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BRS YEAR 2 > Reproductive treatment > Flashcards

Reproductive treatment Flashcards

1
Q

What are the characteristics of PCOS?

A

1) Oligomenorrhoea
2) Hyperandrogenism (Hirsutism and acne)
3) Polycystic ovarian morphology (US scan)

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2
Q

Which aromatase inhibitor is used for ovulation induction?

A

Letrozole

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3
Q

How does Letrozole work?

A

Inhibition of aromatase activity, subsequently resulting in reduced oestradiol conversion from testosterone.
This reduces the negative feedback on the hypothalamus and anterior pituitary gland, stimulating FSH and LH release.

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4
Q

What is clomiphene?

A

A oestradiol receptor antagonist

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5
Q

If there is a male factor of infertility how does IVF take place?

A

Intra-cytoplasmic injection of sperm (ICSI)

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6
Q

What two methods are used to prevent premature ovulation?

A

GnRH antagonist protocol (Short)

GnRH agonist protocol (Long protocol)

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7
Q

How do GnRH antagonists and agonists work?

A

GnRH is secreted in a pulsatile manner, stimulating the release of LH.
High dose continuous GnRH leads to a desensitisation of GnRH receptors and thus causing LH inhibition.

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8
Q

How do combined oral contraceptive pills work?

A

Anovulation
Progesterone causes the thickening of the cervical mucous, prevent sperm penetration, and thinning of the endometrial lining to reduce implantation.
Oestrogen causes negative feedback on GnRH release

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9
Q

What are the non-contraceptive benefits of using OCPs?

A

Help reduce LH and hyperandrogenism

Helps makes periods lighter and less painful (endometriosis or period pain or menorrhagia)

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10
Q

What are the three forms of long-acting reversible contraceptives?

A

1) Intra-uterine device (copper coil)
2) Intra-uterine system (IUS) which secretes progesterone (Mirena coil)
3) Progesterone-only injectable contraceptives or subdermal implants

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11
Q

What is the most effective emergency contraception?

A

Copper intrauterine device (IUD), most effective

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12
Q

What is levonelle, emergency contraceptive pill?

A

Synthetic progesterone prevents ovulation, must be taken within 3 days of unprotected intercourse

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13
Q

Which enzymes reduce the efficacy of contraceptive piill?

A

P450

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14
Q

What is the main treatment for hypogondotrophic hypogonadism?

A

Treat with Gonadotrophins (LH & FSH) to induce spermatogenesis.

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15
Q

Which cells are stimulated by LH?

A

Leydig cells to increase intratesticular testosterone

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16
Q

What is the effect of FSH?

A

Stimulates sertoli cells and induces seminiferous tubule development and spermatogenesis.

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17
Q

What treatment is prescribed to male patients with secondary hypogonadism?

A

Give HCG injections (which act on LH receptors)

Add FSH injections if there is no response in 6 months

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18
Q

What injections should be administer if there is no response to HCG injections within 6 months?

A

Add FSH injections

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19
Q

Why shouldn’t testosterone be prescribed to males desiring fertility?

A

There is a negative feedback effect which subsequently reduces LH and FSH release- further reducing spermatogenesis

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20
Q

Which receptors do HCG injections stimulate?

A

LH receptors on Leydig cells

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21
Q

What type of hypogonadism is Kallmann syndrome?

A

Congenital secondary hypogonadism

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22
Q

What is the relevance of FSH during mini-puberty in males?

A

Important for growing the pool of immature spermatogonia and germ cells

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23
Q

In patients with Kallmann syndrome, what is the recommended pretreatment?

A

2-4 months pretreatment with FSH before HCG injections

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24
Q

What testicular volume range is associated with a better prognosis in patients with Kallmann syndrome?

A

> 6ml

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25
When should a serum testosterone level be conducted during the day?
At least 2 low measurements of serum testosterone before 11am
26
What is the treatment of a testosterone deficiency in a male not desiring fertility?
Testosterone replacement - Daily gel (tostran) - 3 weekly intramuscular injections (sustanon) - 3 monthly intramuscular injections (Nebido)
27
What are the associated risks with testosterone replacement therapy?
- Increased haematocrit (risk of hypervicsosity and stroke) due to stimulation of EPO receptors - Measure prostate specific antigen levels
28
What is the aim of ovulation induction?
Aim to develop one ovarian follicle, to increase FSH by a small amount
29
What are the risks for inducing more than one ovarian follicles?
Risk of multiple pregnancy - causes risks for mother and baby during pregnancy
30
What are the four methods used to restore ovulation in a patient with anovulatory polycystic ovary syndrome?
1) Lifestyle/weight loss/ metformin 2) Letrozole (aromatase inhibitor) 3) Clomiphene (oestradiol receptor antagonist) 4) FSH stimulation
31
What is the mechanism of action of clomiphene (oestradiol receptor antagonist)?
Blocks estrogenic hypothalamic receptors, resulting in blinding of the hypothalamus-pituitary axis to endogenous circulating estrogen. This in turn triggers release of FSH from the anterior pituitary following alterations in GnRH pulsatility. FSH therefore stimulates follicle growth
32
What are the four main stages of IVF treatment?
1) Oocyte retrieval 2) Fertilisation in vitro 3) Embryo incubation 4) Embryo transfer
33
What is the initial stage of IVF treatment?
FSH stimulation to induce superovulation prior to egg retrieval.
34
What is step 2 in IVF treatment?
Prevent premature ovulation by preventing premature LH surge
35
Which short protocol treatment is used to prevent premature ovulation?
GnRH antagonist between day 6-10, after FSH stimulation ,the antagonist inhibits GnRH receptors on gonadotrophs within the anterior pituitary gland, thereby preventing LH release.
36
GnRH agonists are used for which type of protocol treatment to prevent premature ovulation during IVF?
Long protocol, day -7 to day 10
37
What are the effects of non-pulsatile GnRH on LH release?
Continuous high dose removes pulsatile stimulation of gonadotrophs within the anterior pituitary gland, this desensitisation of GnRH receptors thus cause LH inhibition.
38
Upon egg retrieval which hormone is exposed to the eggs for maturation?
LH
39
What is the stage of meiosis reached by the secondary oocyte prior to sperm fertilisation?
Metaphase-II
40
Which hormone is used to trigger egg maturation?
hCG
41
What is the associated risk with hCG overstimulation?
Ovarian hyperstimulation syndrome (OHSS)
42
What are the symptoms of ovarian hyper-stimulation syndrome?
Pleural effusion Ascites Renal failure Ovarian torsion
43
Which factor is released due to hCG stimulation leading to angiogensis?
Vascular endothelial growth factor (VEGF)
44
At what day is the oocyte retrieved?
Day 13
45
At what day should hCG be used as the trigger of oocyte maturation?
Day 11
46
What is done after the embryo is transferred to the endometrium?
Pregnancy blood test followed by a pregnancy | ultrasound scan
47
What are the common forms of contraception?
Barrier: Male/female condom/ diaphragm or cap with spermicide. - Combined oral contraceptive pill (OCP) - Progesterone-only (Pill) - Long acting reversible contraception (LARC) - Emergency contraception
48
What are the permanent methods of contraception?
Vasectomy | Female sterilisation
49
What are the advantages of barrier contraception?
- Easy to obtain- free from clinics - no need to see a healthcare professional - Protection against STIs - No contraindications as with some hormonal methods
50
What are the disadvantages of barrier contraception?
- Can interrupt sex - Can reduce sensation - Can interfere with erections - Some skill to use properly
51
What hormones are within the oral contraceptive pill?
Oestrogen and progesterone
52
How does the oral contraceptive pill work?
Oestrogen and progesterone exert negative feedback on GnRH hypothalamic neurones and gonadotrophs within the pituitary gland, this reduced LH and FSH secretion leading to anovulation. -Oestrogen and progesterone thicken cervical mucous (prevent sperm penetration), and thin the endometrial lining to reduce implantation
53
What are the advantages to using the oral contraceptive pill?
- Easy to take (One pill a day) - Effective - Does not interrupt sex - Can take several packets back to back and avoid withdrawal bleeds. - Reduce endometrial and ovarian cancer - Weight neutral in 80%
54
What are the disadvantages to using the OCP?
- Difficult to remember - No protection against STIs - P450 enzyme inducers may reduce efficacy - Not the best choice during breast feeding.
55
What are the possible side effects with using the OCP?
``` Spotting (bleeding in between periods) Nausea Sore breasts Changes in mood or libido Feeling more hungry ```
56
What are the rare side effects to using the OCP?
Blood clots in the legs and lungs
57
What are the non-contraceptive uses of the OCP?
Helps make periods lighter and less painful (Endometriosis or period pain or menorrhagia) -Withdrawal bleeds -PCOS (reduce LH and hyperandrogenism)
58
Which contraceptive pill can be used by breastfeeding women?
Progesterone only pill
59
What are the advantages of using the progesterone only pill?
Often suitable if can't take oestrogen ``` Easy to take – one pill a day, every day with no break It doesn’t interrupt sex Can help heavy or painful periods Periods may stop (temporarily) Can be used when breastfeeding ```
60
What are the negatives with using the POP?
Can be difficult to remember No protection against STIs Shorter acting – needs to be taken at the same time each day ``` Possible side effects Irregular bleeding Headaches Sore breasts Changes in mood Changes in sex drive ```
61
What are the three forms of LARCs?
1) Intra uterine device (IUD) 2) Intra-uterine system (IUS) 3) Progesterone only injectable contraceptives/subdermal implants
62
What are IUDs?
Copper coils that mechanically prevent implantation and decrease sperm egg survival (lasts 5-10 years)
63
What is the main risk with using an IUD?
Can cause heavy periods and 5% come out during the first 3 months.
64
What is an IUS?
An intra-uterine system which secretes progesterone (Mirena coil) , this thins the lining of the womb and thickens cervical mucous. Lasts 3-5 years.
65
What are the benefits with using a coil?
Coils are suitable for most women including Nulliparous (no previous children). Exclude STI’s and cervical screening up to date before insertion Prevent implantation of conceptus – important for some religions rarely can cause ectopic pregnancy Can be used as emergency contraception
66
How can copper coils be used as emergency contraception?
Can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
67
What is within an emergency contraceptive pill?
Ulipristal acetate 30mg
68
How does the emergency contraceptive pill work?
Delays ovulation
69
Until how many days after unprotected intercourse, does the morning after pill become ineffective?
5 days
70
Which emergency contraception is leat effective?
Levonorgestrel, least effective especially if the BMI > 27
71
What is levonorgestrel?
Synthetic progesterone prevents ovulation | Taken within 3 days of unprotected intercourse
72
What are the three forms of emergency contraception?
1) IUD 2) Pill- ulipristal acetate 3) Levonorgestrel
73
What are the side effects with using the morning after pill?
headache, abdominal pain and nausea Can vomit within 2-3 hours of taking it - may need to take another
74
Which types of medications makes taking the emergency contraceptive pill ineffective?
Liver p450 enzyme inducer | Tetrogenic (lithium or warfarin) drugs
75
In what comorbidities should OCP be avoided?
``` Migraine with aura (Risk of stroke). Smoking (>15/day) + age >35 years Stroke or CVD history Current breast cancer Liver cirrhosis Diabetes with retinopathy/nephropathy/neuropathy ``` Risk of venous thromboembolism (VTE)/CVD/Stroke
76
Which conditions may benefit from an OCP?
Endometriosis Menorrhagia Fibroids
77
What are the risks with hormone replacement therapy?
Venous thrombo-embolism - deep vein thrombosis or pulmonary embolism. - Hormone sensitive cancers (Breast and ovarian) - Endometrial cancer - CVD - Oral oestrogens undergo first pass metabolism in liver - Oral can increase SHBG, triglycerides and CRP
78
Which is the most preferable form of HRT?
Transdermal oestrogens
79
Which type of HRT increases the risk of breast cancer?
Continuous combined HRT (oestrogen and progesterone) Risk is related to duration of treatment
80
What supplement reduces the risk of endometrial cancer in HRT?
Prescribe progesterones in all women with an endometrium
81
What are progestogens?
Synthetic progestins and the natural hormone progesterone
82
Which form of HRT are safer for VTE risk?
Transdermal oestrogen
83
Above what BMI range are oral oestrogen not recommended?
>30kg/m^2
84
In what age group is the risk of cardiovascular disease greater with the use of HRT?
Above the age of 60 Increased risk if HRT is started 10 years after menopause.
85
What are the 6 main risks associated with HRT?
``` Breast cancer Endometrial cancer Ovarian cancer VTE Stroke CHD ```
86
Which is the highest risk associated with oestrogen only HRT?
Endometrial cancer
87
Which is the highest risk associated with combined oral HRT?
Breast cancer
88
What are the benefits of HRT?
``` Relief of symptoms of low oestrogen (flushing, disturbed sleep, decreased libido, low mood) Less osteoporosis (decreased by one third) ```
89
What is cisgender?
Same sex and gender
90
What is gender non-confirming?
Gender does not match assigned sex
91
What is gender dysphoria?
When gender causes depression
92
What is non-binary?
Gender does not match to traditional binary gender understanding. Includes agender, bigender, pangender, and gender fluid
93
What is the management for prepubertal young people undergoing gender transformation?
GnRH agonist for pubertal suppression and then sex steroids | Gender reassignment surgery
94
What are the side effects with testosterone supplements in transgender men?
Polycythaemia, lower HDL, Obstructive Sleep Apnoea (OSA). No increase in CVD).
95
What should be prescribed to transgender males to suppress menstrual bleeding?
Progesterone
96
Within 1 to 6 months what are the effects of hormonal therapy in transgender males?
Balding (depending on your age and family pattern)  Deeper voice / Acne / Increased and coarser facial and body hair Change in the distribution of your body fat Enlargement of the clitoris    Menstrual cycle stops Increased muscle mass and strength
97
What hormones are given for transgender women?
Oestrogen (transdermal, oral , inramuscular) High does 4-5mg a day
98
How is testosterone reduced in transgender women?
GnRH agonists (induce desensitisation of HPG axis) Anti-androgen medications (crypterone acetate, spirnolactone)
99
What will not change in transgender women undergoing hormonal therapy?
Height, voice and Adam's apple.
100
What happens to transgender women during the first 3 months?
Decrease in sexual desire/function (erections) | Baldness slows
101
What happens in 3-6 months for transgender women?
Soft skin, and change in body fat distribution Decrease in testicular size Breast development/tenderness
102
How long does it take for hair to become softer and finer in transgender women?
6 to 12 months

BRS YEAR 2 (12 decks)

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