Female Infertility Flashcards
Causes of female infertility?
Ovulatory disorders - endocrine, iatrogenic, PCOS, anorexia, endometriosis
Tubal disorders - iatrogenic, infections, congenital, endometriosis
Uterine abnormalities
Psychosexual problems
Unexplained infertility
Physiological causes of anovulation?
Before puberty
Pregnancy
Lactation
Menopause
What is oligomenorrhoea?
Cycles >42 days (i.e. less than 8 periods/year)
What is amenorrhoea?
Absent menstruation
What is primary amenorrhoea?
Periods have never started
What is secondary amenorrhoea?
Previously have had periods but now the have stopped
Does oestrogen production have positive or negative feedback on pituitary/hypothalamus?
Both
Mainly negative feedback
However, a sustained level of oestrogen mid-cycle switched to positive feedback which drives more LH, FSH and GnRH production to stimulate ovulation
Does progesterone have positive or negative feedback on the pituitary/hypothalamus?
Negative feedback
What does FSH stimulate in females and when in the menstrual cycle does it increase/peak?
Follicular development
Thickens endometrium
Increases during follicular phase and has a small peak just before ovulation
What does LH stimulate in females and when in the menstrual cycle does it peak?
Ovulation
Development of corpus luteum
Thickens endometrium
Peaks at the LH surge 24-36 hours prior to ovulation
What does oestrogen do in females when in the menstrual cycle does it increase/peak?
Changes cervical mucus
Thickens endometrium
Increases across follicular phase and peaks before ovulation
What does progesterone do in females when in the menstrual cycle does it increase/peak?
Inhibits secretion of LH
Thickens cervical mucus
Maintains a thick endometrium
Increases basal body temperature
Relaxes smooth muscles
Peaks following ovulation in the luteal phase
If someone has regular cycles, are they likely to be ovulating?
Yes
If someone has irregular cycles, are they likely to be ovulating?
No, this is suggestive of anovulation
What investigation would you do to see if a woman was ovulating?
Midluteal serum progesterone
What level on a midluteal progesterone test would be suggestive of ovulation?
> 30 nmol/l
If a woman as irregular cycles, which other hormonal tests would you do?
FSH, LH
TSH
Prolactin
Oestrogen, testosterone, SHBG
What is a progesterone challenge test?
Administer progesterone (Provera 5mg bd) for 5 days
Progesterone levels fall after and they should experience bleeding within 7-10 days
What does bleeding after a progesterone challenge test indicate?
Shows the patient doesn’t have low oestrogen
What does a negative progesterone challenge test indicate?
Indicates that the patient either has low oestrogen levels, uterine/endometrial abnormalities or cervical stenosis
What are the categories of the FIGO Ovulatory Disorders Classification (2022)?
Type I = Hypothalamic
Type II = Pituitary
Type III = Ovarian
Type IV = PCOS
What are some type I (hypothalamic) causes of ovulatory disorders?
Stress, excessive exercise, anorexia
Brain/pituitary tumours
Head trauma
Kallmann syndrome
Drugs e.g. steroids or opioids
What can type I ovulatory disorders also be known as?
Hypogonadotrophic hypogonadism
- low LH and FSH
- low oestrogen
Levels of LH and FSH in type I ovulatory disorders are high/low?
Low
Levels of oestrogen in type I ovulatory disorders are high/low?
Low
Progesterone challenge test positive or negative in type I ovulatory disorders? Why?
Negative as low oestrogen
What are the 2 main treatment options for type I (hypothalamic) ovulatory disorders?
1 - Pulsatile GnRH pumps (very expensive so not usually on NHS)
2 - Gonadotrophin daily injections e.g. Menopur (main treatment on NHS)
Possible complication with daily gonadotrophin injections?
Multiple pregnancy rate is higher
What monitoring is required when using daily gonadotrophin injections?
Ultrasound monitoring of the response and follicle tracking
What are some type II (pituitary) causes of ovulatory disorders?
Mainly pituitary tumours releasing excess hormones
Most common cause is hyperprolactinaemia
Levels of LH and FSH in type II ovulatory disorders are high/low?
Low
Levels of oestrogen in type II ovulatory disorders are high/low?
Low
Progesterone challenge test will be positive or negative in type II ovulatory disorders? why?
Negative as low oestrogen
Some symptoms of hyperprolactinaemia?
Amenorrhoea
Galactorrhoea
Visual field problems
How can hyperprolactinaemia be diagnosed?
<LH> Prolactin greater than 1000 on 2 or more occasions
MRI scan to visualise tumour
</LH>
Treatment for hyperprolactinaemia?
Dopamine agonist - Cabergoline (note - stop when pregnancy occurs)
What are some type III (ovarian) causes of ovulatory disorders?
Premature ovarian failure - Turners syndrome, Fragile X, autoimmune, bilateral oophorectomy, radio/chemotherapy, family history
LH and FSH levels in type III ovulatory disorders are high/low?
High
Oestrogen levels in type III ovulatory disorders are high/low?
Low
What is premature ovarian failure?
Menopause before 40 years old
What treatment options are there for premature ovarian failure?
Hormone replacement therapy (usually the COCP)
For fertility treatment egg or embryo donation is required and supportive counselling
If POF is predicted prior to chemo/radiotherapy then egg or embryo cryopreservation can be offered
Criteria for PCOS diagnosis?
Rotterdam criteria - 2/3 criteria to diagnose
- Oligo/amenorrhoea
- Polycystic ovaries (12 or more 2-9mm follicles, increased ovarian volume >10ml)
- Clinical/biochemical hyperandrogenism (acne, hirsutism)
LH and FSH levels in PCOS are high/low?
Usually normal
Oestrogen levels in PCOS are high/low?
Usually normal
Progesterone challenge test in PCOS is usually positive/negative? Why?
Positive as they usually have normal oestrogen levels
Management of PCOS for fertility?
1st line = Clomifene citrate or Letrozole on day 2-6 of cycle (can add in metformin)
2nd line = gonadotrophin therapy
Laparoscopic ovarian diathermy
IVF
Main risks of ovulation induction?
Ovarian hyperstimulation
Multiple pregnancy
Possible increased risk of ovarian cancer
What is ovarian hyperstimulation syndrome?
Exaggerated response to excess hormones
What things can increase the risk of OHSS?
<35 years
PCOS
Symptoms of OHSS?
Abdominal swelling
Abdominal discomfort/pain
Nausea
Vomiting
Extreme thirst and dehydration
Dark urine
Breathing difficulty
Blood clots - PE, DVT
Infective causes of tubal disease?
Pelvic inflammatory disease e.g. chlamydia, gonorrhoea, syphilis, TB
Transperitoneal spread
Following a procedure e.g. IUD insertion, hysteroscopy, HSG
Non-infective causes of tubal disease?
Endometriosis
Surgical sterilisation
Ectopic pregnancies
Fibroids
Congenital
Polyps
Investigations for female infertility?
History
Examination
Ultrasound scan
Chlamydia screening
Cervical smear up to date
Rubella testing
Check ovulation - day 21 progesterone
Check tubes - hycosy, HSG
Other hormone tests e.g. FSH, LH, oestrogen, prolactin, thyroid function, testosterone, SHBG
