Ovulatory Dysfunction & Infertility Flashcards Preview

Reproductive System > Ovulatory Dysfunction & Infertility > Flashcards

Flashcards in Ovulatory Dysfunction & Infertility Deck (22):
1

What is the difference between ovulation and anovulation?

  • 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

Progestin Challenge Test

Definition

When to use it 

  • 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

What are the 4 classifications of Ovulatory Disorders?

  • Hypothalamic-pituitary failure
  • Hypothalamic-pituitary dysfunction
  • Ovarian failure 
  • Secondary HPO dysfunction

*see table page 3 of handout 

4

Goals in treating ovulatory dysfunction

  • 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

What are some contributing factors in management of ovulatory dysfunction?

  • Stress, anxiety or depressive disorders
  • Excessive weight gain
  • Over or insidious eating disorders
  • Strenuous exercise w/o appropriate nutritional intake
  • Preoccupation w/ thinness 

6

Polycystic Ovarian Syndrome (POS)

Definition

Criteria 

  • 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

Premature Ovarian Insufficiency 

Definition 

Etiology 

 

  • 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

Premature Ovarian Insufficiency 

Causes 

X chromosome anomalies 

Fragile X syndrome

  • 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

What is sufficient for a diagnosis of Premature Ovarian Insufficiency? (POI)

Menopausal serum FSH levels (>40 IU/L) on at least two occasions in a woman <40 YO

10

Intrauterine Adhesions

Definition 

Antecedent factor

Diagnosis 

  • 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

Define

Infertility

Primary Infertility

Secondary Infertility 

  • 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

What are the causes of Infertility?

  • 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

What are the 2 components of a Reproductive Tract Evaluation?

  • 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

What is done in an Evaluation of Oocyte Reserve

  • 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

What is done in an Evaluation of Ovulation?

  • 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 

16

# of remaining ovarian follicles _____ w/ age & become progressively ____ _________ to the gonadotropin stimulation required for maturation/ovulation. 

decline

less sensitive

17

What are the 3 ways to treat infertility?

Clomiphene Citrate 

Aromatase Inhibitors 

Gonadotropins 

18

Clomiphene Citrate

Indications

Mechanism

 

  • Most commonly used oral agent for induction of ovulation
  • 2 main indications
    • Induction of ovulation in women w/ Anovulatory infertility
    • Stimulation of multifollicular ovulation or enhancing ovulation in ovulatory infertile women
  • Non-steroidal triphenylethylene derivative
  • SERM – estrogen agonist & antagonist properties

19

Clomiphene Citrate

Side Effects

  • Hot flashes
  • Bloating, cramping
  • Nausea
  • Mood swings
  • Visual disturbances (rare)
  • Multiple pregnancies (4-10%)
  • Rare risk of Ovarian Hyperstimulation Syndrome 

20

Aromatase Inhibitors

Example

Mechanism 

  • Primary agents for ovulation induction
  • Letrozole (FDA off label use)
  • Inhibition of E2 production
  • Negative feedback --> increases FSH levels
  • Pregnancy rates comparable to those w/ CC alone
  • Reduced incidence of multiple pregnancies 

21

Gonadotropins

Indications 

  • Patients w/ hypothalamic amenorrhea
  • Anovulatory patients who don’t respond to Clomiphene Citrate or Aromatase Inhibitors 
  • Patients undergoing hormonal stimulation for IVF or for multifollicular recruitment to be paired w/ intrauterine insemination 

22

Gonadotropins

Examples 

  • Human menopausal Gonadotropin
    • HMG, Pergonal, Humegon, Menopur
  • FSH – Bravelle, Metrodin, Gonal-F, Follistim
  • GnRH antagonists
    • Ganirelix, Cetrorelix
    • Prevents LH surge during controlled ovarian hyperstimulation
  • hCG administered intramuscularly to induce follicular maturation & ovulation