Test Briefing on Hormonal Disorders and Infertility

Transcription

1 Test Briefing on Hormonal Disorders and Infertility

2 Test Briefing on Hormonal Disorders

3 Common Tests FSH LH Progesterone Estradiol Prolactin Testosterone AFP AMH PCOS Panel

4 FSH (Follicle Stimulating Hormone) In women, FSH controls the menstrual cycle and the production of eggs by the ovaries. In men, FSH stimulates production of sperm. The test is used to help diagnose or evaluate: Infertility in men Men who do not have testicles or whose testicles are under-developed The amounts of FSH and other hormones (luteinizing hormone, estrogen, and progesterone) are measured in both a man and a woman to determine the hormonal cause of infertility. Method: Chemiluminescence Clinical Utility FSH levels are useful in the investigation of menstrual irregularities and aid in the diagnosis of pituitary disorders or diseases involving the ovaries or testes. FSH levels are increased and serve as primary test for menopause evaluation. Aids in evaluation for Hirsuitism FSH level decreased

5 LH (Luteinizing hormone) LH is a hormone produced by gonadotroph cells in the anterior pituitary gland. In females, an acute rise of LH ("LH surge") triggers ovulation and development of the corpus luteum. High level of LH is associated with polycystic ovary syndrome, menopause. Method: Chemiluminescence Clinical Utility Helps in investigation of menstrual irregularities and to aid in the diagnosis of pituitary disorders or diseases involving the ovaries or testes. LH level increased twice FSH level indicative of PCOD Aids in evaluation for Hirsuitism LH level increased

6 Just a quick reminder FSH and LH in Females and Males FSH Female Male stimulates ovary to produce steroids ovary will produce estradiol during follicular phase and progesterone during luteal phase surges at midcycle, with LH, triggers ovulation stimulates Sertoli cells to produce androgen-binding protein (ABP), thereby stimulating spermatogenesis FSH also stimulates Sertoli cells to produce inhibin, which provides negative feedback to the anterior pituitary to decrease FSH secretion LH stimulates ovary to produce steoroids surge at midcycle triggers ovulation remember, luteinizing hormone turns the follicle into the corpeus luteum by triggering ovulation stimulates Leydig cells to produce testosterone -testosterone provides negative feedback to anterior pituitary and hypothalamus

7 Progesterone Progesterone is a female hormone produced by the ovaries during release of a mature egg from an ovary (ovulation). The test measures the amount of the hormone progesterone in a blood sample. Levels of progesterone in a pregnant woman is 10 times higher than non pregnant. Fall in progresterone level can lead to miscarriage Method: Chemiluminescence Clinical Utility Helps to find the cause of infertility. Monitor the success of medicines for infertility or the effect of treatment with progesterone. Assess the risk of miscarriage. Monitor the function of the ovaries and placenta during pregnancy.

8 Estradiol Estradiol (E2) is a type of estrogen, the major sex hormone in women. It is secreted by the ovarian follicles. Estradiol plays an important role in sexual development: It's the most important form of the hormone estrogen. Method: Chemiluminescence Clinical utility To evaluate whether or not the adrenal glands, placenta, and ovaries are functioning properly. Evaluate the possibility of ovarian tumors, to monitor the effectiveness of hormone replacement therapy in menopausal woman, or to monitor women who may have a high-risk pregnancy. Evaluate follicle development prior to a fertilization procedure to rule out cause for infertility in women

9 Prolactin The test measures the level of the hormone prolactin in blood. Pregnant women have high levels of prolactin, which helps to make breast milk. At the same time prolactin inhibits Gonadotrophin Releasing Hormone (GnRH) release, thus induces a state of infertility Method: Chemiluminescence Clinical utility Prolactin test used as part of a work-up for irregular menstrual periods, fertility problems, some types of thyroid or adrenal gland dysfunction, anorexia, and polycystic ovarian syndrome To find the cause of abnormal nipple discharge

10 Testosterone Testosterone is a male sex hormone Plays an important role in sexual development, is produced mainly by the testes in boys and in much smaller amounts by the ovaries in girls. Method total testosterone: Chemiluminescence free testosterone: Radioimmunoassay Clinical utility: Used to evaluate Delayed or precocious (early) puberty in boys Hirsutism and PCOD in girls and women Infertility in men and women Testicular tumors in men Hypothalamus or pituitary disorders

11 Alpha-fetoprotein (AFP) AFP is used as tumor marker to help detect & diagnose cancers of liver, testicles, and ovaries. Elevated AFP concentrations are found in 50% to 70% of patients with nonseminomatous testicular tumors. Clinical Significance: Increased AFP levels may indicate the presence of cancer, most commonly liver cancer, cancer of the ovary, or germ cell tumor of the testicles. The follow-up management of patients undergoing cancer therapy, especially for testicular and ovarian tumors and for hepatocellular carcinoma Failure of the AFP value to return to normal by approximately 1 month after surgery suggests the presence of residual tumor. Elevation of AFP after remission suggests tumor recurrence; however, tumors originally producing AFP may recur without an increase in AFP.

12 Anti-Mullerian Hormone (AMH) It is a glycoprotein hormone and one of the earliest and sensitive marker of ovarian aging Women with lower AMH produce a significantly lower number of oocytes compared with women with higher levels. It is the most discriminating hormonal prognostic marker of ovarian response in Assisted Reproductive Technology (ART). Comparison of Inhibin B & AMH in various ovary disorders

13 AMH Clinical Significance AMH is a hormone marker for quantitative prediction of: ovarian reserve (pool) ovarian aging ovarian dysfunction ovarian responsiveness Menopause Guides in PCOD diagnosis It is the best available marker in infertility evaluation before going for IVF therapy Marker of granulosa cell tumor of ovary

14 The most useful hormone for ovarian reserve/infertility: AMH Causes Mullerian a al regressio i ales (that s why they e o e males!). In females, made by follicular granulosa cells of preantral and antral follicles. AMH levels decline with increasing female age. Serum AMH levels is a good marker for the quantitative aspect of ovarian reserve. AMH levels are strongly correlated with the size of the follicle pool. AMH levels do not change over the course of a menstrual cycle. Serum AMH level can also serve as a marker in ovarian pathophysiology, such as polycystic ovary syndrome (PCOS). Method: EIA In contrast to most hormonal biomarkers of the follicular status, anti- Müllerian hormone (AMH) is exclusively produced by the granulosa cells of ovarian follicles (primary to the early antral stages), FSH-independently.

15 Ovarian Fertility Potential: AMH Ovarian Fertility Potential Optimal Fertility Satisfactory Fertility Low Fertility Very Low/Undetectable High Level pmol/l 28.6 pmol/l pmol/l 15.7 pmol/l pmol/l 2.2 pmol/l pmol/l 0.0 pmol/l pmol/l > 48.5 pmol/l? suspicion of Polycystic Ovarian Disease/Granulosa cell tumours

16 Clinical Utility Evaluating Fertility Potential Serum AMH levels correlate with the number of early antral follicles with greater specificity than inhibin B, estradiol, FSH and LH on cycle day 3. Thus, AMH may reflect ovarian follicular status better than the usual hormone markers. Measuring Ovarian Aging Diminished ovarian reserve, is signaled by reduced baseline serum AMH concentrations. AMH is useful marker for predicting ovarian aging and the potential for successful IVF. Predicting Onset of Menopause AMH can predict the occurrence of the menopausal transition. Assessing Polycystic Ovary Syndrome Serum AMH levels are elevated in patients with polycystic ovary syndrome and serve as a marker for the extent of the disease detection.

17 Testing for Ovarian reserve Tests Day 3 Inhibin B Day 3 FSH LH E2 Testosterone (Free & Total) AMH AMH Plus Plus we do TSH

18 AMH Plus A comprehensive panel which covers seven most common causes of Infertility and helps in providing one step diagnostic solution in female infertility Panel consists of 1. AMH 2. LH 3. FSH 4. Prolactin 5. Testosterone (Free and Total) 6. Estradiol 7. TSH 3G

19 PCOS Panel LH/FSH ratio may be elevated in 1/3rd of women with PCOS Insulin resistance: 2 hour GTT with Insulin levels. A glucose to Insulin ratio of > 4.5 (normal) Women with polycystic ovary syndrome (PCOS) are profoundly insulin resistant, and the resultant hyperinsulinemia exacerbates the reproductive abnormalities of the syndrome. Journal of Clinical Endocrinology and Metabolism, Vol. 83, No. 8, 1998 LH/FSH & Androstenedione better. Androstenedione elevated in upto 50-74% of PCOS cases Testosterone elevated in 70% of cases

20 PCOS Panel Panel includes LH, FSH, Prolactin, Testosterone (Total & Free) and Insulin (Fasting & PP). Inference S.No Tests Included Observed Comments 1 LH Increased LH:FSH ratio >2.0, 2 FSH Decreased accurate clue 3 Testosterone Increased - 4 Prolactin Normal or low D/D -Prolactinoma 5 Insulin - D/D Insulinoma 6 Sugar (Fasting & PP) - Monitor type 2 Diabetes Clinical Utility Combination of above panel and USG provide accurate diagnosis of PCOS.

21 TEST BRIEFING ON INFERTILITY

22 Evaluation of the Infertile Couple 1st Level Diagnostic Testing Female Hormonal assessment of ovulatory function Tubal patency assessment Male Semen analysis FSH, LH, and testosterone measurement. 2 nd Level Diagnostic Testing Female Cervical factors All forms of vaginitis may include cervicitis, leading to a change in cervical mucus ph [Gram-positive and Gram-negative bacteria, Chlamydia trachomatis, Neisseria gonorrheae, Ureaplasma urealyticum, and Mycoplasma hominis] Tubal factors (TB??) Uterus abnormalities Genetic assessment Male Bacteriological examination chronic prostatitis vesiculitis Genetic assessment Testicular Biopsy

23 Male factor Male partner should be evaluated simultaneously with female Causes of male infertility: Sperm production disorders affecting the quality and/or the quantity of sperm Hormonal Anatomical obstructions Other factors such immunological disorders Testicular or pituitary cancer Genetic Anti-sperm antibodies FSH, LH, Prolactin, Testosterone, Inhibin B Sperm count, sperm motility Karyotyping 23

24 Male Infertility Panel Panel consists of: Testosterone total LH FSH Prolactin TSH Blood lymphocyte culture Anti sperm antibodies Urine culture isolation & identification + sensitivity Semen analysis Semen fructose

25 Justification for our Male Infertility Panel Male Infertility Causes Infection Hormonal Semen Analysis Immunologic Infertility Genetic Infertility Test Name Urine Culture & Sensitivity Testosterone (free& total), FSH, LH, Prolactin TSH Semen Analysis Semen fructose AntiSperm antibodies Karyotyping Why? To rule out any infection like Urethritis etc Men who are hypothalamic or have pituitary dysfunction are frequently hypogonadal and have azoospermia or severe oligospermia and low motility. Serum FSH, LH (<2 IU/L), and testosterone levels are low in these men Sub Clinical Hypothyroidism An initial semen analysis should be obtained from the male partner early in the infertility evaluation, before any invasive tests are done on the woman. It should be obtained after 2-5 days of abstinence. for analysing fructose level in Semen Antisperm antibodies can be suspected when urological history is suggestive of hernia or testicular surgery, testicular trauma, genitalia infection or vasectomy. It impairs sperm penetration of cervical mucus, zona pellucida interaction, and oocytes fusion) It has been estimated that 30% of male factor infertility is genetic. In case of testicular failure of severe oligoasthenoteratozoospermia, genetic testing karyotype & Y Chromosome Microdeletion should performed

26 Fertility Panels TEST CODE 4639 TEST NAME PCOS TOTAL (LH, FSH, Prolactin, Testosterone (Free), HOMA IR, DHEAS, TSH, Direct LDL Cholesterol, Cholesterol Total, Triglycerides Price (Rs.) AMH PLUS MALE INFERTILITY PANEL, (Testosterone Total, LH, FSH, Prolactin, TSH, Blood Lympho Culture, Anti sperm Antibodies, Urine culture, isolation & Identification + Sensitivity) SPERM DNA FRAGMENTATION METHOD SPECIMEN FREQUENCY REPORTED CHEMILUMINESCENCE/ RADIO IMMUNOASSAY/ SPECTROPHOTOMETRY Enzyme Immunoassay/Chemilu minescence. CHEMILUMINESCENCE / ENZYME IMMUNOASSAY/ CELL CULTURE/ CULTURE + SENSITIVITY BY MIC BREAKPOINT Indirect assay using acridine orange by Flow Cytometry SERUM ( AGE+GENDER+LMP+CLINICAL HISTORY REQUIRED ) **DRAW SAMPLE BETWEEN 8 AM TO 10AM, 3-4 HRS AFTER THE PATIENT HAS AWAKENED.**+FASTING FLUORIDE PLASMA WITH FASTING SERUM (AGE & GENDER OF THE PATIENT IS MANDATORY FOR REPORTING) DAILY (MON TO SAT): 0500 hrs to 1900 hrs SAME DAY,HOMA Next Day SERUM DAILY:1100 HRS SAME DAY Serum ( Age+ Gender+ Clinical History Required ) **Draw sample between 8 AM to 10AM,After 3-4 hrs patient has awakened.** WB-HEPARIN SPECIMEN TO REACH US within 48 hrs + FAMILY HISTORY + CLINICAL HISTORY in specified format + DETAILED PHYSICAL FEATURES URINE(Early morning mid stream collection) STERILE CONTAINER SEMEN DAILY (MON TO SAT): 0500 hrs to 1900 hrs FOR LH/FSH/PROLACT IN/TOTAL TESTOSTERONE/ TSH & DAILY:0700 HRS FOR BLOOD LYMPHO CULTURE; DAILY: 1700 HRS (FOR URINE C&S) MONDAY 09:00HRS TO FRIDAY 09:00HRS AFTER 3.0 hrs (LH, FSH & PROLACTIN, TOTAL TESTOSTERON E &TSH) & working days (BLOOD LYMPHO CULTURE); 3RD DAY FOR URINE C&S 6 DAYS

27 THANK YOU