Ovulation Disorders

Question 1

oligomenonrrhea

Answer 1

reduction in the frequency of periods to less than 9 a year (menstrual cycles lasting longer than 35 days)

Question 2

anovualtion is the

Answer 2

failure to ovulate and is mostly associated with oligo- or amenorrhoea

Question 3

assessing ovualtion

Answer 3

regular menstrual cycle is highly suggestive that ovulation is taking place but it can be confirmed by measuring mid-luteal (day 21) progesterone levels: >30nmol/L confirms ovulation has occurred

Question 4

WHO classification of ovulation disorders

Answer 4

Group 1: Hypothalamic pituitary failure
Group 2: hypothalamic pituitary dysfunction
Group 3: Ovarian failure

Question 5

Group 1 ovulatory disorders

Answer 5

• hypothalamic pituitary failure
• hyopgonadotrophic hypogonadism
• low levels of FSH, LH and oestrogen
• normal prolactin levels
• accounts for 10% of ovulatory disorders

Question 6

causes of hypothalamic pituitary failure

Answer 6

• kallmans syndrome
• functional hypothalamic amenorrhoea
• idiopathic hypogonadotrophic hypogonadism
• hypopitauatarism

Question 7

management of group 1: hypothalamic pituitary failure

Answer 7

• stabilise weight by increasing BMI to a normal BMI of 18.5
• GnRH pump: pulsatile release of gonadotrophin releasing hormone
• Gonadotrophin (FSH and LH) daily injections but there is an increased multiple pregnancy rate

Question 8

group 2: hypothalamic pituitary dysfunctions

Answer 8

• accounts for 85% of ovulatory disorders
• normal gonadotrophins but an increased LH:FSH ration, normal oestrogen levels
• causes oligo- or amenorrhoea

Question 9

most common cause of group 2: hypothalamic pituitary dysfunction

Answer 9

polycystic ovarian syndrome (PCOS) but another causes is hyperprolactinaemia

Question 10

PCOS is diagnosed in individuals with

Answer 10

2 out of the 3 of the Rotterdam criteria:
- oligo- or an ovulation
- clinical and/or biochemical evidence of hyperandrogenism
- polycystic ovaries on sonography : presence of 12 or more follicles within the ovary with a diameter of 2-9mm and/ or ovarian volume of 10cm3 or greater

Question 11

insulin resistance

Answer 11

occurs in 80% of people with PCOS, insulin acts as a co-gonadotrophin to LH so increased insulin levels cause increased secretion of LH causing the overproduction of androstenedione, insulin also reduces levels of sex hormone binding globulin so increases the levels of free testosterone which is biologically active causing hyperandrogenism

Question 12

general managent of people with PCOS in those wanting to get pregant

Answer 12

• weight loss
• smoking and alcohol cessation
• folic acid supplementation (400mcg per day if the female has no risk factors for neural tube defects) 5mg a day if the female is at high risk for neural tube defects
• rubella immunisation

Question 13

risk factors for neural tube defects which require 5mg of folic acid

Answer 13

coeliac, previous pregnancy with neural tube defects, diabetes, sickle- cell anaemia, anti-epileptic medications, any family history on the mother or fathers side of neural tube defects

Question 14

rubella immunisation

Answer 14

if a pregnant woman gets rubella it is catastrophic to the foetus therefore is a female wants to get pregnant they should be immunised if they are not already and because the vaccine is live attenuated females should not conceive for at least one month after they get the vaccine

Question 15

medical management of PCOS for those wanting to get pregnant

Answer 15

first line= clomifine citrate which is an anti-oestrogen which is taken between days 2-6 of the menstrual cycle, there is a 10% risk of multiple pregnancy so ultrasound follicular monitoring is required

Question 16

if ovulation is not achieved

Answer 16

on the lowest dose of clomifine citrate (50mg) then the dose can be increased to 100-150mg, but ovulation still does not occur in 10-15% of cases and this is called clomifene resistance

Question 17

Second line treatment for PCOS for woman wanting to get pregnant

Answer 17

• gonadotrophin injections (RECOMBINANT FSH) but there is a risk of multiple pregnancy and overstimulate
• laparoscopic ovarian drilling but risk of irreversibly damaging the ovaries

Question 18

role of metformin in ovulation induction

Answer 18

• improves insulin resistance and reduces androgen production
• in some woman causes the return of menstruation and ovulation

Question 19

risks of ovulation induction

Answer 19

• ovarian hyperstimulation syndrome
• multiple pregnancies
• may or may not cause ovarian cancer (not enough current evidence to decide)

Question 20

ovarian hyperstimulation syndrome

Answer 20

iatrogenic complications which occurs in 3-6% of females undergoing assisted reproduction, most common in woman undergoing IVF (10%)

Question 21

risk factors for ovarian hyper stimulation syndrome

Answer 21

age less than 30, PCOS, low BMI, previous history of OHSS, pregnancy occurring duet the same round of IVF

Question 22

OHSS is categorised as

Answer 22

mild moderate and severe depending on the symptoms

Question 23

mild OHSS

Answer 23

abdominal bloating, pain, ovarian size less than 8cm

Question 24

moderate OHSS

Answer 24

moderate abdominal pain, nausea, vomiting, ascites on ultrasound, ovarian size between 8-12cm

Question 25

severe OHSS

Answer 25

ascites, haematocrit >55%, thromboembolism, ARDS

Question 26

ovarian hyperstimulation syndrome most commonly occurs

Answer 26

after injection of HCG which is carried out before oocyte retrieval for IVF, this causes the ovaries to release inflammatory mediators especially VEGF which causes increase capillary permeability causing fluid to shift from the intravascular compartment to the third space compartment

Question 27

risks of multiple pregnancy

Answer 27

• increased risk of hyperemesis gravidarum
• anaemia
• 3x risk of pre-eclampsia and 3x risk of gestational diabetes
• increased risk of early and late miscarriage, low birth weight, prematurity, disability, still-birth/ neonatal death
• twin to twin transfusion syndrome

Question 28

monochorionic twins

Answer 28

have a 3x greater perinatal mortality risk than dichorionc twins
(monochorinons means the twins are in the same sac, dichorionic means the twins are in different sacs)

Question 29

Twin to twin transfusion syndrome

Answer 29

occurs when there is an imbalance in the placenta blood vessels which connect both twins, one twin (recipient twin) gets excess blood while the other twin doesn’t get enough (donor twin)

Question 30

recipient twin develops

Answer 30

polyhydroamins meanwhile the donor twin develops oligohydroamins

Question 31

twin to twin tranfusion syndrome

Answer 31

is fatal if left untreated, treatment is laser division of placental vessels. amnioreduction or septostomy

Question 32

group 3 ovulations disorders

Answer 32

• ovarian failure
• accounts for only 5% of all ovulation disorders

Question 33

most common cause of ovarian failure

Answer 33

premature ovarian failure
- hypergonadotrophic hypogonadism
- low levels of oestrogen and high levels of FSH and LH

Question 34

premature ovarian failure is diagnosed if

Answer 34

FSH levels are greater than 30 on 2 occasions more than one month apart

Question 35

management of ovarian failure

Answer 35

hormone replacement therapy