Ovulatory Dysfunction and Infertility

Question 1

evaluation of oligo/amenorrhea: initial tests

Answer 1

hCG, baseline FSH and estradiol

Question 2

evaluation of oligo/amenorrhea: what test should you order if low or normal FSH?

Answer 2

progestin challenge to assess estrogenization of uterine lining

Question 3

when should you order a progestin challenge?

Answer 3

if patient is experiencing oligo/amenorrhea and has low/normal FSH

Question 4

what is the basis of the progestin challenge?

Answer 4

in order to have bleeding after progesterone administration, patient needs to have been exposed to estradiol because estradiol induces expression of progesterone receptors

Question 5

criteria for polycystic ovarian syndrome (PCOS)

Answer 5

two of three features:

1. polycystic-like ovaries on ultrasound
2. oligomenorrhea
3. hyperandrogenism (hirsutism)

Question 6

first-line treatments for ovulation induction in polycystic ovarian syndrome (PCOS)

Answer 6

weight loss, clomiphene citrate

Question 7

clomiphene citrate: mechanism of action, use

Answer 7

reduces concentration of intracellular estrogen receptors –> diminished negative feedback –> activates GnRH secretion –> ovulation
use: first-line treatment for ovulation induction in polycystic ovarian syndrome (PCOS)

Question 8

potential reasons for lack of withdrawal bleeding in response to progesterone therapy

Answer 8

1. lack of circulating estradiol resulting in inadequate endometrial proliferation
2. severe endometrial adhesions (Asherman’s syndrome)
3. pregnancy

Question 9

ddx: low/normal FSH and low estradiol

Answer 9

hypogonadotropic hypogonadism: absence of sellar mass, Kallman’s syndrome, GnRH receptor mutations

Question 10

Asherman’s syndrome: pathogenesis

Answer 10

intrauterine adhesions resulting from procedures that damage the endometrial cavity; can cause secondary amenorrhea and lack of withdrawal bleed in response to progesterone

Question 11

premature ovarian failure: pathogenesis, clinical presentation, lab findings

Answer 11

premature atresia of ovarian follicles in women of reproductive age
present with signs of menopause after puberty but before age 40
decreased estrogen, increased LH and FSH (HYPERgonadotropic hypogonadism)

Question 12

causes of premature ovarian failure

Answer 12

genetic (Turner’s syndrome, Fragile X), autoimmune, iatrogenic (chemo, radiation)

Question 13

risk factors for tubal disease

Answer 13

history of pelvic infections, tubal or pelvic surgery, endometriosis

Question 14

steps of IVF

Answer 14

1. ovarian stimulation with injectable gonadotropins (FSH, FSH/LH)
2. oocyte retrieval
3. fertilization
4. embryo transfer

Question 15

expected diagnosis, lab findings, and response to progestin challenge: marathon runner with infertility

Answer 15

hypothalamic amenorrhea: low estradiol, low/normal FSH; no withdrawal bleed with progestin challenge

Question 16

dx: 34 year old with irregular menstrual cycles and increased FSH

Answer 16

premature ovarian failure

Question 17

what patients with problems with fertility should be given genetic tests for karyotype and screening for Fragile X?

Answer 17

patients in which you suspect premature ovarian failure

Question 18

what hormone ‘triggers’ ovulation?

Answer 18

LH

Question 19

signs of ovulation

Answer 19

cramping, change in cervical mucus, headaches, bloating