·
The fecundability, or monthly
probability of pregnancy, is 20% among fertile couples.
·
If the histologic
dating of the endometrium lags 4 or more days behind
the chronologic date predicted by the menstrual history, the diagnosis of luteal phase defect
can be made. Clinically, these patients exhibit low serum progesterone, FSH,
and LH levels.
In contrast,
prolonged functioning of the corpus luteum
(persistent luteal phase with continued progesterone
production) results in prolonged heavy bleeding at the time of menses. Histologically, there is a combination of secretory glands mixed with proliferative glands (irregular
shedding). Clinically, these patients have regular periods, but the menstrual
bleeding is excessive and prolonged (lasting 10 to 14 days).
·
Pretesticular causes
are those that affect the hormones that stimulate the testicles, such as a low
LH or FSH. Phenytoin acts by reducing FSH. Other
causes of a low LH or FSH include various hypothalamic-pituitary disorders,
such as panhypopituitarism and gonadotrophin
deficiency, including isolated LH deficiency and Kallmann's
syndrome.
Posttesticular causes
are those that affect sperm transport, and testicular causes are those with a
direct effect on the testicles. Idiopathic causes represent those causes that
are likely genetic and not elsewhere classified.
·
There are no diagnostic criteria for PCOS, but common
findings are increased LH:FSH ratio, decreased fasting
glucose:insulin ratio, polycystic ovaries on
ultrasound, and obesity.
Oral contraceptives have
long been used in the management of PCOS because they suppress pituitary
luteinizing hormone secretion, suppress ovarian androgen secretion, and
increase circulating SHBG. Medications such as metformin
that improve insulin sensitivity have been used to treat PCOS. Spironolactone, which is a diuretic and aldosterone agonist, has been used to treat PCOS because it
binds to the androgen receptor as an antagonist. Weight loss is
recommended as part of the treatment for women with PCOS because it reduces hyperinsulinemia. Insulin is thought to act on the
ovary to stimulate androgen secretion. In addition, hyperinsulinemia
decreases SHBG. There is no role for the use of dexamethasone to treat PCOS.
·
DHAES is a marker of adrenal androgen production; when normal, it essentially excludes
adrenal sources of hyperandrogenism.
·
Therapy with Clomiphene
Citrate:
Ovulation rate: 80%
Pregnancy rate: 50%
·
OHSS is an infrequent but potentially severe
complication of IVF. It is most commonly seen in young women with very high estradiol concentrations and many intermediate-sized
follicles.
OHSS usually presents 1 week after oocyte retrieval. It is characterized by ascites, weight gain, and intravascular volume depletion.
In severe cases, prerenal azotemia,
hemoconcentration, and a hypercoaguable
state can be present.
Treatment with aggressive hydration is
indicated, even if it worsens the ascites. Paracentesis early in the course of OHSS, and repeated as
needed, is often indicated.
·
IVF involves fertilizing eggs and sperm outside
the body then placing embryos in the uterus.
The endometrial glandular integrin avß3
appears to be closely tied to normal uterine receptivity. It initially appears
coincident with the establishment of normal uterine receptivity. avß3 expression is diminished in women suffering from
endometriosis, hydrosalpinges, primary unexplained
infertility, recurrent pregnancy loss, and polycystic ovarian disease. Note
that strategies to optimize uterine receptivity allow for transfer of fewer
embryos.
·
In anorexia nervosa, prolactin,
GH, TSH, and thyroxine levels are normal,
FSH and LH levels are low, and cortisol
levels are elevated.
·
Müllerian
agenesis, also known as MayerRokitansky-Küster-Hauser syndrome,
presents as amenorrhea with absence of a vagina. The incidence is approximately
1 in 10,000 female births. The karyotype is 46,XX. There is normal development of breasts, sexual hair,
ovaries, tubes, and external genitalia. There are associated
skeletal (12%), urinary tract (33%) and auditory anomalies. Treatment
generally consists of progressive vaginal dilation or creation of an artificial
vagina with split-thickness skin grafts (McIndoe
procedure).
·
Of
all the medications studied, SSRIs have
shown the greatest efficacy in PMS treatment.
·
Besides
an increase in androgens and a moderate rise in FSH and LH levels, one of the
first indications of puberty is an increase in the amplitude and frequency of nocturnal LH
pulses.
·
Salpingitis isthmica nodosa, in which there is a characteristic “salt-and pepper” pattern of tubal filling and
evidence of a diverticulum of the tube on one side.
·
Thyroid dysfunction and hyperprolactinemia can both be associated with hirsutism, and therefore it is important to check
levels of TSH and prolactin.
·
Unintended pregnancy in women correctly using oral contraceptive
pills is not related to sexual frequency, gastrointestinal disturbances, or the
development of antibodies.
·
Although
the incidence of ectopic pregnancies with an IUD
was at one time thought to be increased, it is now recognized that in fact the
overall incidence is unchanged. The apparent increase is the result of the
dramatic decrease in intrauterine implantation without affecting ectopic
implantation. Thus, while the overall probability of pregnancy is dramatically
decreased, when a pregnancy does occur with an IUD in place, there is a higher
probability that it will be an ectopic one.
·
Masters and Johnson observed a transudate-like fluid emanating
from the vaginal walls during sexual response. This mucoid
material, which is sufficient for complete vaginal
lubrication, is produced by transudation from the venous plexus surrounding
the vagina and appears seconds after the initiation of sexual excitement. No
activity by Skene’s glands was noted, and
production of cervical mucus during sexual stimulation was observed in only a
few subjects. Fluid from Bartholin’s glands
appears long after vaginal lubrication is well established; in addition, it
appears to make only a minor contribution to lubrication in the late plateau
phase. Uterine and tubal secretions do not contribute to this lubrication.
·
Vaginismus, defined as involuntary painful spasm of the pelvic muscles and
vaginal outlet. It is usually psychogenic. It should be differentiated from frigidity, which implies lack of sexual
desire, and dyspareunia,
which is defined as pelvic and/or back pain or other discomfort associated with
sexual activity.
·
Absolute contraindications to the use of birth control pills include (1) thromboembolic
disorders [deep venous thrombosis (DVT), cerebrovascular
accident (CVA), myocardial infarction (MI), or conditions predisposing to these
conditions]; (2) markedly impaired liver function; (3) known or suspected
carcinoma of the breast or other estrogen-dependent malignancies; (4)
undiagnosed abnormal genital malignancies; (5) undiagnosed abnormal genital
bleeding; (6) known or suspected bleeding; (7) known or suspected pregnancy;
(8) a history of obstructive jaundice in pregnancy; (9) congenital hyperlipidemia; and (10) obesity in women who are smokers
and over age 35. Relative contraindications to
the use of the birth control pill require clinical judgment and
informed consent. These include (1) migraine headaches; (2) hypertension; (3)
uterine leiomyomas; (4) gestational diabetes; (5)
elective surgery; and (6) seizure disorders.
·
Contraindications to the use of an IUD: (1) pregnancy; (2) pelvic inflammatory
disease—acute, chronic, or recurrent; (3) acute cervicitis;
(4) postpartum endometritis or septic abortion; (5)
undiagnosed genital bleeding; (6) gynecologic malignancy; (7) congenital
anomalies or uterine fibroids that distort the uterine cavity; and (8) copper
allergy (for IUDs that contain copper). Other conditions that might preclude
IUD insertion include (1) previous ectopic pregnancy; (2) severe cervical stenosis; (3) severe dysmenorrhea;
(4) menometrorrhagia; (5) coagulopathies;
and (6) congenital or valvular heart disease.
·
On
occasion, following correct use of a full cycle of pills, withdrawal bleeding may fail to occur (silent menses). Pregnancy
is a very unlikely explanation for this event; therefore, pills should be resumed
as usual (after 7 days) just as if bleeding had occurred. However, if a
second consecutive period has been missed, pregnancy should be more seriously
considered and ruled out by a pregnancy test, medical examination, or both.
Women occasionally forget to take pills; however, when only a single pill has
been omitted, it can be taken immediately in addition to the usual pill at the
usual time. This single-pill omission is associated with little if any loss in
effectiveness. If three or more pills are
omitted, the pill should be resumed as usual, but an additional
contraceptive method (e.g., condoms) should be used through one full cycle.
·
Recent
studies in animals have shown that pirfenidone, an antifibrotic
agent, suppresses leiomyoma growth via its potent
inhibition of fibrogenic cytokines, including basic
fibroblast growth factor, platelet-derived growth factor, transforming growth
factor-β, and EGF.
·
In preimplantation genetic diagnosis (PGD), a single cell or
polar body is biopsied from the embryo prior to embryo transfer during an IVF
cycle and subjected to genetic testing. Currently, this technique is most often
used in identifying affected embryos of single gene disorders such as Gaucher disease and cystic
fibrosis. With the results from testing, an unaffected embryo is transferred
back into the uterus. PGD serves as an alternative to chorionic villus sampling or amnio-centesis
for diagnosis and possible abortion of affected fetuses.
·
Swyer syndrome (46,XY) is characterized by a female phenotype with amenorrhea and lack of secondary sex characteristics. Growth is
usually normal, and some virilization
may occur after puberty, especially when gonadal
tumors are present. Swyer syndrome is inherited as an X-linked recessive trait. The clinical picture
without virilization and tumor propensity may also
occur in 46,XX
individuals. This condition is termed pure gonadal dysgenesis and is
an autosomal recessive inheritance.
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