PCOS and Fertility

Question 1

What is PCOS?

Answer 1

Disease due to an imbalance in reproductive hormones
8-13% of Aus, present during puberty, begin mid twenties, main reason for infertility in Aus.

Hereditary, Lifestyle (overweight, lack of physical activity)

Inc risk of T2DM, CVD

Question 2

How is PCOS diagnosed?

Answer 2

Menstrual dist = secondary oligomenorrhoea or amenorrhoea

Clinical or biochemical hyperandrogenism

Polycystic (space ship) appearance of ovaries on ultrasound

Question 3

How is PCOS managed?

Answer 3

Address presenting + long term issues
- type 2 diabetes, other CV risk factors, endometrial cancer

Lifestyle = weight loss (dec diabetes, symptoms, restore ovulation), exercise (reduces insulin resistance)

Metformin (XR or IR for those w/ diabetes or impaired glucose tolerance) = part of treatment for subfertility

Question 4

Other than treating diabetes in PCOS, what other positive impacts can metformin have for suffers?

Answer 4

Improve menstrual regularity

reduce insulin resistance

reduce serum free testosterone

may induce ovulation (+/- clomifene)

Question 5

How are menstrual irregularities/amenorrhoea managed in PCOS?

Answer 5

Treat to provide predictable vaginal bleeding + effective endometrial clearance

COCs = most effective way of managing irregularities, suppress androgen production

Cyclical hormone replacement

Question 6

How are androgenisation managed in PCOS?

Answer 6

Anti-androgens (3-4th gen progestogen)

Spironolactone, cyproterone acetate (only w/ severe testosterone signs)

Question 7

How are facial hirsutism managed in PCOS?

Answer 7

Ovarian suppressive therapy (i.e. COCs) = esp in combination w/ less androgenic progestogens (e.g. cyproterone)
- estrogen and progestin combined ensure gonadotrophin suppression

Antiandrogen therapy = spironolactone, cyproterone acetate

Question 8

What are the C/I and precautions for cyproterone use in PCOS?

Answer 8

C/I = preg (inc defect risk)

Prec = should be suspended several months before planned preg (spironolactone only needs a month)

Question 9

What factors does fertility depend on?

Answer 9

Production of gametes capable of fertilisation

Timely deposition and migration of sufficient fertile sperm in female reproductive tract

Implantation and development of embryo in hormonally primed uterine mucosa

Maintenance of growing foetus in-utero until full term

Question 10

When in the cycle is estrogen at its highest?

Answer 10

Just before the LH surge (just before/at ovulation) in the follicular
phase

This is secreted by the mature follicle

Question 11

When in the cycle is progesterone at its highest?

Answer 11

shortly after the LH surge/ovulation in the luteal phase

This is secreted by the corpus luteum

Question 12

When in the cycle is FSH at its highest?

Answer 12

the start of the follicular phase, peaking during ovulation

Question 13

When can pregnancy tests be taken?

Answer 13

7 days post conception = will produce a positive reading

Question 14

When is a woman most likely to get pregnant?

Answer 14

2 days before, during, and 1 day after ovulation

Question 15

When is the expected time of ovulation of someone w/ a 28 day cycle?

Answer 15

At day 14 of the cycle

The start of the fertile window is 2 days before that

Question 16

How can you predict when ovulation will occur?

Answer 16

Ovulation typically occurs 14 days before the next expected period

Question 17

What can be used to detect female fertility?

Answer 17

More reliable:
- Cervical mucus change, luteal phase progesterone testing

Less reliable:
- Anti-Mullerian hormone (AMH) testing, BB temp, saliva microscopy, ovulation prediction via urine LH detection

Question 18

What is anti-mullerian hormone (AMH) and how is it used to determine fertility?

Answer 18

It is a hormone produced by ovaries and testes –> influence male (high concentrations)+ female (low concentrations) reproductive organs in a foetus

After puberty, follicles produce more AMH –> higher levels means ovaries have more follicles

Menopause = AMH is zero

Question 19

How can cervical mucus be used to determine fertility?

Answer 19

Midcycle cervical fluid = more water, mucin, less protein, fibres align which helps sperm

Fertile mucus is stretchy, slippery, consistency of egg white

Question 20

How can saliva microscopy be used to determine fertility?

Answer 20

Fern like pattern in saliva = days leading up to ovulation

Question 21

How can basal body temperature be used to determine fertility?

Answer 21

Basal body temp raises slightly on day before ovulation

Question 22

How can urine LH tests be used to determine fertility?

Answer 22

instream urine detection of LH

Positive = ovulation likely w/in 20-48 hrs

expensive, open to misinterpretation

Useful if cycles are regular

Question 23

How can post ovulation progesterone testing be used to determine fertility?

Answer 23

More reliable than other commercial options

serum progesterone conducted 7 days before predicted date of period

[progesterone] =>2025 nmol/L means ovulation occurred

lower value = anovulation or incorrect timing of test

Question 24

How can pregnancy urine hCG be used to determine fertility?

Answer 24

Instream urine test for human chorionic gonadotrophin

result 10-12 after fertilisation

first morning urine

Question 25

How can serum hCG be used to determine fertility?

Answer 25

hCG inc rapidly during first 6wks of preg

peaks 60-70 days following implantation