a) Anovulation.
b) LUF syndrome.
c) Luteal phase defect.
b) Luteinized unruptured follicle syndrome (LUF):
♦ Synonyms: trapped ovum syndrome, very rare.
Luteinized unruptured follicle syndrome Definition:
the ovum isn’t extruded from the follicle despite of presence of all systemic manifestations of ovulation.
Luteinized unruptured follicle syndrome Aetiology:
1. Pathological: PCO. 2. Pharmacological: HCG is given before the proper time.
Luteinized unruptured follicle syndrome Investigations:
U/S is done 3 days after LH peak.
Luteinized unruptured follicle syndrome Treatment:
induction of ovulation.
c) Luteal phase defect (LPD):
Luteal phase defect Definition:
Poor function of corpus luteum, secreting insufficient amount and/ or duration of progesterone .
Luteal phase defect Incidence:
5% of cases of infertility.
Luteal phase defect Aetiology:
A. central causes:
1. Hypothalamic causes
: • Hypothalamic defect.
• Inadequate dose of clomid.
2. Pituitary causes:
a) Hyperprolactinemia (prolactin inhibits gonadotrophins release & action).
b) Drugs:
* Synthetic progesterone or prolonged use of natural progesterone inhibits LH ↓ luteal support. Glandular stromal disparity (synthetic)
* Androgens: inhibit gonadotrophin release.
B. Peripheral causes:
1. Ovarian causes:
• Weak function of corpus luteum.
• Androgens: inhibit ovarian steroidogenesis.
• Endometriosis: due to presence of endometriosis on the surface of the ovary with high PG concentration rapid degeneration of corpus luteum.
2. Endometrial causes:
• Weak endometrial response i.e. end organ unresponsiveness.
Luteal phase defect Diagnosis:
* Infertility.
* DUB.
* Recurrent pregnancy loss.
Luteal phase defect Investigations:
1. Basal body temperature (midluteal): Biphasic, but with short luteal phase < 11 days.
2. Serum progesterone: 3- 10 ng / ml.
3. PEB: lagging secretory endometrium.
4. Serum prolactin: elevated in many cases.
Luteal phase defect Treatment:
treatment of the cause.
Ovarian factor infertility power point presentation:
1. Ovarian Factor Infertility Aboubakr Elnashar Benha University Hospital, Egypt ABOUBAKR ELNASHAR
2. CONTENTS I. EVALUATION TYPES OF ANOVULATION INVESTIGATIONS II. TREATMENT TREATMENT OF ANOVULATION TYPES OF OVARIAN STIMULATION DRUGS FOR OVARIAN STIMULATION
3. TYPES OF ANOVULATION % Type Hormonal profile 5-10% WHO type I (Hypogonadotropic Hypoestrogenic) E2 FSH 75-80% WHO type II Normogenadotrophic Normoestrogenic Normal E2 Normal FSH 10-20% WHO type III (Hypergonadotropic Hypoestrogenic) E2 FSH 5-10% WHO type IV (Hyperprolactinemia) prolactin WHO Scientific group, Geneva 1976, Report 514, Rowe et al, 1993 ABOUBAKR ELNASHAR
4. INVESTIGATIONS 1. Midluteal progesterone in regular and irregular cycles {confirm ovulation} In irregular prolonged cycles Depending upon the timing of menstrual periods, conducted later in the cycle (for example day 28 of a 35-day cycle) and repeated weekly thereafter until the next menstrual cycle starts 2. Basal FSH and LH Only in irregular prolonged cycles
5. 3. Prolactin Only in ovulatory disorder galactorrhoea or pituitary tumour 4. TSH: only if symptoms of thyroid disease Endometrial biopsy To evaluate the luteal phase: No {no evidence that medical tt of luteal phase defect improves pregnancy rates]
6. 5. Ovarian reserve testing Woman’s age: An initial predictor of overall chance of success through natural conception or with IVF Predictors of ovarian response to Gnt stimulation High responseLow response 16 or more4 or lessTotal AFC 3.5 or more 25 0.8 or less 5.5 AMH ng/ml pmol/l Conversion ratio:7 4 or less8.9 or moreFSH IU/L
7. Do not use ovarian volume ovarian blood flow inhibin B E2
8. Indications: ≥ 35 ys or < 35 years of age with risk factors for decreased ovarian reserve 1. Endometriosis 2. Unexplained infertility 3. Single ovary 4. Previous ovarian surgery 5. Poor response to FSH 6. Previous exposure to chemotherapy or radiation. (Iii-b)
10. Amenorrhea or severe oligomenorrhea FSH & LH: low Prolactin: normal TREATMENT OF ANOVULATION I. Hypogonadotrophic hypoestrogenic
11. 1. Reverse the life style factors: Increase wt if BMI <19 Moderating exercise if high levels of exercise. Treat stress 2. Gonadotrphins with LH activity or Pulsatile GnRH (pump) CC: not effective.
12. II. Normogonadotrophic Normoestrogenic PCOS 2 of 3 (Noterdam definition,2003): •U/S PCO •Hyperandrogenism (Clinical or Laboratory) •Irregular or absent ovulation
13. OVULATION INDUCTION IN PCOS NICE, 2013 1. Weigh loss: If BMI >30 K/m2 alone may restore ovulation improve response to ovulation induction agents, positive impact on pregnancy outcomes
14. 2. One of the following taking into account •potential adverse effects •ease and mode of use •BMI •monitoring needed: CC: (not more than 6 m) or Metformin or CC + Metformin
15. 3. CC resistance: one of the following 2nd line tt, depending on •clinical circumstances •woman’s preference: CC and met if not already offered as1st line tt or LOD or Gnt US monitoring {measure follicular size and number {reduce the risk of multiple pregnancy and OHSS}
16. Weight reduction Oral anti-estrogens (CC) Obese &overweight Normal weight &No weight loss & No ovulation LODGnT No ovulation after 3 cycles. No pregnancy after 6 cycles. No pregnancy after 6 cycles. No pregnancy after spontaneous, CC, FSH ovulation IVF Other surgical indication Difficult follow up Less aggressive No desire for surgery Add metformin IGT &IR
17. III. Hypergonadotrophic hypoestrogenic < 40 yr, 2ndry amenorrhea Repeated FSH > 20 IU/L Causes 1. Idiopathic. 2. Genetic. 3. Autoimmune 3. Viral/bacterial infection 4. Pelvic surgery, chemotherapy 5. Galactosemia
18. 1. Oral contraceptive suppression of gonadotrpins followed by discontinuation to allow a rebound in gonadotropins & ovarian function. 2. GnRHa suppression of gonadotropins secretion followed by high dose gonadotropin injection 3. Glucocorticoids suppression of immune system. Non of these tts has demonstrated efficacy in RCT
19. IV. Hyperprolactinaemia I. Idiopathic .Dopamine agonist (anxiety, pregnancy). Stop during pregnancy II. Microadenoma . Dopamine agonist (anxiety, pregnancy). Stop after 2-3 yr. . Surgery (rapid growth). III. Macroadenoma . Dopamine agonist: long term . Surgery (No response, suprasellar extension, pregnancy).
20. TYPES OF OVARIAN STIMULATION Controlled ovarian stimulation Super ovulation Induction of ovulation Anovulatory or ovulatoryAnovulatoryPatient Multiple> oneOne mature follicle Objective IVFIUI Unexp infert AnovulatoryExample Down regulation Stimulation Prevent premature LH surge StimulationStimulationMethod
21. DRUGS FOR OVARIAN STIMULATION Anti oestrogens: Clomiphene Citrate, Tamoxifen Gonadotrophins: HMG highly purified ur FSH Rec. FSH GnRHa (intranasal-S.C- I.M) GnRHant (involved in final steps of oocyte maturation) HCG Bromocriptine, Metformin, Letrozole.