Reproductive Endocrinology Investigations and Management

Question 1

Investigation for regular ovulatory cycles.

Answer 1

Midluteal (day 21) serum progesterone (2 samples).

Question 2

Hypothalamic anovulation management.

Answer 2

1. Stabilise weight
2. Pulsatile GnRH if hypogonadotrophic hypogonadism.
3. Gonadotrophin (FSH and LH) daily injections.

Both 2 and 3 need ultrasound monitoring of response.

Question 3

Polycystic ovary syndrome diagnostic criteria.

Answer 3

2 of:

1. Oligo/amenorrhoea
2. Polycystic ovaries on ultrasound.
3. Clinical and/or biochemical signs of hyperandrogenism.

Question 4

LH levels in PCOS.

Answer 4

Raised (due to hyperinsulinaemia, and insulin is a co-gonadotrophin to LH).

Question 5

Pre-PCOS management.

Answer 5

1. Weight loss to optimise results.
2. Stop smoking and alcohol.
3. Folic acid.
4. Check prescribed drugs and rubella immunity.
5. Semen analysis.

Question 6

Ovulation induction in PCOS.

Answer 6

1. Clomifene citrate (anti-oestrogen).
2. 5. Consider metformin if doesn’t work.
3. Gonadotrophin therapy (daily injections, recombinant FSH).
4. Laparoscopic ovarian diathermy.

Question 7

Investigation for dichorionic twins (lower risk).

Answer 7

US - lambda sign.

Question 8

Investigation for monochorionic twins (higher risk).

Answer 8

T sign.

Question 9

Twin-twin transfusion syndrome management.

Answer 9

1. Laser division of placental vessels.
2. Amnioreduction.
3. Septostomy.

Question 10

Hormone findings for ovarian failure.

Answer 10

High FSH and LH (gonadotrophins).

Low oestrogen.

Question 11

Premature ovarian failure management.

Answer 11

1. Hormone replacement therapy.
2. Egg or embryo donation.
3. Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy.
4. Counselling/support network.

Question 12

What do you measure during the early follicular phase (day 2-5)?

Answer 12

FSH
LH
Oestradiol
Testosterone/SHBG
Prolactin
TSH

Question 13

What do you measure mid luteal phase (day 21)?

Answer 13

Progesterone.

Question 14

What is a progesterone challenge test?

Answer 14

Menstrual bleed in response to a five day course of progesterone indicates oestrogen levels normal.

Question 15

Endometriosis investigations.

Answer 15

Ultrasound (chocolate cysts on ovary).

Question 16

Non-obstructive azoospermia biochemical results.

Answer 16

High LH and FSH.

Low testosterone.

Question 17

Obstructive azoospermia biochemical results.

Answer 17

Normal LH, FSH and testosterone.

Question 18

Full investigation of infertile female.

Answer 18

1. Endocervical swab for chlamydia.
2. Cervical smear.
3. Rubella immunity.
4. Midluteal progesterone.
5. Hysterosalpingiogram or laparoscopy (for tubal patency).
   Others if indicated.

Question 19

What is hysteroscopy used for?

Answer 19

Suspected or known endometrial pathology e.g. uterine septum, adhesions, polyp.

Question 20

Management of proximal tubal obstruction.

Answer 20

Selective salpingography plus tubal catheterisation or hysterosopic tubal cannulation.

Question 21

Management of hydrosalpinges and why?

Answer 21

Laparoscopic salpingectomy before IVF to improve chances of live birth.

Question 22

Management for hydrosalpinx in person who have undergone several previous abdominal surgeries.

Answer 22

Tubal occlusion.

Question 23

Surgical management of endometriosis.

Answer 23

Surgical ablation or resection.

May offer laparoscopic adhesiolysis as improves chances of pregnancy.

Question 24

Management of endometrial polyps, septum, intrauterine adhesions and submucosal fibroids.

Answer 24

Hysteroscopic surgery.

Question 25

Management of intramural and subserosal fibroids.

Answer 25

Intramural - case to case basis.

Subserosal - unlikely to have major impact on fertility.