Reproductive Treatments Flashcards
What investigations should be done for suspected hypogonadism in a man with low testosterone?
Confirm at least 2 low fasting measurements of serum testosterone in morning
Investigate the cause of low testosterone
What is the aim of testosterone replacement?
Treat symptoms: loss of early morning elections, libido, decreased energy and shaving
What are the different types of testosterone replacement?
Daily gel - must take care not to contaminate partner
3 weekly intramuscular injection
3 monthly intramuscular injection
Less common - implants, oral preparations
What must be monitored when a person is on testosterone replacement?
Increased Haematocrit - risk of hyperviscosity and stroke
Prostate - PSA levels (prostrate specific antigen)
How are the gonadotrophins LH and FSH involved in fertility?
LH - stimulates Leydig cells to increase intratesticular testosterone levels (much higher than in circulation)
FSH - stimulates seminiferous tubule development and spermatogenesis
Why should you avoid giving testosterone to men desiring fertility?
Giving testosterone treatment could further reduce LH / FSH and worsen spermatogenesis
What is the treatment for inducing spermatogenesis?
hCG injections (which act on LH-receptors)
If no response after 6 months, then add FSH injections
What are the symptoms/signs of PCOS?
Hyperandrogenism (clinical, e.g. hirsutism or biochemical)
PCO morphology (US)
Irregular periods
What can cause hypothalamic amenorrhea?
Low body weight
Excessive exercise
Stress
Genetic susceptibility
What is the aim of ovulation induction and why?
Aim to develop one ovarian follicle by causing a small increase in FSH
If >1 follicle develops, this risks multiple pregnancy (ie Twin / Triplet)
Multiple pregnancy has risks for mother and baby during pregnancy
What steps are taken to restore ovulation in PCOS?
- Lifestyle/weight loss (5%)
- Metformin
- Letrozole (aromatase inhibitor)
- Clomiphene (oestradiol receptor modulator)
- FSH stimulation
What steps are taken to restore ovulation in hypothalamic amenorrhea?
- Lifestyle/weight gain/reduce exercise
- Pulsatile GnRH pump
- FSH stimulation
- Letrozole (aromatase inhibitor)
- Clomiphene (oestradiol receptor modulator)
What are the steps of IVF?
Oocyte retrieval
Fertilisation in vitro
Embryo incubation
Embryo transfer
What are the two different types of fertilisation in vitro?
IVF - sperm left to penetrate egg
Intra-cytoplasmic sperm injection - usually male factor infertility - one sperm is injected directly into egg
What are the non-permanent methods of contraception?
Barrier: male/female condom/diaphragm or cap with spermicide
Combined oral contraceptive pill (OCP)
Progesterone-only pill (POP)
Long Acting Reversible Contraception (LARC)
Emergency contraception
What are the permanent methods of contraception?
Vasectomy
Female sterilisation
What are the positives of condom use?
Protect against STI’s
Easy to obtain – free from clinics
No need to see a healthcare professional
No contra-indications as with some hormonal methods
What are the negatives of condom use?
Can interrupt sex
Can reduce sensation
Can interfere with erections
Some skill to use, eg correct fit
Two are not better than one
What are the effects of the combined OCP on the HPG axis?
Oestrogen and prog - negative feedback - decrease GnRH, LH and FSH
Ovaries:
1. Anovulation
2. Thickening of cervical mucus
3. Thinning of endometrial lining to reduce chance of implantation
What are the positives of the combined OCP?
Easy to take - one a day
Effective
Doesn’t interrupt sex
Can take several packets back to back and avoid withdrawal bleeds
Reduces risk of endometrial and ovarian cancer
Weight neutral in 80% of people
What are the negatives of OCP use?
It can be difficult to remember
No protection against STIs
P450 Enzyme Inducers may reduce efficacy
Not the best choice during breast feeding
What are the possible side effects of the OCP?
Spotting (bleeding in between periods)
Nausea
Sore breasts
Changes in mood or libido
Feeling more hungry (can try different OCPs to see which suits best)
Blood clots in legs or lungs (extremely rare)
What are the non-contraceptive uses of the OCP?
- Helps make periods lighter and less painful
- Endometriosis / Fibroids
- Dysmenorrhoea (painful periods)
- Menorrhagia (heavy periods) - Regular Withdrawal Bleeds / or no Bleeds
- PCOS: OCP can help reduce LH and hyperandrogenism (acne / hirsutism)
What are the positives of taking the Progesterone Only Pill?
Works as OCP but less reliably inhibits ovulation
Often suitable if can’ttake oestrogen
Easy to take – one pill per day with no break
It doesn’t interrupt sex
Can help heavy or painful periods
Periods may stop (temporarily)
Can be usedwhen breastfeeding
What are the negative of taking the POP?
Can be difficult to remember
No protection against STIs
Shorter acting – needs to be taken at the same time each day
What are the possible side effects of the POP?
Irregular bleeding
Headaches
Sore breasts
Changes in mood
Changes in sex drive
What are the different types of Long-Acting Reversible Contraceptives (LARC)?
Coils
- Intra-uterine Device (IUD i.e. copper coil
- Intra-uterine systems (IUS) which secretes progesterone (e.g. Mirena Coil)
Progesterone-only injectable contraceptives or subdermal implants
What must be considered before using a coil?
Suitable for most women
Prevent implantation of conceptus – important for some religions
Rarely can cause Ectopic Pregnancy
Can be used as emergency contraception
What are the differences between an IUD and IUS?
IUD:
- Mechanically prevent implantation, decrease sperm / egg survival
- Lasts 5-10yrs
- Can cause heavy periods, and 5% can come out especially during first 3months with periods
IUS:
- Secretes progesterone (eg Mirena Coil) to thin lining of the womb and thicken cervical mucus
- Can be used to help with heavy bleeding
- Lasts 5yrs
What must be considered before using Progesterone-only injectable contraceptives?
Long lasting - not the best option if desiring fertility soon
What is the most effect emergency contraception?
Copper IUD - can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
What are the two main emergency contraceptive pills?
Ulipristal acetate 30mg (ellaOne)
- Stops progesterone working normally and prevents ovulation
- Must be taken within 5 days of unprotected intercourse (earlier has better efficacy)
- 1-2% can get pregnant if ovulation has already occurred
Levonorgestrel 1.5mg (Levonelle)
- Less effective (esp if incr BMI >27 kg/m2)
- Synthetic Progesterone prevents ovulation (don’t cause abortion)
- Must be taken within 3 days of unprotected intercourse - 1-3% failure rate
What are the side effects and consideration for emergency contraceptive pills?
Side effects: Headache, abdominal pain, nausea
Considerations:
- Liver P450 Enzyme inducer medications make it less effective
- If vomit within 2-3hrs of taking it, need to take another
Compare the efficacy of different types of contraception
What are some contraindications for OCP use and when should they be avoided?
Contraindication for OCP: Risk of Venous Thromboembolism (VTE) / CVD / Stroke
Avoid OCP if:
- Migraine with aura (risk of stroke)
- Smoking (>15/day) at age >35yrs
- Stroke or CVD history
- Current breast cancer
What are some other considerations for OCP use?
- Other conditions may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids
/ PMS (Pre-Menstrual Syndrome) / acne or hirsutism - Need for prevention of STIs - barrier methods better than hormonal
- Concurrent medication — P450 liver enzyme-inducing drugs (eg anti-epileptics, antibiotics) effect efficacy of OCP
Teratogenic drugs (eg lithium or warfarin) - more effective methods of contraception needed (eg progestogen-only implant, or intrauterine contraception) - Ease of use
Distinguish between peri-menopause, menopause and post-menopause
Peri-menopausal- Within the years leading up to menopause
Menopause- Time at 12 months since last menstrual period LMP
Post-menopausal- After menopause
What are the benefits of HRT?
Symptom relief due to low oestrogen eg flushing, sweats, disturbed sleep, decreased libido, low mood
Reduction in osteoporosis related fractures
What are some risks of HRT?
- Venous Thrombo-embolism: Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
- Hormone Sensitive Cancers, e.g. breast, ovarian and endometrial
- Cardiovascular disease
- Risk of stroke
How does HRT increase the risk of VTE and what can be done to reduce this?
Oral oestrogens undergo first pass metabolism in liver
Oral -> Increase clotting factors
Transdermal estrogens are safer for VTE risk than oral
Avoid oral oestrogens in BMI > 30 kg/m2
Describe the implications of HRT on breast cancer risk
Slight increase in women on Combined HRT
Risk related to duration of treatment and reduces after stopping
Continuous worse than sequential
Assess risk in each individual before prescribing
Describe the implications of HRT on ovarian cancer risk
Small increase in risk after long-term use
Describe the implications of HRT on endometrial cancer risk
Must prescribe Progestogens in all women with an endometrium
Progestogens: synthetic progestins and the natural hormone progesterone
Post-menopausal bleeding could indicate endometrial cancer
Outline the factors affecting risk of CVD due to HRT
Improved risk in younger women and recently post-menopausal
Increased risk if started later i.e. 10 years after menopause
Likely benefit in younger women e.g. Premature Ovarian Insufficiency (POI)
Outline the factors affecting risk of stroke due to HRT
Small increased risk
Oral have more risk than transdermal oestrogens
Combined (E2+P) more risk than oestrogen only
Summarise the risks of HRT
Weight the benefits and risks of HRT
How do you treat transgender men?
Testosterone (injections, gels)
Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)
How do you treat transgender women?
- Reduce Testosterone
- GnRH agonists (induce desensitisation of HPG axis)
- Anti-Androgen medications - Estrogen (transdermal, oral, intramuscular)
High dose oestrogen eg 4-5mg per day (side-effects: higher risk of VTE 2.6%)
How are prepubertal young people who would like to change gender supported?
Prepubertal Young people – GnRH agonist to delay puberty
Waiting list for specialist clinic ~4yrs
Post-treatment regret - 1-2%
Gender Reassignment surgery after ~1-2 yrs of hormonal treatment
