Female Infertility Flashcards by Lucy Barnstaple

Causes of female infertility?

Ovulatory disorders - endocrine, iatrogenic, PCOS, anorexia, endometriosis

Tubal disorders - iatrogenic, infections, congenital, endometriosis

Uterine abnormalities

Psychosexual problems

Unexplained infertility

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Physiological causes of anovulation?

Before puberty
Pregnancy
Lactation
Menopause

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What is oligomenorrhoea?

Cycles >42 days (i.e. less than 8 periods/year)

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What is amenorrhoea?

Absent menstruation

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What is primary amenorrhoea?

Periods have never started

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What is secondary amenorrhoea?

Previously have had periods but now the have stopped

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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

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Does progesterone have positive or negative feedback on the pituitary/hypothalamus?

Negative feedback

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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

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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

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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

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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

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If someone has regular cycles, are they likely to be ovulating?

Yes

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If someone has irregular cycles, are they likely to be ovulating?

No, this is suggestive of anovulation

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What investigation would you do to see if a woman was ovulating?

Midluteal serum progesterone

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What level on a midluteal progesterone test would be suggestive of ovulation?

> 30 nmol/l

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If a woman as irregular cycles, which other hormonal tests would you do?

FSH, LH
TSH
Prolactin
Oestrogen, testosterone, SHBG

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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

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What does bleeding after a progesterone challenge test indicate?

Shows the patient doesn’t have low oestrogen

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What does a negative progesterone challenge test indicate?

Indicates that the patient either has low oestrogen levels, uterine/endometrial abnormalities or cervical stenosis

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What are the categories of the FIGO Ovulatory Disorders Classification (2022)?

Type I = Hypothalamic
Type II = Pituitary
Type III = Ovarian
Type IV = PCOS

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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?

Prolactin greater than 1000 on 2 or more occasions MRI scan to visualise tumour

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