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
