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BRS 1b > 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
Q

When should a serum testosterone level be conducted during the day?

A

At least 2 low measurements of serum testosterone before 11am

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26
Q

What is the treatment of a testosterone deficiency in a male not desiring fertility?

A

Testosterone replacement

  • Daily gel (tostran)
  • 3 weekly intramuscular injections (sustanon)
  • 3 monthly intramuscular injections (Nebido)
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27
Q

What are the associated risks with testosterone replacement therapy?

A
  • Increased haematocrit (risk of hypervicsosity and stroke) due to stimulation of EPO receptors
  • Measure prostate specific antigen levels
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28
Q

What is the aim of ovulation induction?

A

Aim to develop one ovarian follicle, to increase FSH by a small amount

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29
Q

What are the risks for inducing more than one ovarian follicles?

A

Risk of multiple pregnancy - causes risks for mother and baby during pregnancy

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30
Q

What are the four methods used to restore ovulation in a patient with anovulatory polycystic ovary syndrome?

A

1) Lifestyle/weight loss/ metformin
2) Letrozole (aromatase inhibitor)
3) Clomiphene (oestradiol receptor antagonist)
4) FSH stimulation

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31
Q

What is the mechanism of action of clomiphene (oestradiol receptor antagonist)?

A

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

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32
Q

What are the four main stages of IVF treatment?

A

1) Oocyte retrieval
2) Fertilisation in vitro
3) Embryo incubation
4) Embryo transfer

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33
Q

What is the initial stage of IVF treatment?

A

FSH stimulation to induce superovulation prior to egg retrieval.

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34
Q

What is step 2 in IVF treatment?

A

Prevent premature ovulation by preventing premature LH surge

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35
Q

Which short protocol treatment is used to prevent premature ovulation?

A

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.

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36
Q

GnRH agonists are used for which type of protocol treatment to prevent premature ovulation during IVF?

A

Long protocol, day -7 to day 10

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37
Q

What are the effects of non-pulsatile GnRH on LH release?

A

Continuous high dose removes pulsatile stimulation of gonadotrophs within the anterior pituitary gland, this desensitisation of GnRH receptors thus cause LH inhibition.

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38
Q

Upon egg retrieval which hormone is exposed to the eggs for maturation?

A

LH

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39
Q

What is the stage of meiosis reached by the secondary oocyte prior to sperm fertilisation?

A

Metaphase-II

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40
Q

Which hormone is used to trigger egg maturation?

A

hCG

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41
Q

What is the associated risk with hCG overstimulation?

A

Ovarian hyperstimulation syndrome (OHSS)

42
Q

What are the symptoms of ovarian hyper-stimulation syndrome?

A

Pleural effusion
Ascites
Renal failure
Ovarian torsion

43
Q

Which factor is released due to hCG stimulation leading to angiogensis?

A

Vascular endothelial growth factor (VEGF)

44
Q

At what day is the oocyte retrieved?

A

Day 13

45
Q

At what day should hCG be used as the trigger of oocyte maturation?

A

Day 11

46
Q

What is done after the embryo is transferred to the endometrium?

A

Pregnancy blood test followed by a pregnancy

ultrasound scan

47
Q

What are the common forms of contraception?

A

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
Q

What are the permanent methods of contraception?

A

Vasectomy

Female sterilisation

49
Q

What are the advantages of barrier contraception?

A
  • Easy to obtain- free from clinics
  • no need to see a healthcare professional
  • Protection against STIs
  • No contraindications as with some hormonal methods
50
Q

What are the disadvantages of barrier contraception?

A
  • Can interrupt sex
  • Can reduce sensation
  • Can interfere with erections
  • Some skill to use properly
51
Q

What hormones are within the oral contraceptive pill?

A

Oestrogen and progesterone

52
Q

How does the oral contraceptive pill work?

A

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
Q

What are the advantages to using the oral contraceptive pill?

A
  • 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
Q

What are the disadvantages to using the OCP?

A
  • Difficult to remember
  • No protection against STIs
  • P450 enzyme inducers may reduce efficacy
  • Not the best choice during breast feeding.
55
Q

What are the possible side effects with using the OCP?

A 
Spotting (bleeding in between periods)
Nausea
 Sore breasts
 Changes in mood or libido 
 Feeling more hungry
56
Q

What are the rare side effects to using the OCP?

A

Blood clots in the legs and lungs

57
Q

What are the non-contraceptive uses of the OCP?

A

Helps make periods lighter and less painful
(Endometriosis or period pain or menorrhagia)
-Withdrawal bleeds
-PCOS (reduce LH and hyperandrogenism)

58
Q

Which contraceptive pill can be used by breastfeeding women?

A

Progesterone only pill

59
Q

What are the advantages of using the progesterone only pill?

A

Often suitable if can’ttake 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 usedwhen breastfeeding
60
Q

What are the negatives with using the POP?

A

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
Q

What are the three forms of LARCs?

A

1) Intra uterine device (IUD)
2) Intra-uterine system (IUS)
3) Progesterone only injectable contraceptives/subdermal implants

62
Q

What are IUDs?

A

Copper coils that mechanically prevent implantation and decrease sperm egg survival (lasts 5-10 years)

63
Q

What is the main risk with using an IUD?

A

Can cause heavy periods and 5% come out during the first 3 months.

64
Q

What is an IUS?

A

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
Q

What are the benefits with using a coil?

A

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
Q

How can copper coils be used as emergency contraception?

A

Can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)

67
Q

What is within an emergency contraceptive pill?

A

Ulipristal acetate 30mg

68
Q

How does the emergency contraceptive pill work?

A

Delays ovulation

69
Q

Until how many days after unprotected intercourse, does the morning after pill become ineffective?

A

5 days

70
Q

Which emergency contraception is leat effective?

A

Levonorgestrel, least effective especially if the BMI > 27

71
Q

What is levonorgestrel?

A

Synthetic progesterone prevents ovulation

Taken within 3 days of unprotected intercourse

72
Q

What are the three forms of emergency contraception?

A

1) IUD
2) Pill- ulipristal acetate
3) Levonorgestrel

73
Q

What are the side effects with using the morning after pill?

A

headache, abdominal pain and nausea

Can vomit within 2-3 hours of taking it - may need to take another

74
Q

Which types of medications makes taking the emergency contraceptive pill ineffective?

A

Liver p450 enzyme inducer

Tetrogenic (lithium or warfarin) drugs

75
Q

In what comorbidities should OCP be avoided?

A 
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
Q

Which conditions may benefit from an OCP?

A

Endometriosis
Menorrhagia
Fibroids

77
Q

What are the risks with hormone replacement therapy?

A

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
Q

Which is the most preferable form of HRT?

A

Transdermal oestrogens

79
Q

Which type of HRT increases the risk of breast cancer?

A

Continuous combined HRT (oestrogen and progesterone)

Risk is related to duration of treatment

80
Q

What supplement reduces the risk of endometrial cancer in HRT?

A

Prescribe progesterones in all women with an endometrium

81
Q

What are progestogens?

A

Synthetic progestins and the natural hormone progesterone

82
Q

Which form of HRT are safer for VTE risk?

A

Transdermal oestrogen

83
Q

Above what BMI range are oral oestrogen not recommended?

A

> 30kg/m^2

84
Q

In what age group is the risk of cardiovascular disease greater with the use of HRT?

A

Above the age of 60

Increased risk if HRT is started 10 years after menopause.

85
Q

What are the 6 main risks associated with HRT?

A 
Breast cancer
Endometrial cancer
Ovarian cancer
VTE
Stroke
CHD
86
Q

Which is the highest risk associated with oestrogen only HRT?

A

Endometrial cancer

87
Q

Which is the highest risk associated with combined oral HRT?

A

Breast cancer

88
Q

What are the benefits of HRT?

A 
Relief of symptoms of low oestrogen (flushing, disturbed sleep, decreased libido, low mood) 
Less osteoporosis (decreased by one third)
89
Q

What is cisgender?

A

Same sex and gender

90
Q

What is gender non-confirming?

A

Gender does not match assigned sex

91
Q

What is gender dysphoria?

A

When gender causes depression

92
Q

What is non-binary?

A

Gender does not match to traditional binary gender understanding. Includes agender, bigender, pangender, and gender fluid

93
Q

What is the management for prepubertal young people undergoing gender transformation?

A

GnRH agonist for pubertal suppression and then sex steroids

Gender reassignment surgery

94
Q

What are the side effects with testosterone supplements in transgender men?

A

Polycythaemia, lower HDL, Obstructive Sleep Apnoea (OSA). No increase in CVD).

95
Q

What should be prescribed to transgender males to suppress menstrual bleeding?

A

Progesterone

96
Q

Within 1 to 6 months what are the effects of hormonal therapy in transgender males?

A

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
Q

What hormones are given for transgender women?

A

Oestrogen (transdermal, oral , inramuscular)

High does 4-5mg a day

98
Q

How is testosterone reduced in transgender women?

A

GnRH agonists (induce desensitisation of HPG axis)

Anti-androgen medications (crypterone acetate, spirnolactone)

99
Q

What will not change in transgender women undergoing hormonal therapy?

A

Height, voice and Adam’s apple.

100
Q

What happens to transgender women during the first 3 months?

A

Decrease in sexual desire/function (erections)

Baldness slows

101
Q

What happens in 3-6 months for transgender women?

A

Soft skin, and change in body fat distribution
Decrease in testicular size
Breast development/tenderness

102
Q

How long does it take for hair to become softer and finer in transgender women?

A

6 to 12 months

BRS 1b (62 decks)

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