Ovulatory Dysfunction & Infertility Flashcards
1
Q
What is the difference between ovulation and anovulation?
A
-
Ovulation
- Menstrual bleeding at regular intervals btwn 21-35 days
- Presence of premenstrual moliminal
- Breast tenderness, abdominal bloating, mood disturbance
-
Anovulation
- Bleeding at longer or irregular intervals
2
Q
Progestin Challenge Test
Definition
When to use it
A
- When estrogen status is unclear
- Medroxyprogesterone acetate (5-10 mg) administered daily (7-14 days)
- Menstrual bleed should ensue in normally estrogenized patients
- Any spotting or bleeding in 2 wks after progestin withdrawal is considered a + progestin challenge
- See flow chart on slide 6
3
Q
What are the 4 classifications of Ovulatory Disorders?
A
- Hypothalamic-pituitary failure
- Hypothalamic-pituitary dysfunction
- Ovarian failure
- Secondary HPO dysfunction
*see table page 3 of handout
4
Q
Goals in treating ovulatory dysfunction
A
- Identify hypoestrogenic patients who lack spontaneous or progestin-induced menstrual bleeding
- Differentiate Hypogonadotropism, Hypergonadotropism & Normogonadotropism
- Exclude underlying medical conditions that produce secondary ovulatory dysfunction
5
Q
What are some contributing factors in management of ovulatory dysfunction?
A
- Stress, anxiety or depressive disorders
- Excessive weight gain
- Over or insidious eating disorders
- Strenuous exercise w/o appropriate nutritional intake
- Preoccupation w/ thinness
6
Q
Polycystic Ovarian Syndrome (POS)
Definition
Criteria
A
- Most common endocrine disorder in women
- Broad spectrum of clinical phenotypes
-
2/3 of the following criteria
- Oligo-ovulation or anovulation
- Clinical and/or biochemical signs of Hyperandrogenism
- Polycystic ovaries
- < 12 follicles in each ovary
- 2-9 mm and/or ovarian volume < 10 mL
7
Q
**Premature Ovarian Insufficiency **
Definition
Etiology
A
- Hypergonadotropic hypogonadism before age 40 (elevated FSH/LH)
- Commonly associated w/ depletion of ovarian follicles (like menopause)
- Cessation of regular menses
- 1% of all women, 90% of cases 30-40 YO
- Etiology
- Normal physiologic process but at unusually young age
- Identifiable pathology
8
Q
**Premature Ovarian Insufficiency **
Causes
X chromosome anomalies
Fragile X syndrome
A
- Causes: genetic, autoimmune, idiopathic, iatrogenic
- Specific X chromosome anomalies
- Most common: 45, X & 47, XXY
- 2nd most common: variable mosaicism
-
Fragile X syndrome
- Pre-mutation carriers at increased risk for POI (16-21%)
- Expansion of triplet repeat w/i exon 1 of the FMR1 X-linked gene
- Expansions of 50-200 repeats are pre-mutations
9
Q
What is sufficient for a diagnosis of Premature Ovarian Insufficiency? (POI)
A
Menopausal serum FSH levels (>40 IU/L) on at least two occasions in a woman <40 YO
10
Q
Intrauterine Adhesions
Definition
Antecedent factor
Diagnosis
A
- Synechiae (Asherman’s syndrome)
- Can obliterate the endometrial cavity & produce secondary amenorrhea
- Most likely to result from procedures that damage the endometrial cavity
- Rare: missed abortion or endometrial tuberculosis
- Most frequent antecedent factor: endometrial curettage associated w/ pregnancy
- Confirmation of diagnosis
- Hysterosalpingogram or hysteroscopy
- Severe cases
- Endometrium obliterated
- Amenorrhea b/c of adhesions & lack of normal endometrial tissue
- Patients still have menstrual periods but either recurrent miscarriage or infertility
11
Q
Define
Infertility
Primary Infertility
Secondary Infertility
A
- Infertility – 1 yr period of unprotected intercourse w/o successful conception
- Primary Infertility – patient who has never been pregnant
- Secondary Infertility – patient w/ previous history of pregnancy regardless of outcome
12
Q
What are the causes of Infertility?
A
- Abnormalities of sperm production/transport (25%)
- Ovulation disorders (27%)
- Abnormalities of the female reproductive tract (22%)
- Tubal factor (scarring due to endometriosis, surgery)
- Peritoneal factor (endometriosis, scarring)
- Unexplained (15%)
- Immunologic factors (less common)
13
Q
What are the 2 components of a Reproductive Tract Evaluation?
A
-
Hysterosalpingography (HSG)
- Radiographic evaluation that allows visualization of the cavity of the uterus & tubes
-
Sonohysterography & Sonohysterosalpingography
- Ultrasound-based test similar to HSG
- Fluid medium instilled through cervix to evaluate the reproductive anatomy
14
Q
What is done in an Evaluation of Oocyte Reserve?
A
-
Day 2 or 3 FSH & Estradiol
- Elevated levels consistent w/ diminished ovarian reserve
- HPO feedback loop
-
Anti-Müllerian hormone
- β-glycoprotein synthesized by granulosa cells
- Small antral & preantral follicles in the ovary
- Directly proportional to a woman’s ovarian reserve
- **Antral follicle counts by ultrasound **
15
Q
What is done in an Evaluation of Ovulation?
A
- Regular menstrual cycles & moliminal symptoms = most likely ovulating
- Basal body temperature (BBT) chart
- Home urinary ovulation predictor kits
- Serum progesterone levels
- >3 mg/mL provides reliable evidence of ovulation
- Endometrial biopsy
- Confirm presence of secretory endometrium
