Reproduction-Related Disorders Part 4

Evaluation of Ovulation Currently, laboratory tests will not confirm ovum release. However, measurement of the concentration of mid- luteal plasma progesterone does indicate that a corpus luteum was formed. Other methods such as measurement of the LH surge (to predict ovulation) and basal body temperature (to detect a rise in progesterone) have been used to assess ovulation.

Evaluation of Ovulation Clinical Utility of Progesterone Measurements. Measurement of serum progesterone concentration is the primary assay used for the evaluation of ovulation. Beginning immediately after ovulation, serum progesterone concentrations rise and peak within 5 to 9 days during the mid-luteal phase (days 21 to 23). If ovulation does not occur, the corpus luteum fails to form, and the expected cyclic rise in progesterone concentration is subnormal. If pregnancy occurs, hCG maintains the corpus luteum, and progesterone production continues to rise.

Evaluation of Ovulation Progesterone Measurements Mid-luteal progesterone concentrations greater than 3 ng/mL indicate that ovulation has taken place, although conc. of 10 ng/mL or more are more common in conception cycles. Conc. less than 10 ng/mL indicate the possibility of inadequate luteal phase progesterone production, or inappropriate timing of sample collection.

Evaluation of Ovulation Basal Body Temperature Basal body temperature charts have long been accepted as simple, cost-effective indicators of ovulation. Ovulation is associated with a rapid rise in body temperature (by 0.5 °F), which persists through the luteal phase. The rise in temperature is due to increased quantities of progesterone. However, similar to progesterone, the rise in body temperature is evident only retrospectively and therefore does not predict forthcoming ovulation in a way helpful for timing intercourse.

Evaluation of Ovulation Measurement of the LH Surge LH appears in the urine just after the serum LH surge and 24 to 36 hours before ovulation. Measurement of LH does not confirm ovulation or provide insight into the cause of anovulation, but rather indicates when ovulation should occur and provides a guide with which to time intercourse. Home LH kits provide information as to the timing of ovulation, and may reduce stress and costs associated with infertility programs. These tests effectively predict ovulation in 70% of women.

Evaluation of Ovulation Measurement o the LH Surge

Evaluation of Endocrine Parameters Disorders of the endocrine which causes infertility in women are: The hypothalamus, The pituitary, and The ovary

Hypergonadotropic Hypogonadism In women younger than 40 years, hypergonadotropic hypogonadism is indicated by repeatedly elevated basal FSH concentrations (>30 IU/L) or a single elevation of greater than 40 IU/L. These patients are hypoestrogenic (E2 <20 IU/L) and do not respond to a progestin challenge because their endometrium is atrophic. Basal serum FSH has been used as an indicator of relative ovarian reserve.

Hypergonadotropic Hypogonadism/ Assessing Ovarian Reserve Women in their mid to late 30s and early 40s with infertility constitute the largest portion of the total infertility population and are at increased risk or pregnancy loss. This reflects a diminished ovarian reserve as a result of follicular depletion and a decline in oocyte quality. As women age, serum FSH concentrations in the early follicular phase begin to increase.

Hypergonadotropic Hypogonadism/ Assessing Ovarian Reserve A rise in basal FSH is an excellent indicator of ovarian aging. In general, day 3 FSH concentrations greater than 20 to 25 IU/L (RI < 10) are considered to be elevated and associated with poor reproductive outcome. Basal E2 concentrations greater than 75 to 80 pg/mL are associated with poor response to ovarian stimulation and pregnancy outcome. The concentration of inhibin B has been used in conjunction with serum FSH and E2 to assess ovarian function.

during the follicular phase Laboratory Test Normal Values When to Measure Important Points Follicle Stimulating Hormone (FSH) 5–20 mIU/L Follicular phase, days 2–3 of menstrual cycle FSH values >10 IU/L predict poor response to ovarian stimulation  FSH values >18 IU/L predictor of poor pregnancy outcome Estradiol (E2) 20–400 pg/mL Helpful in combination with FSH to establish baseline ovarian reserve Anti-Müllerian Hormone 0.9–9.5 ng/mL Not cycle dependent so can be measured at any time Low values (0.2–0.7 ng/mL) predict poor response to COH but are not useful in predicting pregnancy Inhibin B <139 pg/mL  during the follicular phase Follicular phase, days 2–3 of the menstrual cycle Serum levels <45 pg/mL have been associated with poor response to gonadotropins

Hypogonadotropic Hypogonadism In hypogonadotropic hypogonadism, serum E2 concentrations are less than 40 pg/mL. Quantities of LH (<10 IU/L) and FSH (<10 IU/L) are decreased.