Hypothalamic Anovulation By Dr Mohammad Wali Naseri MD

Hypothalamic Anovulation By : Dr Mohammad Wali Naseri MD Associate Prof of Internal Medicine, Division of Endocrinology Metabolism and Diabetes, Kabul University of Medical Sciences

Hypothalamic pituitary gonadal axis

WHO Classification of ovulation disorders Group 1 Hypothalamic pituitary failure (hypothalamic amenorrhea or hypogonadotropic hypogonadism) • This group of disorders is characterized by low gonadotrophins, normal prolactin and low estrogen, and it accounts for about 10% of ovulatory disorders

WHO Classification of ovulation disorders Group 2 Hypothalamic pituitary dysfunction • This group, which is characterized by gonadotrophin disorder and normal estrogen, accounts for about 85% of ovulatory disorders

WHO Classification of ovulation disorders Group 3 Ovarian failure • This group, which is characterized by high gonadotrophins with hypogonadism and low estrogen, accounts for about 4– 5% of ovulatory disorders

Background Definition: Infertility: 1 year unprotected coitus without conception 10 -15% couples affected Etiology Couples: ○ ○ ○ 35% Tubal and pelvic pathology 35 % Male problems 15% Ovulatory dysfunction 10% Unexplained 5% unusual causes

Background • Etiology • Women: • • 40% Tubal and pelvic pathology 40% Ovulatory dysfunction 10% Unexplained Infertility 10% Unusual causes • Normal couple: • 25 -30% chance of pregnancy per ovulatory cycle • Fertility decreases with age

Infertility Time of Exposure 3 months 6 months 1 year 18 months % Pregnant 60% 70% 85% 90%

Approach to Infertility • DDX • Tests/Inv • Dx • Rx

Female Infertility • Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%) • Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)

Pathophysiology • Production • Storage • Delivery

Pathophysiology • Production: • Hypothalamus • Pituitary • Ovary

Hypothalamic-Pituitary-Gonadal Axis

Causes • Hypothalamus: • • • Stress Exercise Eating disorders Psychogenic Congenital/genetic: Kallman’s syndrome (hyposmia & hypoplasia olfactory lobes of brain) Starvation/stress or severe illness Tumors (craniopharyngioma, metastatic tumor) Head injury Inflammation (sarcoidosis) Infection (tuberculosis) XRT Drugs

Evaluation History: Age GTPAL Regulatory of period Prolactin S/S Thyroid S/S Infections, Surgeries Medication, Smoking, Ethanol Medical history Previous investigations

Physical Examination: • • • Visual Field Thyroid Breast (milk) Abdomen (masses, scars) Vaginal (abnormalities) Bimanual (Uterus, masses)

Lab Investigations Blood work: TSH PRL D 3 FSH D 3 LH Luteal phase Progesterone Imaging: Pelvic Ultrasound HSG Diagnostic Laparoscopy (later)

Treatment • Treat the underlying cause • Medical • Surgical

Treatment of WHO Group I ovulation disorders Treatment options include: • Lifestyle interventions (normalizing weight and exercise) • Pulsatile gonadotrophin-releasing hormone (Gn. RH) (‘Gn. RH pump’) • Gonadotrophins (human menopausal gonadotrophin [h. MG]).

Treatment of WHO Group II ovulation disorders Options for treatment include: • Weight loss • Medical treatment • Second-line treatments including laparoscopic ovarian diathermy (LOD) and injectable gonadotrophin ovulation induction • Assisted conception (usually in vitro fertilization [IVF])

Take Home Points • DDx – Hx – Px – Inv - Rx • Age is important factor female • Hypothalamic-Pituitary-Gonadal axis central in working up both male and female infertility • Investigations: • Male: Sperms • Female: Tubes (HSG) + Ovaries (FSH, LH, PRL, TSH)

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