TESTS FOR OVULATION

Explanation:

Endometrial biopsy

Explanation:

Ans. is a and b i.e. Laparoscopy and Observation                                                             

• Perforation of the uterus occurs in 0.63% of D and C’s done.
• Perforation should be suspected when the sound / curette meets no resistance at the point expected. Management
• Curettage can be continued if the area of suspicion can be avoided.
• In case suction curettage is being done and is associated with perforation : Laparoscopy must be used to continue the procedure to avoid aspiration of bowel into the uterine cavity.
• Unless there is evidence of haemorrhage injury to bowel or evulsion of omentum -conservative treatment of uterine perforation is the best                                                                                                                
• In hemodynamically stable patients, laparoscopy is the method of choice for evaluating perforation size and site.
• The patient should be observed for atleast 24 hours in the hospital for possible infection or hemorrhage.
• Most of the patients require only expectant treatment. Only in those who bleed internally laparotomy may be required.

Explanation:

Ans. is a i.e. Progesterone is inadequately secreted                

Luteal phase Defect is a condition when there is delay in the development of the endometrium of more than 2 days beyond the actual cycle day.

This adversely affects the endometrial receptivity to blastocyst implantation.

Etiology :

Luteal phase defect is due to inadequte progesterone production by corpus luteum. Inadequate progesterone secretion could be due to :

1. Inadequate follicular development
2. Inadequate FSH or LH secretion
3. Hyperprolactinemia

Diagnosis : The diagnosis of luteal phase defect can be done by :

• BBT Chart :

1. slow rise of temperature taking 4 – 5 days following fall in the mid cycle.
2. rise of temperature sustains less than 10 days.

• Endometrial biopsy: Biopsy done in post ovulatory period reveals endometrium at least 2 days out of phase.
• Serum progesterone° estimated on 5^th day following ovulation is less than 10 ng/ml.

Management :

• Adminstration of vaginal or intramuscular progesterone (50 – 100 mg/d) begining 3 days after documentation of an LH surge and continued till :

–  Either first day of next menstrual cycle. Or

–  If pregnancy occurs till 8-10 wks of gestation.

• In unresponsive cases, clomiphene citrate may be tried.

Explanation:

Ans. is c i.e. 20 – 22 days     

ENDOMETRIAL BIOPSY

• OPD procedure for hormonal evaluation in case of infertility / DUB/TB.
• Usually performed in pre – menstrual phase from lateral wall of vagina.
• Interpretation :

Presence of secretory endometrium Progesterone phase (cycles has been ovulatory)

Presence of proliferative endometrium  Anovulatory cycle

Luteal phase defect can also be diagnosed by endometrial biopsy (which shows a lag of 2 – 3 days between calendar and histological dating of specimen).

Endometrial biopsy is contraindicated in suspected malignancy / sepsis. 130

Test	Time	Observation
TESTS FOR DOCUMENTING OVULATION
Basal Body Temp Cervical mucus Vaginal cytology Endometrial Biopsy Serum Progesterone Follicular Monitoring Laparoscopy	Through out cycle Day 12 – 14 Day 21 – 23 Day 12 – 14 Day 21 – 23 Premenstrual phase D8 and D21 D10 – D14 Secretory phase	Biphasic pattern Cervical mucus is clear watery, stretchability present, ferning present. Cervical mucus is thick, viscid, tack present ferning absent. Estrogen dominated smears – clear. discrete corn-fined, polygonal, superficial cells (predominant cells) Progesterone dominated smear –containing dirty, predominantly intermediate (Navicular) cells. Secretory Endometrium (Confirming ovulation) D – 8 < 1 ng/ml D – 21 > 6.5 ng/m1 Follicle is measured by USG. Recent corpus luteum is directly seen

PAT TESTS FOR TUBAL ENCY : (Or for any Tubal Pathology) : viz

Insufflation test HSG Sono hystero salpingography Fallopscopy

(Mid follicular phase) Day 6 – Day 11 (not performed later so that if pregnancy has occurred & zygote formed it is not disrupted & not earlier when the patient is menstruating as retrograde menstruation can cause endometriosis)

TEST FOR CERVICAL FACTOR : viz

• Post coital test 
• Immunological tests              Done just before ovulation (as cervical mucus is most
• Miller kurzrok test                    receptive for sperm at that time).

Also know :

• Any radiological investigation in a young / reproductive age woman should be done between Day 1 to Day 10 of cycle.
• Endometrial Biopsy for diagnosis of T:B should be done in late premenstrual phase° as tubercles are present in superficial layer and shed during menstruation. The tissue obtained is subjected to polymerase chain reaction test instead of culture. 

Explanation:

Ans. is B i.e. Presence of NaCl under the estrogenic effect        

• Fern test is for documenting ovulation.
• Procedure: A specimen of cervical mucus is obtained and is spread on a clean glass slide and allowed to dry. It is then viewed under the low power microscope.
• Result and interpretation: Under the influence of estrogen on Day12-Day 14 cervical mucus shows a characteristic pattern of fern formation. The ferning is due to the presence of sodium chloride in the mucus secreted under the estrogen effect.
• After ovulation on Day 21-23, ferning disappears because protein content increases and Sodium chloride decreases under the effect of progesterone.
• The disappearance of ferning after ovulation and if previously present its disappearance is presumptive evidence of corpus luteum activity.
• Cervical mucus will show a palm leaf pattern due to Estrogen.
• Spinnbarkeit of cervical mucus in a woman is maximum at the ovulatory phase.
• Spinnbarkeit is demonstrated in the Proliferative phase.

Explanation:

Estrogen

Explanation:

Ans. is a i.e MDPA

Synthetic progesterones :

Progesterone derivatives

have weak antiovulatory actions.

except – Chlormadione acetate

eg : MDPA, Mesogestrol, Dydrogesterone, Hydroxy progesterone caproate, Nomegesterel

19 Nortestosterone derivatives

have strong antiovulatory actions

eg- Desogestrel, Norgestimate, Gestodene, Norethindrone, Norethisterone Norgesterel

In the question the infertile woman’s endometrial biopsy shows proliferative changes. As we know endometrial biopsy for infertility is taken on D 21-23 with the aim to rule out anovulation. Normally on these days endometrial biopsy should show secretory changes (as ovulation occurs on D-14 and subsequent there is increase in progesterone levels in body) But in case of anovulation endometrial biopsy does not show secretory changes but show proliferative changes.

The hormone which should be administered here is obviously progesterone. but that derivative of progesterone which has weak antiovulatory effect and not strong one as it would further inhibit anovulation

So, our answer is MDPA

Explanation:

LH surge REF: Ganong WF: Review of Medical Physiology, 22nd ed (chapter 23) Figure 6-10, William’s obstetrics 22″^d edition Figure 3-1.

“The onset of the gonadotropin surge resulting from increasing secretion of estrogen by preovulatory follicles is a relatively precise predictor of the time of ovulation, occurring some 34 to 36 hours before the release of the ovum from the follicle. The peak of LH secretion occurs 10 to 12 hours before ovulation and stimulates the resumption of the meiosis process in the ovum with the release of the first polar body”

Explanation:Endometrial biopsy REF: Novak’s gynecology 13 th edition p. 453

The importance of the endometrial biopsy cannot be overemphasized for the pre- or postmenopausal woman with abnormal uterine bleeding. It is well accepted that endometrial biopsy performed in the office is just as accurate as dilation and curettage and certainly more economical

Explanation:

Ans is C. i.e. Hysteroscopy 

METHODS TO DOCUMENT OVULATION:

• Luteinizing Hormone Monitoring Documentation of the LH surge represents a remarkably reproducible method of predicting ovulation. 
• Ovulation occurs 34 to 36 hours after the onset of the LH surge and about 10 to 12 hours after the LH peak.
• Basal Body Temperature The least expensive method of confirming ovulation is for the patient to record her temperature each morning on a basal body temperature (BBT) chart.
• Midluteal Serum Progesterone
• Ultrasound Monitoring Ovulation can also be documented by monitoring the development of a dominant follicle by ultrasound until ovulation takes place.
• A ferning pattern is seen when periovulatory cervical mucus is spread and dried on a microscope slide.

Explanation:

The uterus is a hollow, muscular organ that lies between the bladder and the rectum in the true pelvis.

The uterus can be divided into three major segments: the uterine fundus, the uterine corpus (or body), and the cervix.

The fallopian tubes enter the uterine fundus laterally in the region called the cornua.

Moving from the inside (or hollow) portion of the uterus to the peritoneal cavity, the layers that would be penetrated are the endometrium, the myometrium, and the serosa.

Explanation:

The finding of secretory endometrium confirms ovulation.

The use of an endometrial biopsy (EMB) near the end of the luteal phase can provide reassurance of an adequate maturational effect on the endometrial lining.

Within 48 hours of ovulation, the cervical mucus changes under the influence of progesterone to become thick, tacky, and cellular, with loss of the crystalline fernlike pattern on drying.

 

Explanation:

The best method of assessment of female fertility that allows accurate prediction of ovulation is the measurement of urinary LH surge (Hormonal Test).

 

Explanation:

Methods to document ovulation:

• Luteinizing Hormone Monitoring Documentation of the LH surge represents a remarkable reproducible method of predicting ovulation. Ovulation occurs 34 to 36 hours after the onsof the LH surge and about 10 to 12 hours after the LH peak.
• Basal Body Temperature
• Midluteal Serum Progesterone
• Ultrasound Monitoring Ovulation
• A ferning pattern is seen when periovulatory cervical mucus is spread and dried on a microscope slide.

Explanation:

 

Explanation:

Explanation:

Explanation:

The endometrial biopsy is done just prior to the expected menstrual period, when the uterine lining is at its thickest. Indications for doing endometrial biopsy are chronic anovulation, abnormal vaginal bleeding, suspected uterine cancer, and infertility. Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy.

Explanation:

D i.e. Progesterone

Progesterone is thermogenic & responsible for the rise in basal body temperatureQ at the time of ovulation

• Increase in basal body temperature at the time ovulation in reliable indicator of time of ovulation The rise starts 1-2 days after ovulation
• Other indicators of ovulation

– Secretory patternQ on biopsy of endometrium

– Thick cervical mucus that forms a fern pattern

Explanation:

Ans. B i.e. Urine FSH

Physiology

• The best predictor of ovulation: Pre-ovulatory rise in LH
• In the normal menstrual cycle, progesterone is secreted by Corpus luteum
• Inhibin is secreted by Graffian follicle
• LH precedes ovulation by 24 hours (Ovulation coincides with LH surge)
• Ovulatory period: Corresponds to 14 days before next menstruation
• FSH stimulates: Growth of granulosa cells (a measure of ovarian reserve)
• LH stimulates Follicle rupture and ovulation.