Ovarian Factor Infertility

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
ABOUBAKR ELNASHAR

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
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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
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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]
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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
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7.  Do not use
ovarian volume
ovarian blood flow
inhibin B
E2
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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)
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9. ABOUBAKR ELNASHAR

10. Amenorrhea or severe oligomenorrhea
FSH & LH: low
Prolactin: normal
TREATMENT OF ANOVULATION
I. Hypogonadotrophic hypoestrogenic
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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
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12. II. Normogonadotrophic Normoestrogenic
PCOS
2 of 3 (Noterdam definition,2003):
•U/S PCO
•Hyperandrogenism (Clinical or Laboratory)
•Irregular or absent ovulation
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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
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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
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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}
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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
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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
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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
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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).
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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
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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
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22. ABOUBAKR ELNASHAR