a leiomyoma?
Menorrhagia
Infertility
Mass effect
Pain
384
What is the growth of a leiomyoma dependent on?
Oestrogen
385
How does a leiomyoma appear histologically?
Interlacing smooth muscle cells
