- Credits - Section Writer: Dr. Om J Lakhani - Section Editor: Dr. Om J Lakhani Support us: 1. Support us by purchasing our book - Click here for more details: [[Volume 1- THE BEST OF NOTES IN ENDOCRINOLOGY BOOK SERIES]] 2. [Support you by Becoming a YouTube member (Click here)](https://www.youtube.com/channel/UC6zQSf7dLDqfQOeM4mNUBTQ/join) - Q. What points should be covered in clinical history when dealing with a case of [[Female Infertility]]? - Duration of infertility - Number and outcome of any prior pregnancies (including ectopic and miscarriages) with the same or a different partner - Gynecologic history, including pelvic inflammatory disease, fibroids, endometriosis, cervical dysplasia; surgery of the cervix, ovary, uterus, fallopian tube, pelvis, or abdomen; intrauterine device use, other prior contraceptive use, diethylstilbestrol exposure in utero, uterine anomalies. - Menstrual history (age at menarche, cycle length, and regularity), presence of molimina or vasomotor symptoms (hot flashes), dysmenorrhea - Changes in hair growth, body weight, or breast discharge - Other medical and surgical histories - Medications - History of chemotherapy or radiation - Cigarette smoking, alcohol, marijuana, and other drug use; environmental and occupational exposures - Exercise and dietary history - Frequency of intercourse, use of lubricants (which may be toxic to sperm). presence of deep dyspareunia suggestive of endometriosis - Previous infertility testing and therapies - Family history of congenital disabilities, mental retardation, or reproductive failure - Pelvic or abdominal pain, symptoms of thyroid disease - Q. What does tenderness in the pouch of Douglas suggest? - Chronic PID  or - Endometriosis - Q. Which are four essential initial tests in the evaluation of infertility? - Semen analysis - Documentation of ovulatory function – history - Tests for ovarian reserve - Test for tubal patency and uterine anatomy - **Assessment of ovulatory function** - Q. What point in history generally rules out ovulatory dysfunction? - Most likely to be ovulatory: - Regular menses every 28 days - with molimina symptoms before menses - Q. If the woman does not give the above history of normal ovulatory cycles, then what is done? - Do a mid-lueteal phase progesterone - It is done seven days before the expected date of menses (21st day of cycle) - If the level is >3 pg/ml- it suggests that ovulation has occurred - Q. What are other tests for detection of ovulation? - Use of Home LH detection kit - Ultrasound assessment for ovulation - Endometrial biopsy - Q. What is done if mid-lueteal progesterone is <3 pg/ml? - Assessment of ovulatory dysfunction is done - Baseline tests include PCOS work up – Ultrasound, testosterone, thyroid function, prolactin, 17 OHP - **Assessment of ovarian reserve ** - Q. Which patients should undergo ovarian reserve testing? - Age >35 years and not conceived for six months - Women with risk for POI- radiation exposure, chemotherapy, genetic abnormalities, autoimmune disease, etc - Q. What is the difference between older women vs. younger women with poor ovarian reserve? - Younger women with poor ovarian reserve- have less quantity of ovaries but good quality - Older women- vice versa - Q. What are tests done for assessment of ovarian reserve? - Day 3 FSH and estradiol - Antral follicular count on TVS - Clomiphine challenge test - AMH levels - **FSH, estradiol, and clomiphene challenge** - Q. When we say day 3, what is day 1? - Day 1 is the first day of menstrual flow - Q. What value of Day 3 FSH suggests normal ovarian reserve, and what suggests abnormal? - FSH  <10 mIU/ml- normal - 10-20- borderline - more than 20 mIU/ml- poor ovarian reserve - Q. What is the fundamental of day 3 FSH? - Will with good ovarian reserve  good amount of hormone production from small antral follicles → suppresses FSH - Q. What does day three estradiol level suggest ovarian reserve? - Day 3 estradiol <80 pg/ml- good ovarian reserve - More than 80 pg/ml- poor reserve - Very important - ASRM says that estradiol interpretation is important mainly in women with normal FSH yet risk of poor ovarian reserve - When used alone, it is not very useful - Q. What is the fundamental measurement of estradiol? - High estradiol means premature recruitment of ovarian follicle which occurs in women with poor ovarian reserve - Interestingly, this would suppress the FSH, and hence both FSH and estradiol measurements are required - Q. Describe the clomiphene challenge test? - FSH and estradiol are measured on day 3 of the cycle - Clomiphene given for days 5 to 9 in a dose of 100 mg - FSH again measured on day 10 - Q. What is the interpretation of the clomiphene challenge test? - Again, day three and day 10 FSH <10 – normal - 10- 20 (some use 15) – inadequate - More than 20- poor - Estradiol – similar interpretation as earlier - Q. What is the prognosis of women with poor ovarian reserve? - Generally poor prognosis - They can rarely conceive without the use of donor oocytes - **Antral follicle count ** - Q. What is the definition of antral follicles? - Measuring 2-10 mm in diameter - Q. When is a measurement of antral follicle count done? - Generally, on days 2-4 - However, studies have shown that it can be done at any phase of the cycle - Q. How is AFC count done? - It is done by TVS - Ovary is assessed in both transverse and longitudinal planes - Diameter measured in 2 perpendicular planes and larger of the two dimensions is used for assessment - Q. What AFC values suggest poor ovarian reserve? - Value <4-10 antral follicles on days 2-4 suggest poor ovarian reserve - **AMH ** - Q. Which follicles secrete AMH? - Preanteral  follicle- <8 mm - Early antral follicles - Q. What does AMH tell us? - AMH tells us the size of the primordial follicular poor - Hence it is a good biochemical marker of ovarian reserve - #Pearl - AMH cutoffs vary according to labs; hence difficult to generalize - Q. What is the interpretation of AMH? - <0.5 ng/ml- very poor ovarian reserve - <1 ng/ml  - poor - 1.0 – 3.5 ng/ml – good ovarian reserve - More than 3.5 ng/ml- chance of ovarian hyperstimulation on ovulation induction - Newer assay uses cut point of 0.2-0.7 ng/ml - Q. Does AMH need to be measured in the follicular phase? - No - It can be measured in any phase of the cycle  since the growth of preantral follicles is continuous and not dependent on the phase of the cycle - Q. Apart from AMH, which other similar test is used to judge ovarian reserve? - Inhibin B - Cutoff value is 40-45 pg/ml - However, it has poor sensitivity and specificity and is hence not used routinely - #Pearl - The cut points of AMH depends on the assay used - There is an older assay for AMH and a newer assay that have different cut points - So, it is important to known which assay is used and what is its cut point for interpretation - **Assessment of fallopian tube patency and uterine anatomy ** - Q. Which is the first-line assessment of tubal patency? - HSG- hysterosalpingography - Q. What is HyCoSy? - Hysteria-salphingo contrast sonography - Q. What does HSG not tell you? - Does not tell you about adhesions and endometriosis - It also tells you more about distal tubal blocks – but does not tell you much about the proximal tubal blocks - Q. What is the gold standard for tubal patency? - Laparoscopy with chromotubation - Q. Which is another suitable non-invasive method for the tubal assessment? - Chlamydia trachomatis IgG antibody testing - Q. What can be a cost-effective approach for tubal disorder? - First do chlamydia trachomatis IgG antibody - If negative- less likelihood of tubal disease - If positive- it can be falsely positive due to cross-reaction with C. pneumonia  - hence to HSG - If the high risk of tubal disease- do HSG directly - Q. Which is the test of choice for uterine cavity assessment? - Saline infusion sonohysterography - It is a special sonography - HSG can also assess the uterine abnormality - It is confirmed with further imaging like MRI or hysteroscopy - Q. What is the role of hysteroscopy? - It is helpful for diagnosis and treatment of uterine abnormalities - Q. What can hysteroscopy not tell you? - Status of the myometrium - Fallopian tube - Adnexal structures - #Pearl - Fallopian and uterine assessment  HSG is a good test - Uterine assessment alone (patient undergoing IVF)- saline infusion sonohysterography or Hysteroscopy - Q. What is the role of laparoscopy? - It is done for the treatment of endometriosis and fallopian tube blocks - If it is done for any other reason- it must be combined with chromotubation to look for tubal patency - **Tests with limited clinical utility ** - Q. What is the role of endometrial biopsy? - To document secretory endometrium- which is a marker of ovulation has occurred - To correlate the endometrial timing with that of the IVF date – to assess Luteal phase defect - However, this test is rarely done for either indication these days - Q. What is the fundamental of basal body temperature measurement? - Progesterone in the luteal phase affects the hypothalamus and increases basal body temperature - Q. Describe the process of basal body temperature measurement? - Women measures the temperature by keeping the thermometer beneath the tongue every day before getting out of the bed - During the luteal phase, the temperature increase by 0.5 F compared to the follicular phase - It begins to rise 1-2 days after LH surge and remains high for ten days