Reproductive treatments Flashcards
Symptoms of low testosterone
loss of early morning erections, libido, decreased energy,decreased shaving frequency
how is testosterone prescribed to males not desiring fertility?
daily gel- take care not to contminate partner
3 weekly IM injections
3 monthly IM injections
implants/oral preparations less common
Testosterone treatment safety monitoring
Increased Haematocrit (risk of hyperviscosity and stroke)
Prostate Specific Antigen (PSA) levels)
How do gonadotrophins stimulate spermatogenesis?
LH stimulates Leydig cells to increases intratesticular testosterone levels much higher than in circulation (x100).
FSH stimulates seminiferous tubule development and spermatogenesis.
what to prescribe to males desiring fertility?
hCG injections (act on LH receptors)
if no response after 6mnth, add FSH injections
Should we use testosterone replacement to treat deficient males wanting fertility?
NO TESTOSTERONE - -ve feedback on LH/FSH
when is testosterone prescribed to males presenting with infertility?
if fertility is not desired, only for symptomatic relief
How many ovarian follicles are we aiming to develop through ovulation induction and why?
How is this acheived?
Aim to develop one ovarian follicle
If >1 follicle develops, this risks multiple pregnancy (ie Twin / Triplet)
Multiple pregnancy has risks for mother and baby during pregnancy
Ovulation induction methods aim to cause small increase in FSH
what is primary amenorrhoea?
menses not started after 16 years old
what is secondary amenorrhoea?
periods start at puberty but stop for at least 3-6mnths
what is amenorrhoea?
no periods for at least 3-6mnths
or up to 3 periods/yr
what is oligomenorrhoea?
irregular/infrequent periods, >35day cycles
or 4/9 cycles/yr
Treatments to induced ovulation in PCOS
Lifestyle / Weight Loss 5%
Metformin
Letrozole (Aromatase inhibitor)
Clomiphene (Oestradiol receptor modulator)
FSH stimulation
what is early menopause?
menopause occurring in a female under 45
Treatments to induce ovulation in PCOS
Lifestyle / Weight Loss 5%
Metformin
Letrozole (Aromatase inhibitor)
Clomiphene (Oestradiol receptor modulator)
FSH stimulation
Treatments to induce ovulation in hypothalamic amenorrhoea
Lifestyle / Weight gain / reduce exercise
Pulsatile GnRH pump
FSH stimulation
Letrozole (Aromatase inhibitor)
Clomiphene (Oestradiol receptor modulator)
What is the chance of conception over 1 year without Contraception?
85%
simply, what is the process of IVF?
oocyte retrieval (after high dose FSH)
fertilisation in vitro
IVF/ICSI
embryo incubation
embryo transfer
what is ICSI and when is it used?
intra-cytoplasmic sperm injection
used for when sperm has mobility issues/male factor infertility
What is the chance of conception over 1 year with fertility awareness / withdrawal?
25%
what are the impermanent methods for contraception?
barriers e.g male / female condom / diaphragm or cap with spermicide
combined OCP
progesterone only pill (mini pill)
long acting reversible contraception
emergency contraception
what are the permanent methods for contraception?
vasectomy
female sterilisation
what are the positives for condoms?
protect against STIs
easy to obtain- free from clinic, no need to see healthcare professional
no contraindications unlike some hormonal treatment
what are the negatives of condoms?
can interrupt sex
can reduce sensation
can interfere with erections
some skill needed to use e.g. correct fit
how does the combined oral contraceptive pill act for contraception?
high oest and prog negative feedback on LH/FSH
low LH/FSH cause anovulation
prog thickens cervical mucus
thinning of endometrial lining to reduce implantation
what are the positives for the combined OCP?
Easy to take – one pill a day (any time of day)
Effective
Doesn’t interrupt sex
Can take several packets back to back and avoid withdrawal bleeds
Reduce Endometrial and Ovarian Ca
Weight Neutral in 80% (10% gain, 10% lose)
what are the negatives for the combined OCP?
may not remember to take it
no protection against STIs
P450 enzyme inducers may reduce efficacy
not best choice during breastfeeding
Possible side effects:
Spotting (bleeding in between periods)
Nausea
Sore breasts
Changes in mood or libido
Feeling more hungry
(try different OCPs to see which suits best)
Extremely rare side effects:
Blood clots in the legs or lungs
what are the non-contraceptive uses of the combined 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 helps reduce LH and hyperandrogenism (acne / hirsutism)
what are the positives of the mini 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 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
Possible side effects
Irregular bleeding
Headaches
Sore breasts
Changes in mood
Changes in sex drive
what are long acting reversible contraceptives? (LARC)
intra-uterine devices, intrauterine systems, subdermal implants, progesterone only injections
Advantages and disadvantage of using coil ascontraception
Suitable for most women
Prevent implantation of conceptus – important for some religions
Can be used as emergency contraception
Rarely can cause Ectopic Pregnancy
what is an IUD?
Disadvantages
Example
a LARC mechanically preventing implantation, decreasing
sperm / egg survival. Lasts 5-10yrs.
Can cause heavy periods, and 5% can come out especially during first 3months with periods.
e.g copper coil
what is an IUS?
Example
Used to thin lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding). Lasts 5yrs.
e.g mirena coil
what are the choices for emergency contraception?
How longafter unprotected sex can these be fitted?
How effective are they?
copper coil (most effective) can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
contraceptive pill - ulipristal acetate 30mg- 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- Must be taken within 3 days of unprotected intercourse. 1-3% failure rate.
what is the ulipristal acetate emergency contraceptive? (ellaOne)
stops progesterone working normally
prevents ovulation
what is the levonorgestrel emergency contraceptive pill? (levonelle)
synthetic progesterone prevents ovulation
doesnt cause abortion
what are the side effects of emergency contraceptive pills?
What drug class interferes with emergency contraceptive pills action?
headache, abdo pain, nausea- If vomit within 2-3hrs of taking it, need to take another.
Liver P450 Enzyme inducer medications make it less effective.
what are the contraindications for combined OCP?
Migraine with aura (risk of stroke)
Smoking (>15/day) at age >35yrs
Stroke or CVD history
Current Breast cancer
what medications may interact with the combined OCP?
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).
Symptoms of menopause
Hot flushes, sweating, disturbed sleep,
Low libido, vaginal dryness, low mood.
Joint and muscle aches
Benefits of HRT
Symptomatic relief
Reduction in Osteoporosis related fractures
what are the risks for hormone replacement therapy in menopause?
venous thrombo-embolism
hormone senstive cancers
increased risk of CV disease
risk of stroke
why is venous thrombo-embolism a risk for oral oestrogen HRT?
How can wereduced this risk?
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
why are hormone sensitive cancers a risk in oestrogen HRT?
Slight increase in women on Combined HRT
(ie oestrogen AND progesterone)
Risk related to duration of treatment and reduces after stopping
Continuous worse than Sequential
Assess risk in each individual before prescribing
Ovarian cancer- Small Increase in risk after long-term use.
Endometrial Cancer-
Must prescribe Progestogens in all women with an endometrium !
Progestogens: synthetic progestins
and the natural hormone progesterone.
Post-menopausal bleeding could indicate endometrial cancer
what is the cardiovascular disease risk of oestrogen HRT?
Improved risk in Younger Women & Sooner after Menopause
Increased risk if started later i.e. 10 years after menopause
Likely benefit in younger women e.g. Premature Ovarian Insufficiency (POI)
what is the risk of stroke with oestrogen HRT?
Small increased risk
Oral have more risk than transdermal oestrogens
Combined (E2+P) more risk than oestrogen only
which transgender gender is more common?
transgender women 3x more common than transgender men
what is the process for transgender treatment?
in prepubertal young people - GnRH agonist for pubertal suppression and then sex steroids
gender reassignment surgery after 1-2 years of hormonal treatment
what are the masculising hormones for transgender men?
testosterone (injections, gels)
progesterone given to suppress menstrual bleeding if needed
what are the feminising hormones for 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
what should be monitored when giving testosterone ton males not desiring fertility?
haematocrit - risk of stroke/hyperviscosity
prostate specific antigen - risk of prostate cancer
first line treatment for PCOS?
metformin for weight loss
letrozole - aromatase inhibitor
inhibits test-oestr
Symptoms of low testosterone?
loss of early morning erections, libido, decreased energy,decreased shaving frequency
