Reproductive Treatments Flashcards
How easy is primary hypogonadism in males treated?
Hard to treat via hormones
How is secondary hypogonadism in males treated? How does this help? (requiring fertility)
Gonadotrophins (LH/FSH)
Stimulates spermatogenesis
What hormone stimulates testosterone via what cells?
LH stimulates it via leydig cells
Increases intratesticular testosterone to much higher levels
What hormone stimulates spermatogenesis in what structure?
FSH in seminiferous tubules
What injections for male infertility target LH receptors?
hCG injections (act on LH receptors)
Does Congenital Secondary Hypogonadism have better, same or worse prognosis than Acquired Secondary Hypogonadism in males and why?
Worse- he has not gone through mini puberty
When is testosterone replacement given?
If not desiring fertility
Testosterone lowes FSH/LH so reduces spermatogenesis
What testosterone replacements are available?
Daily gel- tostran
3 weekly IM injections
3 monthly IM injection
Less common: implants, oral preparations
What do we have to monitor when giving testosterone replacement?
Observe haematocrit (risk of hyperviscosity and stroke- stimulates erythropoiesis) Prostate (PSA levels)
How is fertility mainly improved for patients with PCOS?
Try to stimulate ovulation (ovulation induction) via development of one ovarian follicle (avoids multiple pregnancy as this has risks for mother and baby)
We aim to cause a small increase in FSH
How is ovulation induction encouraged?
- Lifestyle / Weight Loss / Metformin
- Letrozole (Aromatase inhibitor)
- Clomiphene (Oestradiol receptor antagonist)
- FSH stimulation (injection)
How does letrozole/ aromatase inhibitor/ oestradiol receptor antagonist work?
Reduces negative feedback from oestradiol
Aromatase inhibitor prevents conversion from testosterone to oestradiol
This increases FSH and stimulates follicle growth
How does IVF work?
High dose of FSH to stimulate eggs
Prevent premature ovulation via GnRH agonist/antagonist
Give LH to allow egg maturation
Retrieve oocyte from ovary
Fertilisation in vitro or intracytoplasmic injection of sperm
Embryo incubation
Embryo transfer
When is intracytoplasmic injection of sperm (ICSI) used and what is it?
When theres a problem with the sperm, inject one sperm into an egg
What do we do to premature ovulation in IVF?
Prevent it by giving medicine to prevent premature LH surge
How is premature LH surge prevented in IVF?
Via GnRH antagonist (short protocol) or GnRH agonist (long protocol) - if given GnRH in a non pulsatile way LH is inhibited
How are eggs matured in IVF and where?
By giving LH (activates the oocyte maturation promoting factor, MPF and oocyte chromosome segregation) then hCG (promotes VEGF and neovascularization)
They should still be in the ovary
What happens in egg maturation?
Egg goes from metaphase 1 to metaphase 2 - goes from diploid to haploid
How does Ovarian hyperstimulation syndrome occur?
Due to long lasting hCG during IVF
How does Ovarian hyperstimulation syndrome present?
Pleural effusion
Ascites
Renal failure
Ovarian torsion
Cause: increased renin and VEGF (vascular endothelial growth factor) so more fluid moving into interstitial space
What are methods of contraception?
Barrier: male / female condom/ diaphragm or cap with spermicide
Combined Oral Contraceptive Pill (OCP)
Progestogen-only Pill (POP)
Long Acting Reversible Contraception (LARC)
Emergency Contraception
Permanent methods:
Vasectomy
Female sterilisation (hysterectomy)
What are positives of the oral contraceptive pill (OCP)?
Easy to take Effective Doesn’t interrupt sex Can take several packets back to back and avoid withdrawal bleeds Reduce endometrial and ovarian cancer
What are negatives of the OCP?
It can be difficult to remember
No protection against STIs
P450 Enzyme Inducers may reduce efficacy (OCP metabolised by p450)
Not the best choice during breast feeding
What are side effects of the OCP?
Spotting (bleeding in between periods) Nausea Sore breasts Changes in mood or libido Feeling more hungry
What are non contraceptive uses of the OCP?
Lighter/less painful periods
PCOS (reduces LH and hyperandrogenism)
What is the progesterone only pill (mini pill)?
Works as OCP but less reliably inhibits ovulation
Often suitable if cant take oestrogen
Can be used when breastfeeding
What are negatives of the mini pill?
Can be difficult to remember
No protection against STIs
Shorter acting – needs to be taken at the same time each day
What are the common long acting reversible contraceptives (LARCs)?
IUD (copper coil)- decreases sperm survival and prevents implantation
Intra-uterine systems- secretes progesterone which thins lining of sperm and thickens cervical lining
Progestogen-only injectable contraceptives or subdermal implants
What are the emergency contraceptives?
IUD
Emergency contraceptive pill : Ulipristat acetate 30mg (ellaOne) within 5 days, Levenorgestrel 1.5mg (Levonelle) within 3 days- less effective
What are side effects of emergency contraception?
Headache, abdominal pain, nausea
Liver p450 enzyme inducer medication makes it less effective
If vomit in 2-3 hours of taking need to take another
What should we consider when chosing contraception?
Risk of venous thromboembolism
Other conditions
Need for prevention of STIs
Concurrent medication e.g. P450 liver enzyme inducing medication
What are risks of HRT?
- Venous thrombo embolism- use transdermal oestrogens if this is the case (oral oestrogens go past first pass metabolism in liver so can increase clotting factors along with SHBG, triglycerides and CRP)
- Hormone sensitive cancers: Slight increase in risk for breast cancer only on combined HRT (assess risk before prescription), small increase in ovarian cancer risk after long term use, highest risk is endometrial cancer
- Cardiovascular disease: no inc. risk if started before 60yrs, inc. risk if started 10 years post menopause
- Small risk of stroke: risk is higher when taking oral over transdermal oestrogens and higher when taking combined over oestrogen only.
What must we give to women with an endometrium on HRT? Why?
Progesterone- to prevent endometrial cancer (sometimes presents with post menopausal bleeding)
Oestrogen thickens endometrium (risk of cancer) so progesterone thins it
Assess HRT safety/ efficacy at 3 months then annually
What are benefits of HRT?
Relief of symptoms of low oestrogen
Less osteoporosis related fractures (decreased by 1/3)- oestrogen promotes activity of osteoblasts
How is gender different to sex?
Gender- what you identify as, its a social construct
Sex- biological
What is gender dysphoria?
When gender non conforming causes distress
What are treatments for supporting transgender males/females?
Trans Men- Testosterone injections or gels, progesterone to suppress menstrual bleeding
Trans Women- high dose oestrogen, reduce testosterone via GnRH agonists (desensitisation of HPG axis- make GnRH non-pulsatile) and anti androgen medication
If there is no response to hCG injections for sperm induction after 6 months what should be given?
Add FSH injections
What are positives of condoms?
Protect against STI’s
Easy to obtain- free from clinics
Non contraindications as not hormonal
What are negatives of condoms?
Can interrupt sex Can reduce sensation Can interfere with erection Some skill to use Two aren't better than one
How does the OCP work?
Causes anovulation
Thickens cervical mucus
Thickens endometrial lining to reduce implantation
With what conditions should you avoid OCP?
Migraine with aura Smoking Stroke or CVD Current breast cancer Liver cirrhosis Diabetes with complications
What is cisgender?
Same sex and gender
What is gender non-conforming?
Gender that doesn’t match assigned sex
What is the effect of taking masculinising hormones for transgender men?
Balding Deeper voice/ acne/ increased coarser facial and body hair Change in distribution of body fat Enlargement if clitorus Menstrual cycle stops Increased muscle mass and strength
What is the effect of feminising hormones for transgender women?
Height, voice and adams apple will not change
Consider sperm banking before taking therapy
1-3 months: decrease in sexual desire/ function / baldness slows or may reverse
3-6 months: softer skin/ change in body fat distribution/ decrease in testicular size/ breast development/ tenderness
6-12 months: hair may become softer and finer
What are 2 causes of irregular periods?
PCOS
Hypothalamic amenorrhea
What are causes of hypothalamic amenorrhea?
Stress
Excess exercise
Low body weight
Genetic susceptibility
How does the OCP work?
Increases progesterone which neg. feedbacks on hypothalamus to decrease GnRH which decreases LH and FSH- no LH surge so follicle is lost and ovulation prevented.
Progesterone also thickens cervical mucus- hard for sperm penetration
Increases Estrogen which neg. feedbacks to ant. pituitary to dec. FSH secretion
What is a possible sign of endometrial cancer?
Post menopausal bleeding
