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Clinical Conditions of the Female Causing Infertility Flashcards

1
Q

what are the most common ways that ovarian tumours are detected?

A

Clinical signs dependent upon hormones produced (this is more often)
OR
incidental finding on rectal exam

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2
Q

most common ovarian tumour? a couple runners-up?

A

granulosa-theca cell tumour

also:
b. teratoma
c. angiosarcoma
d. carcinoma/adenocarinoma e. fibroma
f. fibrosarcoma
g. dysgerminoma
h. cystadenoma

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3
Q

equine Clinical signs of Granulosa (theca) cell tumour

A

Male behaviour if producing testosterone (most common scenario = stallion‐like behaviour)
◦ Aggressive, difficult to handle, mounting other mares

Persistent estrus if producing estrogen
◦ Nymphomania in cows

INHIBIN production by granulosa cells in tumour– Inhibits FSH production by pituitary
‐ Contralateral ovary is very small, inactive

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4
Q

what do theca cells make?

A

testosterone in the female

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5
Q

what cells produce estrogen in the female?

A

Granulosa cells of follicle, Placenta

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6
Q

equine granulosa cell tumour diagnosis?

A

◦ Rectal Exam – one large Ovary (usually unilateral)
◦ other ovary small and inactive
◦ Ultrasound – variable appearance – cystic or solid; any
combination
◦ Multicystic classic appearance is most common

Confirm with Laboratory testing and Histopathology

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7
Q

presentation of bovine granulosa cell tumour

A

Presents as Infertility
Aggressive/bullish behaviour
Non‐retractable uterus
Very large, “lumpy” right ovary

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8
Q

are GCT tumours hormonally active?

A

Usually hormonally active

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9
Q

what does a GCT diagnostic panel look at? what is diagnostic? what do we do if levels are low?

A

GCT Diagnostic Panel: Testosterone, Inhibin, AMH
- Elevated levels diagnostic (High Testosterone plus
Inhibin > 0.7ng/ml)
- Elevated Anti‐Mullerian Hormone (AMH) Levels
> Can detect tumours earlier than inhibin

What if levels low/borderline? – repeat 3‐6 mos. later

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10
Q

treatment for ovarian tumours - how is it done and what are the results? what are possible complications?

A

Unilateral Ovariectomy
◦ Usually by flank laparoscopy via paralumbar fossa
-Eliminates unwanted behaviour; rarely metastasize
-May require several months to resume cycling

Complications – difficult surgical exposure if large (requires ventral abdominal surgery)
◦ Severe hemorrhage
◦ Incisional complications

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11
Q

when are transitional ovaries in mares normal?

A

spring

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12
Q

what are parovarian cysts? what is their origin? how are they usually found and what do they look like? are they common? what is their effect on fertility and how do we usually treat them?

A

◦ Remnants of mesonephric ducts
◦ Fluid filled, variable size
◦ Incidental finding on U/S
◦ “follicle that is always there”
◦ Sporadic/ not uncommon in mares
◦ No affect on fertility (can be confused for a follicle)
◦ No treatment required

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13
Q

what is a common finding on the mare ovary in transition?

A

multiple large ovaries and anovulatory follicles
-ovaries will be bilaterally large
-ovulation fossas will be palpable and hormone levels will be normal

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14
Q

ultrasound appearance of an anovulatory follicle can resemble what?

A

granulosa cell tumor

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15
Q

how does an ovarian hematoma arise? how do we usually find out about it?

A

bleed into a follicle instead of ovulating
-incidental finding or history of pain

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16
Q

do we often see ovarian hematoma with abdominal bleeding? what is a possible consequence?

A

no, rarely
-If large, rarely cause abdominal hemorrhage and death

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17
Q

how large is an ovarian hematoma, generally?

A

6-8cm

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18
Q

how long does an ovarian hematoma take to regress?

A

4-6 weeks

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19
Q

most common cause of big ovary in cows

A

cystic ovarian disease

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20
Q

what does bovine cystic ovarian disease look like? how long do they last? what may they interfere with?

A

Abnormal structures on the ovaries
‐usually follicular cysts – often multiple fluid filled structures
‐persist for >10 days ‐ >2.5 cm in diameter; and absence of a CL
May (or may not) interfere with normal cycling

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21
Q

at what point in a cows life are we more likely to see cystic ovarian disease?

A

Dynamic disease – cysts come and go
common is early post-partum cows

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22
Q

how are most cases of bovine cystic ovarian disease resolved?

A

most will recover spontaneously

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23
Q

what is the salpinx?

A

oviduct

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24
Q

Up to 70 % of cows with endometritis / pyometra also have:

A

*Salpingitis, hydrosalpinx
*Bursitis/bursal cysts
*Ovaritis
May result in oviductal blockage (infertinity > culling)

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25
what is a bovine bursal adhesion? what can it result in?
◦ Adhesions between ovary and fimbria ◦ Can interfere with oocyte pickup –leads to infertility
26
what is a bursal cyst?
Fluid accumulation when bursal adhesions become severe
27
how does oviduct blockage occur in mares? what is the consequence and is it common?
Only live embryos pass thru the oviduct into the uterus in mares ‐embryo produces PGE‐2 to open the oviduct papilla -Mare oviduct can become plugged with old oocytes and large amounts of follicular fluid Uncommon cause of infertility in mares
28
how do we diagnose oviduct blockage in a mare? How do we treat it?
-Diagnosis is by exclusion -When ALL other causes of infertility (especially endometritis) have been ruled out (consider including karyotyping if a young maiden mare) -Application of PGE2 gel directly onto oviducts via laparoscopic surgery, or onto the oviductal opening via hysteroscopy or deep horn AI technique -In selected cases, results have been excellent
29
what are common reasons for cervicitis?
Often occurs with chronic irritation (trauma, air feces, urine, endometritis)
30
how do we diagnose cervicitis?
vaginoscopy ◦ Look for endometritis, poor perineal conformation, urovagina, rectovaginal fistula
31
how do we treat cervicitis?
treat the underlying cause (often endometritis)
32
why do we get cervical tears in cows?
Occurs in cows when a calf is pulled too early before cervix is fully dilated
33
easiest way to palpate cervical tear
vaginal exam
34
how to visualize a cervical tear
visualize with vaginoscope
35
how to treat cervical tear
Minor tears often heal with time and medical management in the postpartum period Re‐assess at 30 days after foaling Surgical repair is needed if >50% of the length of the cervix is affected Usually re‐tear at subsequent foaling and repair needs to be repeated Embryo Transfer
36
Severe vaginal and cervical trauma at foaling often leads to:
adhesions and vaginal/cervical stenosis
37
partail or complete double cervix (congenital abnormalities of cervix) are caused by:
Incomplete fusion of paramesonephric ducts
38
Varicose Veins in Mares are a common cause of what?
‐common cause of frank bloody discharge during pregnancy in mares ‐usually minor amount but can become severe in rare cases
39
how to treat varicose veins in mare cervix/hymen/vagina
‐if minor hemorrhage, topical application of Preparation H may shrink varicose veins ‐if significant, surgical laser or Ligasure cautery of vessels
40
common causes of vaginitis in cows
IBR (herpes) or Ureaplasma are most common
41
what is the cause of Imperforate (Persistent) Hymen in the mare?
Failure of canalization during development of the paramesonephric duct system at the level of the urogenital sinus
42
how is Imperforate (Persistent) Hymen found? how does it present?
May be partial or complete If partial, may only be found during first AI – as a band or tight sphincter If complete may present as pink membrane protruding from vulva of maiden young filly
43
complete Imperforate (Persistent) Hymen can lead to what? how do we treat?
If complete – leads to fluid accumulation anterior to it (ultrasound) Treatment – manual rupture (under sedation !!) or electrocautery if thick
44
3 common vaginal tumor types
Fibrosarcoma Leiomyoma Squamous Cell Carcinoma
45
presentation of vaginal tumors
May present with vaginal discharge, self‐mutilating behaviour (licking in bitches, rubbing area in large animals)
46
diagnosis of vaginal tumors
Excision or biopsy for diagnosis and prognosis
47
avoid confusing what with vaginal tumor
prolaspse, especially in pregnant cows in late gestation
48
where anatomically will we usually see a vaginal squamous cell carcinoma?
Usually caudal tract – clitoris, vestibule, hymen area
49
how to differentiate a vaginal squamous cell carcinoma in a mare vs intersex? how to treat?
History is different from an intersex/DSD ◦ Older animal; malodorous discharge often present ◦ May have offspring born previously ◦ Cycle normally, normal behaviour ◦ Self‐mutilation common Locally invasive Diagnosis by tissue biopsy Treatment – excision + local chemotherapy (5‐FU)
50
1st Degree Perineal Laceration - what is it and how do we treat?
Minor tears of the dorsal commisure of the vulva Tear is limited to the skin, mucous membrane Treatment – Clean, debride and suture as soon as possible after parturition
51
2nd Degree Perineal Laceration - what is it and how do we treat?
Tear extends into muscle layers of vulva Debride and Suture if fresh Allow to granulate if too old to suture
52
3rd Degree Perineal Laceration - what is it, how does it arise, and how do we treat? prognosis?
Complete tearing of the shelf between rectum and vulva Usually the result of dystocia or improperly applied traction at foaling The tear is complete through the perineal body Communication between rectum and vagina Fecal contamination Surgical repair delayed 6‐8 weeks Wash daily and debride as required It will look worse before it looks better! Dietary management – laxative diet Prognosis Good – for future fertility and uneventful foaling
53
what is segmental aplasia of the uterus? how does it develop? what are the common presentations and what animals do we often see this in?
Most often present for infertility Lack of development of a portion of the paramesonephric duct system High prevalence in some breeds of cattle “white heifer disease” in white Shorthorns 0.2% prevalence in slaughterhouse studies
54
what can occur with uterine segmental aplasia that can be confused with pregnancy?
Fluid accumulation in cranial parts of the tracts often occurs ◦ May result in falsely diagnosing as pregnant
55
a cow is run through a chute for preg check with a small vulva and a big tuft of hair at the bottom of it. What are you thinking?
looks like a freemartin!
56
what is a freemartin? how does this condition arise? what is the physical presentation?
-Heifers born co‐twin to a bull -Placental vascular anastomoses result in male fetus influencing development of female’s reproductive tract -Ovaries and uterus are underdeveloped to varying degrees -Vagina and vulva are hypoplastic -Clitoris enlarged -Seminal vesicles present, other male accessory structures vary
57
in the case of freemartinism what is usually the case for the bull twin?
Fertility of the twin bull is also reduced
58
how can we diagnose freemartinism?
-Diagnosis on physical findings -PCR test of blood for Y-specific sequence
59
how can we diagnose equine intersex condition? what is a common fate for these animals?
Often inappropriate stallion‐like behaviour in an apparent filly ‐Or ambiguous external genitalia The external appearance varies widely ‐from normal appearing female with male‐like behaviour to clitoromegaly and very long ano‐genital distance Variety of syndromes Diagnosis on examination findings, karyotype and cytogenetic tests These animals can be gonadectomised (and enlarged clitoris removed) and be useful pleasure horses
60
Pyometra
Pyometra – pus accumulation in uterus, with CL retained (exception = mare)
61
Mucometra
Mucometra – mucous accumulation in uterus
62
Endometritis
Endometritis – inflammation of endometrium, animal is not systemically ill
63
Metritis
Metritis – inflammation of all layers of uterus, animal is systemically ill
64
Septic metritis
– early postpartum, toxic infection, acute, severe illness
65
Pyometra – Why is the CL Retained?
Damage to endometrium – inability to produce PGF2a – no luteolysis Production of luteotropic PGE’s by wbc’s in exudate
66
why would we generally see pyometra in a cow? what are clinical signs?
After first ovulation post‐calving ie > 25 days PP Anestrus +/‐ vaginal discharge Large fluid‐filled uterus ◦ Do not confuse with pregnancy Cows are not sick ◦ Typically T. pyogenes
67
Pyometra – Treatment for COWS? I
PGF2a Two injections 14 days apart ‐lyse CL, estrus – opens cervix to allow drainage ‐uterine defenses Prognosis ‐ ? Generally poor esp. if longstanding
68
prevention for pyometra in cows
◦ Examine all cows by 30 days postpartum to identify those with uterine disease
69
how does Pyometra in the Mare present? how is it differentiated from endometritis?
Present with periodic vaginal discharge Differentiated from endometritis by extremely large volume of fluid in uterus
70
what is the usual cause for pyometra in the mare?
Usually due to cervical trauma
71
is Pyometra in the Mare easy to treat?
difficult to treat
72
how to treat Pyometra in the Mare?
Difficult to treat Previously hysterectomy was often the best/only option Cervical wedge resection may help with drainage ◦ Uterine lavage and antibiotics
73
Clinical Signs of Pyometra in the Bitch. What types are there?
Open Pyometra – vaginal discharge usually 4‐6 weeks after a heat (when a CL is present) vs Closed Pyometra (Sick), no discharge
74
Pyometra Treatment ‐ Bitch. what condition is it associated with?
Associated with cystic endometrial hyperplasia Spay often best option Medical treatment for breeding bitches
75
mucometra is secondary to what condition?
Secondary to cystic ovarian disease or associated with Segmental Aplasia
76
mucometra may be confused with what? how do we differentiate?
Maybe be confused with a pregnancy ◦ No fetal membranes, placentomes or or fetus
77
how do we treat mucometra in the cow?
Treatment – Ovsynch/ PGF2a/ treat COD Cull if segmental aplasia
78
endometritis usually affects cows at what time of their life?
postpartum period
79
result of endometritis?
infertility
80
Types of Endometritis in the Mare
1. Persistent Breeding Induced Endometritis (PBIE) 2. Acute Endometritis ◦ Venereal ◦ Infusion of Irritants into Uterus ◦ Contamination (feces, poor A.I. technique etc.) ◦ Can become chronic ie repeated breedings without pregnancy 3. Chronic Endometritis (diagnose by biopsy – presence of lymphocytes and plasma cells)
81
what is is purpose of breeding induced inflammation – transient inflammatory response in the uterus? when does it develop? what can go wrong in some mares?
A normal physiologic reaction to semen Natural process to eliminate sperm and debris ◦ Innate immune reaction ◦ Mechanical clearance Normal “resistant” mares resolve this inflammation within ~24 hours “Susceptible” mares can’t and develop Persistent breeding-induced endometritis
82
how common is Persistent breeding‐induced endometritis (PBIE) in mares? why does it occur? what does it lead to?
10‐15% of mares have a failure of the natural immune defense mechanisms Failure of physical clearance ◦ Decreased uterine contractility ◦ Failure of cervical relaxation ◦ Pendulous uterus (gravity) Accumulation of fluid/debris/bacteria Leads to infertility
83
what is the pathological process whereby persistent breeding induced endometritis arises?
breeding > inflammation > NO/REDUCED CLEARANCE (as there would be in normal mares) > increased intraluminal fluid > increased inflammation > increased endometrial irritation > destruction of mucociliary barrier > bacterial colonization => in susceptible mares, we see an abnormal inflammatory resonse: influx of PMNs, IgG, proteins
84
how do we diagnose persistent breeding induced endometritis
History: infertility Previously retained fluid after breeding Ultrasound mares at risk within 24 hours of breeding ◦ Presence of intrauterine fluid more than 24 hours after breeding is diagnostic
85
Management of mares with PBIE
Breed only once per cycle to minimize contamination Ultrasound check for fluid within 24 hours after breeding Uterine lavage with sterile saline (as early as 6 hrs post breeding) ◦ ~ 1L at a time until returning fluid is clear Ecbolic (cause uterine contractions=clearance) ◦ Oxytocin ◦ PGF2a
86
things that can cause acute endometritis?
Usually bacterial Can be venereal But can be iatrogenic due to irritants infused into uterus
87
clinical signs of acute endometritis?
+/‐ Vaginal discharge after breeding or at next estrus ◦ May “short cycle” (come back into estrus early – due to inflammation and endometrial PGF2a release
88
diagnosis of acute endometritis?
Diagnosis by ultrasound (fluid and/or excessive edema) and endometrial swab Submit for Culture and cytology
89
Treatment of endometritis in mares? What do we hope to accomplish?
◦ Treatment usually involves: ◦ Uterine lavage ◦ Antibiotic infusion ◦ Ecbolic therapy ◦ Correct perineal conformation defects ◦ Correct defects in uterine defense mechanisms ◦ Neutralize bacterial/fungal contaminants ◦ Control inflammation ◦ Promote uterine clearance
90
Qualities of a Good Antibiotic Choice for endometritis
Effective against organism Effective in environment Reaches good uterine concentration Non‐irritating to uterus
91
treatment for Acute Bacterial Endometritis in Mares
Treatment is based on bacteria cultured Combination of uterine lavage and antibiotic infusion into uterus
92
what antibiotic should we not use in the uterus?
◦ Note: DO NOT use Baytril (enrofloxacin) intrauterine >causes adhesions
93
how do we diagnose chronic endometritis?
Diagnosed by biopsy ◦ Presence of lymphocytes and/or plasma cells Culture swab (often negative – bacteria has been cleared but inflammation remains)
94
where do we find Endometrial Cysts in Mares? what is usually their origin? what mares get them more commonly?
Fluid filled structures in the uterus Usually within lumen Usually are lymphatic in origin (dilated lymphatics) Sometimes glandular Often seen in older mares
95
effects of Endometrial Cysts in Mares
May interfere with fertility if they are large or in a large group Prevent the early embryo from migrating ‐‐‐ no maternal recognition of pregnancy Or, may interfere with placental attachment
96
what do endometrial cysts in mares indicate?
Indicate uterine pathology – usually fibrosis
97
how do we treat Endometrial Cysts in Mares? what should we do first?
◦ Do nothing if small and few in number ◦ Laser ablation if clusters or single large cysts ◦ Uterine biopsy first to determine prognosis
98
Degenerative Endometrial Fibrosis (DEF) in Mares - how do we diagnose?
Diagnosed by endometrial biopsy
99
what is Degenerative Endometrial Fibrosis (DEF) in Mares?
A chronic degenerative process with progressive changes over time ◦ Fibrosis ◦ Glandular dilatation ◦ Nesting of glands ◦ Vascular degeneration
100
effects of Degenerative Endometrial Fibrosis (DEF) in Mares? treatment?
Can interfere with uterine clearance, and secretion of histotroph ‐‐‐‐ leads to EED Non‐reversible -Biopsy helps give owners realistic expectations

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