Anovulatory Infertility Flashcards
physiological reasons for anovulation?
before puberty
pregnancy
lactation
menopause
pathological reasons for anovulation?
o Hypothalamic: anorexia/bulimia, excessive exercise
o Pituitary: hyperprolactinaemia, tumours, Sheehan syndrome [pituitary damaged during childbirth]???
o Ovarian: PCOS, premature ovarian failure
o Other conditions: systemic disorder (RF), endocrine disorder (e.g. testosterone secreting tumours), drugs (contraceptives)
what is anorexia nervosa?
• 1% of population
• More in females
• Clinical features: low BMI (below 18.5), loss of hair, increased lanugo (fine, soft hair), low pulse and BP, anaemia
• Endocrine features: low FSH, LH and oestradiol
can cause anovulation
what is polycystic ovarian syndrome?
- Most common endocrine disorder in women (20-33%)
* Inherited, condition can be exacerbated by weight gain
how does PCOS present?
- Clinical features: obesity, hirsutism or acne, cycle abnormalities and infertility
- Endocrine features: high free androgens, high LH, impaired hypererance
how is PCOS diagnosed?
need 2/3
- chronic anovulation
- polycystic ovaries (on ultrasound)
- hyperandrogenism (clinical or biochemical)
what is premature ovarian failure?
- In 1% of those under 40
- Aetiology: idiopathic, genetic (Turner’s syndrome, fragile X), chemotherapy, radiotherapy, oophorectomy (also known as ovariectomy, surgical removal of one/both ovaries)
- Clinical features: hot flushes, night sweats, atrophic vaginitis
- Endocrine features: high FSH and LH, low oestradiol
what is tubal disease?
damaged or blocked fallopian tubes (women)
what can cause tubal disease in women?
Infective
o Pelvic inflammatory disease [PID]: infection of the female genetic tract, due to chlamydia, gonorrhoea, anaerobes, syphilis, TB
o Transperitoneal spread: appendicitis, intra-abdominal abscess
• Following procedure: IUCD [intrauterine contraceptive device] insertion, hysteroscopy, HSG [hysterosalpingogram]
• Non-infective
- Endometriosis
- Surgical (sterilisation, ectopic pregnancies)
- Fibroids
- Polyps
- Congenital
- Salpingitis isthmica nodosa
how is tubal disease managed?
- Mild tubal disease: surgery
- Proximal tubal obstruction: selective salpingography and tubal catheterisation OT hysteroscopic tubal cannulation [these treatments improve the chance of pregnancy]
- Hydrosalpinx: salpingectomy (preferably by laparoscopy) before IVF treatment as this improves the chance of live birth
- Laparoscopy, if contraindicated then do hysteroscopy
features of hydrosalpinx
• PID can cause hydrosalpinx (fallopian tube is blocked and fills with serous/clear fluid near the ovary) clinical features: abdominal/pelvic pain fever vaginal discharge, dyspareunia (painful sexual intercourse), cervical excitation, menorrhagia, dysmenorrhoea (menstrual cramps), infertility, ectopic pregnancy, can cause miscarriage
what is endometriosis?
presence of endometrial glands outside the uterine cavity
what causes endometriosis?
most likely retrograde menstruation
Can also be caused by altered immune function, abnormal cellular adhesion molecules, genetic
what are the clinical features of endometriosis?
dysmenorrhoea (classically before menstruation), dyspareunia, menorrhagia (abnormally heavy/prolonged periods), painful defaecation, chronic pelvic pain, uterus may be fixed and retroverted, infertility, may be asymptomatic
how is endometriosis diagnosed?
scan may show characteristic chocolate cysts on ovary
oligomenorrhoea
refers to cycles >35 days
amenorrhoea
refers to absent menstruation (there is primary and secondary)
what is the female version of the HPG axis
The Hypothalamic-Pituitary-Ovarian [HPO] axis
The hypothalamus stimulated the pituitary by GnRH.
The pituitary then produces FSH and LH which stimulates progesterone release from the ovary.
There is increased estradiol from the ovary in the follicular phase, and decreased estradiol during the luteal phase.
Progesterone inhibits FSH/LH release from the pituitary and estradiol inhibits GnRH (from hypothalamus) and FSH/LH [negative feedback].
what is indicative of ovulation?
regular cycles
can be confirmed by a midluteal (D21) serum progesterone of ?30nmol/L in 2 samples
irregular cycles are probably anovulatory what do they need?
further hormone evaluation
how many couples experience fertility issues
1 in 7 couples
ovulatory dysfunction affects 25% of these infertile couples
what are the groups of ovulatory disorders?
Group 1 = hypothalamic pituitary failure
Group 2 = hypothalamic pituitary dysfunction
Group 3 - ovarian failure
Other causes e.g. hyperprolactinaemia
if someone present with amenorrhoea…
do a pregnancy test
