Reproduction: Ovulation Disorders

Question 1

Oligomenorrhoea

Answer 1

Cycle lasts >35 days

Question 2

Amenorrhoea

Answer 2

Absent menstruation
Primary: Never had a period
Secondary : Period has stopped

Question 3

Gonadotrophin Releasing Hormone

Answer 3

Synthesised by neurons in hypothalamus 
Pulsatile release 
Stimulates synthesis/ release of 
- FSH (low frequency)
-LH (high frequency)

Question 4

Follicular Stimulating Hormone

Answer 4

Secreted by anterior pituitary
Stimulates follicular development
Thicken endometrium

Question 5

luteinising hormone

Answer 5

Secreted by anterior pituitary
Peak (LH surge) stimulates ovulation
Stimulates corpus luteum developement
Thickens endometrium

Question 6

Hormone Peaks during Menstrual Cycle

Answer 6

Estradoil peaks before ovulation
LH surge triggers ovulation
Progesterone peak follows ovulation

Question 7

Estrogen

Answer 7

Secreted primarily by ovaries (follicles) and adrenal cortex
Stimulates thickening of endometrium
Responsible for fertile cervical mucus

High oestrogen concentration inhibits secretion of FSH and prolactin
(-ve feedback)

Question 8

Progesterone

Answer 8

Secreted by corpus luteum to maintain early pregnancy
Inhibits secretion of LH
Responsible for infertile (thick) cervical mucosa
Maintains thickness of endometrium
Has thermogenic effect
- increases basal body temp
Relaxes smooth muscles

Question 9

Assessing Ovulation

Answer 9

Regular cycles very suggestive of ovulation
- Confirm by midluteal (day 21) serum progesterone (>30nmol/l)

Irregular cycles: probably anovulatory: needs further hormone evaluation

Question 10

Ovulatory Disorders Classifications

Answer 10

Group 1: Hypothalamic Pituitary Failure

Group 2: Hypothalamic Pituitary Dysfunction

Group 3 : Ovarian Failure

Question 11

Group 1 ovulatory Disorders

Answer 11

hypogonadotrophic hypogonadism

Question 12

Group 1 Ovulatory Disorders Finding

Answer 12

Low levels LH/ FSH 
Oestrogen deficiency 
- negative progesterone challenge test 
Normal prolactin 
Amenorrhoea

Question 13

Group 1 Ovulatory Disorders Aetiology

Answer 13

Stress
Excessive exercise
Anorexia/low BMI 
Brain/ pituitary tumours 
Head trauma 
kallmanns syndrome 
Drugs (steroid, opiates)

Question 14

Group 1 Disorder : Pre-treatment

Answer 14

Stabilise weight 
Lifestyle modification (smoking, alcohol) 
Folic acid (400mcg daily) 
Check prescribed drugs 
Rubella Immune
Normal semen analysis

Question 15

Group 1 Disorder: Medical Management

Answer 15

Pulsatile GnRH

• SC or IV pump worn continuously
• Pulsatile administration every 90 mins

Gonadotrophin (LH and FSH) daily injections

Pulsatile GnRH and gonadotrophin injections both need US monitoring of response
–> follicle tracking

Question 16

Group 2 Ovulatory Disorder

Answer 16

Hypothalamic Pituitary Dysfunction

Question 17

Group 2 Disorders Findings

Answer 17

Normal gonadotrophins
- possible excess LH

normal oestrogen levels

Oligomenorrhoea or Amenorrhoea

Question 18

Group 2 Disorders Example

Answer 18

PCOS

Question 19

PCOS

Answer 19

heterogenous disease characterised by hyperandrogegism and ovarian dysfunction which results in oligomenorrhoea or amenorrhoea and is associated with subfertility

Question 20

PCOS Presentation

Answer 20

Oligomenorrhoea (80- 90%)

Amenorrhoea (10-20%)

Question 21

PCOS Diagnosis

Answer 21

Requires 2 out of 3

Oligomenorrhoea or Amenorrhoea

polycystic Ovaries (US appearance)

• 12 or more 2-9mm follicles
• Increased ovarian volume (>10ml)
• Uni or bilateral

Chemical +/- biochemical signs of hyperandrogegism (acne, hirsutism)

Question 22

PCOS and insulin resistance

Answer 22

Insulin resistance seen in 50 to 80%

Diminished biological response to a given level of insulin

Normal pancreatic reserve
- hyperinsulinaemia

Insulin acts as co-gonadotrophin to LH

• 60% elevated LH
• 955 altered LH: FSh ratios

Insulin lowers SHBG levels: increased free testosterone leads to hyperandrogegism

Question 23

Group 2 (PCOS) Management

Answer 23

Treat patients symptoms/ needs

pre-treatment (lifestyle etc)

Subfertility: Ovulation Induction

Question 24

Ovulation Induction

Answer 24

1st Line: Clomiferene Citrate
2nd : Gonadotrophin Therapy (daily injections)
3rd: Laparoscopic Ovarian Diathermy

Question 25

Ovulation Induction Risks

Answer 25

Ovarian hyperstimulation - affects 10% IVF -Ranges from mild to severe Multiple pregnancy

Question 26

Risks of multiple pregnancy

Answer 26

Increased maternal pregnancy complications - hyperemesis, anaemia, hypertension, pre-eclampsia, gestational diabetes, postnatal depression/ stress Increased risk of miscarriage Risk of low birth weight and prematurity Risk of still birth Monochorionic

Question 27

Chorionicity

Answer 27

The number of chorionic (outer) membranes that surround babies in a multiple pregnancy Monochorionic - Fetus share a chorion - Increased perinatal mortality - T sign on US Dichorionic - Two placenta masses - Lambda sign on US

Question 28

Twin Twin Transfusion

Answer 28

Unbalanced vascular communications with placental bed Recipient develops polyhydramnios Donor develops oliguria, oligohydramnios and growth restriction 80-100% fatal if untreated Treatment - laser division of placenta vessels - Amnioreduction - Septostomy

Question 29

Group 3 Ovarian Failure Findings

Answer 29

high level gonadotrophins - Raised FSH >30IU/L Low oestrogen levels Amenorrhoea menopausal

Question 30

Premature Ovarian failure

Answer 30

Menopause before age 40

Question 31

Premature Ovarian failure Aetiology

Answer 31

``` Genetic -Turner syndrome. -XX gonadal Genesis - Fragile X Autoimmune ovariaan failure Bilateral oophorectomy Pelvic chemotherapy/ radiotherapy ```

Question 32

Premature Ovarian Failure Management

Answer 32

Hormone replacement therapy | Counselling/ Support network

Question 33

Ovarian Failure; Gynaecological History

Answer 33

``` Details of menstrual cycle Amenorrhoea Hirsutism Acne Galactorrhoea Headaches Visual symptoms PMH and DHx ```

Question 34

Ovarian Failure Biochemistry

Answer 34

Mid luteal progesterone (day 21) Early follicular phase(day 2 to 5) - serum TSH, oestradiol & LH - serum testosterone/ SHBG - prolactin Gold Standard: Progesterone Challenge test (menstrual bleeding in response to a 5 day course of progesterone: indicates oestrogen levels normal)

Question 35

Ovarian Failure Ultrasound

Answer 35

Transvaginal Routine part of infertility consultation Examines pelvic anatomy - uterus - ovarian morphology Scan to look for follicular growth/ monitor ovulation induction

Question 36

Ovarian Failure Tests

Answer 36

Karyotype ute-antibody screen MRI of pituitary fossa Bone density scan

Question 37

hyperprolactinaemia

Answer 37

Raised prolactin Can cause ovulatory disorder

Question 38

hyperprlactinaemia history and exam

Answer 38

AAmenorrhoea Oligomenorrhoea Current medication Examine visual fields

Question 39

Hyperproolactinaemia Investigations

Answer 39

Normal LH/FSH Low oestrogen Raised serum prolactin - >1000iu/l on 2 or more occasions TFT normal MRI - Diagnose micro/macro prolactinoma

Question 40

Hyperprolactinaemia management

Answer 40

Dopamine agonist - cabergoline (2x weekly) - stop when pregnancy occurs