Gynekologisk endokrinologi og fertilitet

Question 1

Hva er normal eggløsning avhengig av?

Answer 1

Normal ovulation is dependent on a cyclic interplay between the hypothalamus, the pituitary and the ovary leading to maturation of one egg in each cycle. Here you see the mature folllicle by Ultrasound in the ovary. Size is about 20 mm before rupture and ovulation.

Question 2

Hva er hypothalamus - hypofyse - gonadeaksen, og hvilken mekanisme er viktig regulator når det kommer til hypothalamus - hypofyse - gonadeaksen?

Answer 2

The negative feedback is a very important regulator. Gonadotrophin releasing hormone (GnRH) from the hypothalmus give the signal for follicular stimulating hormone (FSH) secretion from the pituitary. FSH select and usually mature one egg per cycle, and the luteinizing hormone (LH) surge fulfill the ovulation. The growing follicle produce estradiol and testosterone. After ovulation the corpus luteum produce progesterone. Finally as these increase, a negativ feedback are sent to the brain.

Question 3

Hvordan er en normal menstruasjonssyklus?

Answer 3

Main message is: The hormones are cycling- and remember to perform the hormonal analyses on cycle day 2-3 in the menstrual periode.

Question 4

Hvilke hormoner er viktigst for menstruasjonssyklusen?

Answer 4

FSH; Follicular stimulating hormone. LH; Luteinizing hormone. This are the main four hormones.

Question 5

Hvilken rolle har FSH i menstruasjonssyklusen?

Answer 5

In general: A high FSH above 10 is not a good for fertility. It´s a signal of reduced ovarian reserves.

Question 6

Hvilken rolle har LH i menstruasjonssyklusen?

LH; Luteiniserende hormon

Answer 6

The LH is also from the pituitary gland, and the preovulatory LH surge promotes the ovulation. The blue one is the serum-estradiol. You see the preovulatory increase as the leading follicle grows.

Question 7

Fra hvor secerneres østradiol fra under menstruasjonssyklusen?

Answer 7

Estradiol is secreted mainly from the the granulosa cells in the dominant and growing ovarian follicle. The estradiol is increasing as the follicle grows.

Question 8

Ved hvilke tilstander er østradiolverdiene høy, og når er de lav?

Answer 8

The circumstances the patient have a low/hardly measurable s-estradiol: Before puberty or after menopasue. In cases of ovarian insufficiency. In women with amneorrea (absence of bleeding) due to anorexia nervosa/over-exercising or stressed women. Also early in follicular phase, or if she is on the contraceptive pill. On the contrary; the s-estradiol is high when: At ovulation/midcycle. In pregnant women (from the placenta). In women following IVF-stimulation (lots of follicles grow rarely in tumors).

Question 9

Når er progesteron verdiene høye hos kvinner, og hvilke strukturer produserer substansen?

Answer 9

The progesteron is synthesized by the corpus luteum, that is following a normal ovulation. peaking normally between cycle day 21-25. Can also be synthesized from placenta in the pregnant woman.

Question 10

Hvilken generell regel har man når det kommer til prøvetaking av hormonverdiene hos kvinner?

Gynekologi

Answer 10

Question 11

Hvordan kan man vite om en kvinne har eggløsning?

Answer 11

A regular cycle length is 28 days ± 2-3 days is a strong, simple and quite reliable marker of ovulation. you can evaluate midcycle cervix mucous. Mittelschmerz (ovulation pain is a benign preovulatory lower abdominal pain that occurs midcycle (between days 7 and 24) in women) and mastalgia (breast pain) might occur following ovulation. S-progesteon above 7 nmol/L in luteal phase. Biphasic basal body temperature. Ovulation occuring 12-24 hours after a positive LH-stix in the urine.

Question 12

Hvilke tre kategorier kan man plassere irregulære, sjeldne eller ikke tilstedeværende menstruasjon hos kvinner?

Answer 12

If her menstrual cycle is irregular or rare or even absent; the reason could be placed in three main categories.

Question 13

Hva er forskjellen melllom de ulike kategoriene som kan gi irregulær mestruasjon hos kvinner?

Answer 13

Inhibition of opioids on GnRH release from the hypothalamus → ↓ LH and FSH from the pituitary gland → ↓ production of testosterone and estrogen.

Question 14

Hva kjennetegner hyperprolaktinemi?

Answer 14

Prolactin is the milk hormone, also secreted by the pituitary gland. A low value is not a problem. A high value could be stress-related. Check the sample at least twice. The lab will also rule out wether it is caused by inactive polymer form - so called big-big prolactin or not. The condition can be caused by mikro or makro adenomas in the pituitary gland, Diagnosis is nowadays by MRI. Treatment is by Carbercolin, who is a dopamin agonist. GnRH stimuleres av insulin og hemmes av prolaktin.

Question 15

Hvordan foregår modningen av eggcellene (oocyttene)?

Answer 15

From the menstuation, a cohort of 20-30 follicles are ready for further growth and development. By FSH increasing one follicle, it becomes dominant and selected for further growth. Rest of the follicles go into atresiae. Primordial follicles constitutes the ovarian reserves. The maximal number is in midfetal life. The primordila follicles are not renewed, and steadily decrease trough the woman life and aging.

Question 16

Hva er S-AMH tegn på?

Answer 16

AMH is secreted by the granulosa celles in primary and secondary follicles. The more follicles, the higher s-AMH and the better are the ovarian reserves. Because the number correlates to the number of the primordial follicles (the egg pool/the egg store). The s-AMH correlates with the ovarian reserves. Not fully settled yet, but the optimal fertility seems to be between 10-40 pmol/L. By the menopause the egg store is emptied. Fertility is very low or even completely absent the last 5-10 years you are menstruating.

Question 17

Hvor mange oocytter har en kvinne, og hvordan er utviklingen?

Answer 17

The maximum number of eggs/that is the primordial follicles is fetal life II trimester. From then the number is steadliy decreasing, and after the women pass 35-37 years this atresia/follicular loss actually speeds up. At menopause, there are hardly no more primordial follicles left. However; The individual differences are huge. Less than 1 % women enter premature menopause at age 40, and are probably not fertile in their thirties at all.

Question 18

Hvordan kan man evaluere en kvinnes “eggreserver”?

Answer 18

By ultrasound and counting the number of the antral follicles. Traditionally by s-FSH on cycle day 2-3; a value above 10 is usually a bad sign. S-AMH as the new and promising marker.

Question 19

Når er det størst sjanse for å bli gravid?

Answer 19

Normal sperm can survive for 4-5 days. The egg only survive 12-24 hours. Fertilization usually occurs in the ampillar part of the tube. In conclusion: The sperm have to be on their way before the ovulation occurs.

Question 20

Hvor mange spermatozoer når egget, og kan fertilisere det?

Answer 20

There is only one egg, size 0.1 mm, and usually about 200 spermatozoer tha reaches the egg in the ampullar part of the tube thats compete to fertilize the egg.

Question 21

Hvilken type assistert reproduksjonshjelpemidler har man?
Hvor mange trenger dette?

Answer 21

Nature is not always perfectly functioning; ABOUT 15 % of couples suffer infertility and will be in need of assisted reproduction; either IVF (In vitro fertilization) or in case of male factor/defect sperm, will need ICSI (intracytoplasmatic sperm injection).

Question 22

Hvordan fungerer IVF?

Answer 22

We start the IVF stimulation by blocking the FSH signal from the pituitary gland. We either use a GnRH agonist and have a chemical menopause within 14 days or use a quick, selective reseptor block by the GnRH antagonist. This way, you block the secretion of FSH and LH from the pituitary gland. We can then give a large dose of exogenous FSH; by that we can hopefully stimulate several eggs to grow in the ovary. The picture on the bottom left is the ultrasound showing 7-8 mature follicles in the ovary. We usually wish about 10 eggs to have a reasonable chance of success. This is quite a lot of mature follicles, and normally this would not lead to pregnancy. When the eggs are mature we induce ovulation hormonally, and 36 hours later we aspirate alle the eggs transvaginally, lead by the ultrasound picture of the ovary. Sperm is added to the egg on the same day in a beaker. The next moring we can observe 2 pronuclei if the egg is fertilized. Normally the embryo is cleaved into two cells in day 1 and into about 4 cells in day 2. If the sperm is too few or not motile enough we have too help a sperm to get into the egg, so called ICSI. It´s important to select the best embryo. We use a 4-cell embryo on day 2, and gently put it back in the middle of the uterine cavity. Then the patient are instructed to live normally, work and exercise as normal for 14 days. Either she is pregnant or the bleeding will come. Of course zero alcohol , no smoking and generally a helathy life style is recommended.

Question 23

Hvordan er resultatene når det kommer til assistert befruktning?

Answer 23

To increase success rate; please inform the patients to have as healthy lifestyle; normal BMI, healthy diet, regular exercise, no alcohol, no smoking, drugs. This is mandatory and important.

Question 24

Hva er den vanligste årsaken til infertilitet hos par som sliter med å få barn?

Answer 24