Reproductive Treatments Flashcards
How to confirm hypogonadism in a man?
Man with low testosterone (Hypogonadism)-
(Confirm at least 2 low fasting measurements of serum testosterone in morning)
Investigate the cause of low testosterone.
What symptoms suggest low testosterone
loss of early morning erections
libido
decreased energy
shaving
What can be done to replace testosterone
Daily Gel. Care not to contaminate partner.
3 weekly intramuscular injection
3 monthly intramuscular injection
Less Common (Implants, oral preparations)
Why is it important to safely measure testosterone levels
Increased Haematocrit (risk of hyperviscosity and stroke)
Prostate (Prostate Specific Antigen (PSA) levels)
What to do for a man with hypogonadism desiring fertility:
Secondary Hypogonadism-
deficiency of gonadotrophins (LH/FSH) ie hypogonadotrophic hypogonadism:
Gonadotrophins (ie LH and FSH) needed to induce Spermatogenesis
LH stimulates Leydig cells to increases intratesticular testosterone levels much higher than in circulation (x100).
FSH stimulates seminiferous tubule development and spermatogenesis.
Should you give testosterone to men desiring fertility?
Avoid giving testosterone to men desiring fertility.
Giving testosterone treatment could further reduce LH / FSH and worsen spermatogenesis!
Treatment for inducing spermatogenesis:
hCG injections (which act on LH-receptors)
If no response after 6 months, then add FSH injections.
What does this woman have?
30 year old woman trying to conceive for 3 years.
Lack of periods (amenorrhoea)
Hyperandrogenism (hirsutism and acne)
Ultrasound Scan –
Polycystic ovarian (PCO) morphology.
LH 8.0 iU/L, FSH 4.5 iU/L
Testosterone 2.5 nmol/L (raised)
Polycystic Ovary Syndrome (PCOS
-Hyperandrogenism
(Clinical or Biochemical)
—-Therefore hirsutism and acne
-PCO morphology
on Ultrasound
-Irregular periods
Hypothalamic
Amenorrhoea (not enough energy for fertilisation)
-Irregular periods
-Low body weight
-Excessive exercise
-Stress
-Genetic susceptibility
What is ovulation induction?
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
How to restore ovulation in Polycystic Ovary Syndrome (PCOS)
Lifestyle / Weight Loss 5%
Metformin, reduces insulin resistance and increases androgen production
Letrozole (Aromatase inhibitor)
Clomiphene (Oestradiol receptor modulator)
FSH stimulation
How to restore ovulation in Hypothalamic amenorrhoea
Lifestyle / Weight gain / reduce exercise
Pulsatile GnRH pump
FSH stimulation
Letrozole (Aromatase inhibitor)
Clomiphene (Oestradiol receptor modulator)
What happens in IVF treatment
Stimulate ovaries to make follicles by giving more FSH
Oocyte retrieval is a small surgical procedure with an ultrasound
Fertilisation in vitro or intra-cytoplasmic sperm injection (directly inject sperm into egg - usually when sperm is the problem)
After eggs are fertilised, zygotes formed and then embryo that is incubated for a few days
Then transfer embryo into endometrium
What are contraception methods?
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
What are permanent methods of contraception
Vasectomy
Female sterilisation
What are the positives and negatives with condoms?
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
Can interrupt sex
Can reduce sensation
Can interfere with erections
Some skill to use eg correct fit.
Two are not better than one
How does the oral contraceptive pill work?
Either oestrogen or progesterone
Negative feedback to decrease GnRH, and lower FSH and LH (both in hypothalamus and pituitary gland)
1) Anovulation
2) Thickening of cervical mucus
3) Thinning of endometrial lining to reduce implantation
What are the positives and negatives to the combined oral contraceptive pill?
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)
Negatives
It can be difficult to remember
No protection against STIs
Metabolised in the liver so can be ineffective when used with antibiotics that interfere with liver metabolism
P450 Enzyme Inducers may reduce efficacy
Not the best choice during breast feeding
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 (2 in 10,000)
What are other benefits with the combined oral contraceptive pill?
- 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 positives and negatives of the progesterone only pill or mini pill?
Positives
Works as OCP but less reliably inhibits ovulation
Often suitable if can’ttake oestrogen (eg for blood clotting reasons)
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
Negatives
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 the different types of long acting reversible contraceptives
. Coils
Suitable for most women
Prevent implantation of conceptus – important for some religions
Rarely can cause Ectopic Pregnancy
Can be used as emergency contraception
Intra-Uterine Device (IUD) ie Copper Coil-
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.
- Intra-Uterine Systems (IUS)which 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.
- Progestogen-only injectable contraceptives or subdermal implants.
Long-lasting so may not be best option if desiring fertility soon.
What examples of emergency contraception’s are there?
What side effects are there?
- Copper intrauterine device (IUD) most effective
can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
Emergency contraceptive pills:
2. Ulipristal acetate 30mg (ellaOne)
Ulipristal acetate 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.
Side effects- headache, abdominal pain, nausea.
Liver P450 Enzyme inducer medications make it less effective.
If vomit within 2-3hrs of taking it, need to take another.
What should you consider when choosing contraception?
- Contraindication for OCP eg 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 - Other conditions that may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids
/ PMS (Pre-Menstrual Syndrome) / acne or hirsutism - Need for prevention of Sexually Transmitted Infections (STI’s): 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
Describe symptoms of menopause
Hot flushes, sweating, disturbed sleep,
Low libido, vaginal dryness, low mood.
Joint and muscle aches
Absent periods for 10 months
How to define menopause
Peri-menopausal- Within the years leading up to menopause
Menopause- Time at 12 months of LMP.
Post-menopausal- After menopause
What are benefits of HRT as menopause hormone treatment
Symptom Relief due to low oestrogen
eg Flushing, Sweats, Disturbed Sleep,
Decreased Libido, Low Mood
Reduction in Osteoporosis related fractures
What are the risks of HRT
- Venous Thrombo-embolism: Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
Oral oestrogens undergo first pass metabolism in liver
Oral»_space; Increase clotting factors
Transdermal estrogens are safer for VTE risk than oral Avoid oral oestrogens in BMI > 30 kg/m2
- Hormone Sensitive Cancers:
Breast Cancer
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
3.Cardiovascular disease
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)
- Risk of Stroke
Small increased risk
Oral have more risk than transdermal oestrogens
Combined (E2+P) more risk than oestrogen only
What is sex
Gender?
Non binary?
Cisgender?
Gender non-conforming?
Gender dysphoria?
Transgender?
Sex is biologically defined eg male, female, or Intersex.
Gender is a Social Construct, how you see yourself as male, female, or non-binary.
Non-binary- Gender does not match to traditional binary gender understanding,
includes agender, bigender, pangender, gender fluid.
Cisgender – cis means same ie Birth Sex & Gender Identity are aligned.
Gender non-conforming – Gender does not match assigned sex.
Gender Dysphoria- when that causes distress.
Transgender- Transitioning from one gender to another.
Transgender men- Female Sex at birth, but Male Gender (FtM is no longer used).
Prevalence- Transgender women 3x more common than transgender men
How to treat a transgender man with masculinising hormones
Testosterone (injections, gels)
Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%).
How to treat a transgender woman with feminising hormones
- 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%)
