Ovarian Pathology Notes

What does the menstrual cycle involve?

The interplay of the endometrium, hormones, and the ovary, including the preovulatory, ovulation, and postovulatory phases. A typical cycle is approximately 28 days (range 26-32).

When does the first menarche typically occur?

Around 12.5 years of age, with 95% of individuals experiencing it between 11 and 15 years. Cycles are often irregular and anovulatory initially.

What defines precocious puberty?

The start of secondary sexual characteristics (SSC) before the age of 8 years or menarche before the age of 10 years. Treatment may involve GnRH agonists, progestins, or growth hormone.

What defines delayed puberty?

Failure to menstruate by 16 years in the presence of normal SSC or by 14 years in the absence of other markers of puberty. Potential causes include haematocolpos, resistant ovary syndrome, H-P problems, or constitutional delays.

What is amenorrhea?

Absence of menstrual cycles.

What is primary amenorrhea?

Never having had a menstrual cycle.

What is secondary amenorrhea?

Cessation of menstrual cycles for at least 6 months.

What is oligomenorrhea?

Irregular cycles, defined as less than 9 cycles per year.

What are the symptoms of ovarian dysfunction?

Oligomenorrhea, amenorrhea, infertility, oestrogen deficiency, hirsutism, acne, androgenic alopecia, weight changes, galactorrhoea.

How is ovarian dysfunction diagnosed?

Pregnancy test, FSH/LH levels (day 2/3), progesterone levels (day 21).

What does a progesterone withdrawal bleed indicate?

Medroxyprogesterone acetate is administered for 5 days; a bleed should occur 2-7 days after completing the course, indicating normal E2 levels, a functional endometrium, and a patent outflow tract.

What are the primary causes of ovarian dysfunction?

Ovarian insensitivity or damage, high FSH/LH levels, premature ovarian failure/primary ovarian insufficiency, Turner’s Syndrome (XO), damage from chemotherapy or radiotherapy.

What are the central causes of ovarian dysfunction?

Hyperprolactinaemia, Kallman Syndrome, lifestyle factors.

What is Polycystic Ovarian Syndrome (PCOS)?

The most common endocrine condition, affecting approximately 10% of pre-menopausal women. Symptoms include oligoamenorrhoea, hirsutism, obesity, infertility, polycystic ovaries on ultrasound, and hyperandrogenism.

What are the Rotterdam Diagnostic Criteria for PCOS?

Need 2 out of 3 criteria for diagnosis: Oligo- or Amenorrhea, clinical or biochemical signs of hyperandrogenaemia, Polycystic Ovaries.

What are the Ultrasound Criteria for Polycystic Ovaries (USS)?

(\geq 12) cysts, 2-9 mm in diameter, (>10) ml ovarian volume.

What is premature ovarian failure?

Amenorrhea, low oestrogen, and high FSH/LH levels prior to the age of 40 years. Causes can include congenital conditions like Turner’s syndrome, autoimmune disorders, and iatrogenic factors.

What are the requirements for fertility?

Production of normal sperm and eggs, sperm traversing female tract, sperm penetrating and fertilizing oocyte, implantation of the embryo into the uterus, normal pregnancy.

Where does fertilization occur?

In the ampulla region of the uterine tube. Sperm remain capable of fertilization for approximately 5 days within the female tract; oocytes remain viable for approximately 24 hours.

What is the clinical definition of infertility?

Failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology or after 1 year of regular unprotected sexual intercourse for further clinical investigation.

What are some infertility statistics?

One in six UK couples have difficulty conceiving. Around 2.5% of all UK births are the result of fertility treatment.

What are the causes of infertility?

Female factors (35%), male factors (35%), combination (15%), unknown (15%).

What female factors contribute to infertility?

Ovulatory disorders (60%), disorders of the female tract, issues related to implantation, growth, and development.

What characterizes unexplained infertility?

Normal frequency and timing of unprotected intercourse, no obstructions or malformations, ovulation confirmed, normozoospermic (normal sperm parameters).

What is the effect of delayed reproduction & aging?

Fertility declines after the 20s and a sharp decline after 35 in females; age-related factors such as diabetes and hypertension can contribute to infertility in males.

What are some treatments for infertility?

Assisted conception techniques.

What does ovulation induction involve?

Clomiphene: an oral anti-oestrogen taken for five days at the beginning of the cycle, which removes inhibition, leading to an increase in FSH, requires monitoring the number of follicles.

What is Intrauterine Insemination (IUI)?

Injection of prepared sperm into the uterine cavity, bypassing cervical mucus, allows for perfect timing. Indications: inability to have sexual intercourse, need for sperm washing, same-sex relationship. Contraindicated in cases of unexplained infertility.

What is In Vitro Fertilisation (IVF)?

50,000-100,000 motile sperm added to an oocyte and left to fertilise.

What is IntraCytoplasmic Sperm Injection (ICSI)?

Involves injecting a single sperm per egg. Indications: Severe male factor, failure at IVF, epididymal or testicular sperm.

What are the ovarian stimulation steps?

1. Pituitary suppression (GnRH agonist/antagonist) 2. Ovarian stimulation (rFSH): Aim: multifollicular development 3. Monitoring of follicular growth 4. hCG triggering (c.f. LH surge): Aim: Final egg maturation

What happens during egg collection?

Ovary is viewed via ultrasound.

What are the post-egg collection procedures?

Insemination/injection, embryo culture (day 2/3 or day 5/6), embryo transfer (1 or 2 embryos), luteal support (cf. corpus luteum function in natural pregnancy).

What is blastocyst culture?

Culture of embryos for 5-6 days before transfer. Selects best embryos, potentially improving success rates.

What are the risks of IVF/ICSI?

Multiple pregnancies, Ovarian Hyperstimulation Syndrome (OHSS), very invasive for women, risk of congenital abnormalities/long-term maternal risks/imprinting disorders, inheritance of male infertility.