Ovulatory Dysfunction and Infertility- Schoyer

Question 1

How long is the standard menstrual cycle?

What consitutes oligomenorrhea?

Answer 1

24-32 days long; typical cycle is 28 days

A cycle that is longer than 35 days

Question 2

What is the first test that should be done in a patient who presents with oligomenorrhea?

But…….

Since you’ll probably run other tests at the same time, what other tests can be run concurrently?

Answer 2

PREGNANCY!!

TSH, prolactin, FSH

Question 3

What are the four categories of ovulation disorders?

What hormonal results are seen with each?

Answer 3

1. Hypothalamic- Pituitary Failure
   
   • Failure of FSH release or FSH effect
   • Low/normal FSH
2. Secondary Hypothalamic-Pituitary Dysfunction
   
   • Abnormalities in hormone levels outside of the normal feedback cycle
   • EG tumors, thyroid disease, hyperprolactinemia
3. Hypothalamic- Pituitary Dysfunction
   
   • Normal FSH, estradiol; maybe hyperandrogenism
   • EG PCOS, idiopathic
4. Ovarian Failure
   
   • Burn-out of the ovaries
   • High FSH (but ovaries won’t respond)

Question 4

What is the point of the progesterone challenge?

What can it tell us about the etiology of infertility?

Answer 4

Progesterone challenge is done to females with low/normal FSH. The challenge tells us whether the ovary is developing a viable follicle.

If there is bleeding, there is initially a viable follicle, but there is a problem with ovulation (and therefore progesterone production); if there isn’t bleeding, the hypothalamus is not stimulating follicle development.

Question 5

What three symptoms are associated with PCOS?

How many are needed for a diagnosis of PCOS?

Answer 5

• Cysts on ovaries on ultrasound
• Oligomenorrhea
• Hyperandrogenism

Two out of the three symptoms are needed, plus tumors/CAH/thyroid disease/Cushing’s must be ruled out

Question 6

How is PCOS treated?

Answer 6

• Hormonal birth control
• Cyclic progesterone
• Weight loss
• Treat diabetes
• Clomiphene citrate (ovulation stimulant)
• Aromatase inhibitor (off-label use)

Question 7

What mechanism does clomiphene citrate use?

What are some side effects?

Answer 7

Reduces translocation of estrogen receptors

Diminishes negative feedback on GnRH

Prompts increased FSH, LH release

Dry genital mucus

Thin endometrial lining

Multiple pregnancy

Ovarian hyperstimulation syndrome

Question 8

What hormone tests might indicate hypogonadotropic hypogonadism?

What are some specific causes of HH?

Answer 8

Low/normal FSH, low estrogen, negative progesterone test

• Absence of a pituitary
• Stress (too much) or weight (too little)
• Kallman’s (congenital GnRH deficiency)
• GnRH receptor mutations

Question 9

What might cause amenorrhea in patients whose hormone levels are normal?

What sort of medical history would they have?

Answer 9

Physical obstruction from adhesions

History of endometrial/cervical procedures which might cause scarring

Question 10

What hormone tests might indicate hypergonadotropic hypogonadism?

Who does it affect?

Answer 10

High levels of FSH, without menorrhea and no bleed in response to progesterone

(AKA premature menopause or Ovarian insufficiency)

Women between the ages of 30 and 40

Question 11

What are some potential causes of Premature Ovarian Insufficiency/hypergonadotrophic hypogonadism?

Answer 11

• Turner’s syndrome or Turner’s Mosaic
• Fragile X syndrome
• Autoimmune
• Alkylating agents (chemo)
• Radiation
• Idiopathic

All things that would damage germ cells!

Question 12

What are some options for patients with hypergonadotrophic hypogonadism who want to have kids?

Answer 12

• Oocyte donation
• Adoption

Unfortunately, conceiving, even with hormonal aids, is extremely unlikely

Question 13

What is the definition of infertility?

Which partner should be examined?

Answer 13

>1 year trying to get pregnant; can treat at 6 months if older, special concerns

Both partners should be examined with blood panels, but specimen samples are less invasive for men

Question 14

What is the ovarian reserve?

What tests can be done to determine the size of a patient’s reserve?

Answer 14

Essentially time left until menopause; accelerated follicular loss, reduced oocyte pool, decreased oocyte quality

• Day 3 FSH/Estradiol levels
• Antral follicle counts
• Anti-Mullerian hormone (corresponds with egg reserve)

Question 15

What are some indications for IUI (Intrauterine Insemination)?

What are some indications for IVF?

Answer 15

Anything that might prevent sperms from reaching the egg: mild male infertility (EG low number, low mobility) or cervical mucus abnormalities

Severe male infertility, tubal diseases, endometriosis, diminished ovarian reserve, failed IUI