Ovulatory disorders Flashcards
How common are conception difficulties?
1 in 7 couples experience difficulty in conception
What percentage of infertility does ovulatory dysfunction cause?
25%
What is anovulation?
Irregular menstrual cycle
What are some early forms of management to increase fertility and decrease anovulation?
- Stabilising weight (18.5 - 35)
- Smoking cessation
- Reduced alcohol consumption
- Folic acid 400ug/5mg daily
- Check presribed drugs
- Cervical smear
- Rubella vaccination
- Semen analysis
What are the 3 classes of ovulatory disorders? (HPO)
- Group I - Hypothalamic pathology leading to pituitary failure (Hypogonadotrophic hypogonadism)
- Group II - Pituitary dysfunction with normal gonad hormones
- Group III - Ovarian failure
(Hypergonadotrophic hypogonadism)
What are some causes of type I ovulatory disorders?
- Kallman’s syndrome
- Drugs (E.g. Steroids, opiates)
- Brain/Pituitary tumours
- Stress
- Head trauma
- Excessive exercise
- Anorexia or low BMI
How will type I ovulatory disorders present?
- Amenorrhoea
- Hypogonadotrophic hypogonadism:
- Low FSH
- Low LH
- Low oestrogen levels
How are type I ovulatory disorders investigated?
Progesterone challenge - Will be negative
FSH, LH and oestrogen levels
What are the 2 main management options in type I (Hypothalamic) ovarian disorders?
- Pulsatile GnRH
- Daily gonadotrophin (FSH+LH) injections
How is pulsatile GnRH given?
Pulsatile GnRH is given via SC or IV pump, which provide a pulsatile administration of GnRH every 90 minutes
What are the advantages of the 2 management options for type I ovulatory disorder?
Daily gonadotrophin injections increase pregnancy rate in multiple pregnancies, whereas pulsatile GnRH increases ovulation and single pregnancy by a greater amount
What investigation is required in management of type I ovulatory disorders?
Both require ultrasound monitoring of the response (Follicle tracking)
What are some causes of type II (Pituitary) ovulatory disorders?
- Hyperprolactinaemia
- Tumours (Most commonly prolactinoma)
- Sheehan’s syndrome
How will type II ovulatory disorders present?
- Amenorrhoea
- Low FSH
- Low LH
- Low oestrogen
- Possible ACTH, TSH, GH and prolactin abnormalities
How will prolactinomas affect ovulation?
This will cause amenorrhoea or galactorrhea
When do type III (Ovarian) ovulatory disorders most commonly occur?
During menopause
How will type III ovulatory disorders present?
- Amenorrhoea
- Raised FSH (>30IU/L in 2 samples)
- Raised LH
- Low oestrogen
What are some causes of type III (Ovarian) ovulatory disorders?
- Premature ovarian failure
- Polycystic ovarian syndrome
- Metformin
- Hydrosalpinx (Fluid build up in fallopian tubes)
What is involved in a progesterone challenge test?
A progesterone challenge test involves administration of progesterone to induce a period
This involves Provera 5mg BD for 5 days
Withdrawal bleed usually occurs 7-10 days after progesterone challenge
This is used to show if oestrogen levels are low
What is suggested by a negative (No bleeding) in progesterone challenge test?
- Low oestrogen levels (E.g. hypogonadotrophic hypogonadism)
- Uterine/Endometrial abdnormality (E.g. Uterine adhesions, Asherman’s syndrome)
- Reproductive outflow issues (E.g. Cervical stenosis)
What is premature ovarian failure?
This is a condition in which menopause occurs before the age of 40
What are some causes of premature ovarian failure?
- Turner syndrome (46XO)
- XX gonadal agenesis
- Fragile X
- Autoimmune ovarian failure
- Bilateral oophractomy
- Pelvic radiotherapy or chemotherapy
What are some clinical features of premature ovarian failure?
- Hot flushes
- Night sweats
- Atrophic vaginitis (Dry, painful sex)
- Amenorrhoea
- Infertility
What will biochemistry show in premature ovarian failure?
- High FSH
- High LH
- Low oestrodiol
What are some management options for premature ovarian failure?
- Hormone replacement therapy (HRT)
- Egg or embryo donation (assisted conception)
- Ovary/Egg/Embryo cryopreservation prior to chemotherapy and radiotherapy
- Counselling
How common is polycystic ovarian syndrome (PCOS)?
This makes up around 85% of ovulatory disorders
What causes PCOS?
Genetics (Inherited)
What can exacerbate PCOS?
Weight gain
What is the diagnostic classification of PCOS?
- Oligo/Amenorrhoea
- Polycystic ovarias (USS appearance)
- 12 or more 2-9mm follicles
- Increased ovarian volume >10ml
- Unilateral/Bilateral
- Clinical and or biochemical signs of hyperandrogenism (Acne, Hirsutism, Obesity)
What will biochemistry show in PCOS?
- Normal FSH
- Possibly raised LH
- Normal oestrogen
- High free androgens
- Impaired glucose tolerance
How common is insulin resistance in PCOS?
50-80% of patients
How does insulin affect ovulation?
Insulin acts as co-gonadotrophin to LH and lowers sex-hormone binding globulin levels, causing a increase in free testosterone release, leading to elevated LH and hyperandrogenism
What are some management options in PCOS?
- Clomifene citrate (Anti-oiestrogen)
- Tamoxifen
- Letrozole (Aromatase inhibitors)
- Gonadotrophin therapy
- Metformin
- Laprascopic ovarian diathermy
- IVF
How can metformin help in PCOS?
Metformin can help to reduce insulin resistance and so reduce androgens
This can help to restore menstruation and ovulation, increase pregnancy rate and improves sensitivity to clomifene and letrozole
What is involved in laparoscopic ovarian diathermy?
Key hole surgery and needle dlivery of heat (40W current, 4 seconds, 4 punctures) to disrupt the ovarian cortex and stroma
What is a risk of gonadotrophin therapy?
Pregnancy
Overstimulation (Increased risk in those over 35)
What are some risks associated with multiple pregnancy?
- Hyperemesis
- Anaemia
- 4x hypertension risk
- 3x pre-eclampsia risk
- Post-natal depression or stress
- Increased risk of low birth weight, prematurity, disability and miscarriage
What are some risks associated with child prematurity?
40-60% of twins require NICU due to prematurity, and 20% risk in singleton babies
8% of premature babies need help with breathing
6% suffer from respiratory distress syndrome
There is also an increased risk of disability in prematurity, including cerebral palsy, impaired sight and congenital heart disease
Prematurity is also linked to lower IQ, increase risk of ADHD and problems with language development
