N. Shirazian, MD. Endocrinologist

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1 N. Shirazian, MD Internist, Endocrinologist

2 Inside the ovary Day 15-28: empty pyfollicle turns into corpus luteum (yellow body) Immature eggs Day 1-13: 13: egg developing inside the growing follicle Day 14: ovulation egg released from follicle

3 Copyright 2008 Pearson Allyn & Bacon Inc. 3

4 The role of Hormones in the menstrual cycle FSH released from pituitary gland. Produces follicle on ovary & stimulates egg to mature. If fertilisation occurs the yellow body will secrete progesterone, until placenta is formed & then takes over. Follicle secretes oestrogen. High oestrogen levels makes uterus lining i thick & spongy & stops the release of FSH from pituitary If no fertilisation i occurs yellow body disappears & progesterone levels decrease. This causes uterus lining to shed & menstruation occurs. LH released from pituitary. LH triggers ovulation (release of egg cell) Empty follicle (yellow body) secretes progesterone. Progesterone stops further ovulation & prevents shedding of uterus lining.

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6 Uterus lining The lining of the uterus becomes thicker with blood vessels & more stable during the menstrual cycle. Why is this important? uteru us lining thic ckness period days after start of period A fertilized egg will bury itself (implant) in the uterus lining. The egg needs a plentiful supply of oxygen and nutrients to develop.

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9 Pregnancy If the egg is fertilized, the uterus lining must not break down otherwise the fertilized egg will not develop. egg fertilized: uterus lining maintained, egg implanted corpus luteum (structure that develops after the ovum is discharged but degenerates if no pregnancy): continues to produce progesterone & oestrogen

10 Contraceptive pills contain progesterone & need to be taken every day. How do they work? no FSH received: no egg maturing Contraceptive pills mimic pregnancy, which means that the ovaries do not produce any eggs.

11 DETECTION OF OVULATION, TIME OF OVULATION hormone ovary

12 DETECTION OF OVULATION; 1. Menstrual cycle charting, 2. basal body temperature monitoring, 3. measurement of the serum progesterone TIME OF OVULATION; 1. measurement of follicle size 2. luteinizing hormone (LH) surge.

13 DETECTION OF OVULATION; 1. Menstrual cycle charting The simplest & least expensive Normal cycles;25 35 days also note moliminal symptoms

14 DETECTION OF OVULATION; 2.Basal body temperature monitoring ~ 0.5ºc rise begins 1 2 days after LH surge & persists for at least 10 days.

15 DETECTION OF OVULATION; 3. Serum progesterone concentration Another simple test in mid luteal phase, (18 24 days after the onset of menses) or (7 days before the next menses are expected). progesterone > 2.0 ng/ml is consistent with luteinization but values this low may not correspond to a normal luteal phase. Normal mid luteal progesterone; ; 6 25 ng/ml.

16 DETECTION OF OVULATION; 3. Serum progesterone concentration there is considerable variability ibili in single blood samples for progesterone because progesterone levels can increase in response to LH pulsations occurring after ovulation. a single low value cannot reliably detect an abnormal luteal phase, it may be obtained between LH pulses. In comparison, a single level labove 6 ng/ml is usually indicative of normal corpus luteum function.

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18 TIMING OF OVULATION Identifying the fertile period (intercourse 1 2 days prior to ovulation) 1. Calendar & basal body temperature (BBT) 2. examine vaginal discharge for changes suggestive of a preovulatory estrogen effect (Better alternatives) 3. Measurement of urinary luteinizing hormone( more expensive).

19 TIMING OF OVULATION Measurement of LH surge urine or serum. Home urinary LH kits; available. serum LH surge ~ 36 hours before ovulation. Urine LH surge 12 hours after it appears in serum; Both urine estradiol & LH predict more precisely. high amplitude LH pulses at surge leading to considerable hour to hour variability.

20 TIMING OF OVULATION Measurement of LH surge The kit instructions must be followed precisely, as different kits are standardized to different times of the day. In addition, the urine kit should probably be used only after ovulation has previously been documented. d there is little utility for serum LH in conventional practice, except for preparing ivf. Use of serum measurement requires very precise knowledge of normal LH ranges in the immunoassay used & there is considerable variability in assay results depending di upon antibodies, standards, d and techniques.

21 Adequate ovarian reserve inolderorinfertilewomen; or infertile earlyfollicularphase (EFP) FSH. follicularphase shortens prior to menopause, EFP FSH levels increase before any detectable fall in peak estradiol, or progesterone levels, or in luteal phase length. ivf. elevation of day 3 FSH above a particular level ishighly correlated witha poorresponseresponse to ovulation induction & poor pregnancy rates.

22 Adequate ovarian reserve single FSH may not be sufficient becauseof fluctuation from cycle to cycle. limited use, lack of standardization of FSH assays. 3 fold difference on the same samples with differentassays. un interpretable marginally elevated serum FSH levels? very high levels ( 2 times the upper range of normal very high levels ( 2 times the upper range of normal for a given assay) have high negative predictive value.

23 Adequate ovarian reserve day 3 serum estradiol As with FSH, estradiol levels vary widely with different assays does not appear to have the same negative prognostic value as FSH levels l on day 3. We measure serum FSH & estradiol on cycle day 3 in all women over the age of 35 years who are contemplating IVF, & we do not start IVF cycles in those with serum FSH concentrations >20 miu/ml or serum estradiol concentrations >100 pg/ml (367 pmol/l).

24 Thank you

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