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Questions and Answers
Which hormone is primarily associated with the proliferative phase of the menstrual cycle?
Which hormone is primarily associated with the proliferative phase of the menstrual cycle?
The presence of subnuclear vacuoles is a marker of the early secretory phase.
The presence of subnuclear vacuoles is a marker of the early secretory phase.
True
What type of tumor arises from the myometrium and is dependent on estrogen and progesterone?
What type of tumor arises from the myometrium and is dependent on estrogen and progesterone?
Fibroid
In Turner's syndrome, the ovaries are often described as _____.
In Turner's syndrome, the ovaries are often described as _____.
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Match the following menstrual phases with their associated characteristics:
Match the following menstrual phases with their associated characteristics:
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Which hormone is produced by granulosa cells that exerts negative feedback on FSH?
Which hormone is produced by granulosa cells that exerts negative feedback on FSH?
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AMH can only be measured on days 2-3 of the menstrual cycle.
AMH can only be measured on days 2-3 of the menstrual cycle.
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What FSH level is considered diagnostic of premature ovarian insufficiency (POI)?
What FSH level is considered diagnostic of premature ovarian insufficiency (POI)?
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Granulosa cells produce __________ and inhibin B.
Granulosa cells produce __________ and inhibin B.
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What is the main drawback of the Antral Follicle Count (AFC) test?
What is the main drawback of the Antral Follicle Count (AFC) test?
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Match the hormone or test to its function or interpretation:
Match the hormone or test to its function or interpretation:
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Ovarian reserve tests are always performed while patients are undergoing IVF treatment.
Ovarian reserve tests are always performed while patients are undergoing IVF treatment.
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What is suggestive of premature ovarian insufficiency (POI) based on FSH levels?
What is suggestive of premature ovarian insufficiency (POI) based on FSH levels?
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What is the gold standard test for assessing tubal patency?
What is the gold standard test for assessing tubal patency?
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Hysterosalpingography (HSG) provides a complete visual of the exterior of the fallopian tubes.
Hysterosalpingography (HSG) provides a complete visual of the exterior of the fallopian tubes.
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What are the two types of dye used in laparoscopic chromopertubation?
What are the two types of dye used in laparoscopic chromopertubation?
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The procedure of hysterosalpingography (HSG) is performed during days _____ of the menstrual cycle.
The procedure of hysterosalpingography (HSG) is performed during days _____ of the menstrual cycle.
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Match the following terms with their descriptions:
Match the following terms with their descriptions:
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What is the most common type of fibroid associated with uterine causes of infertility?
What is the most common type of fibroid associated with uterine causes of infertility?
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Cervical stenosis can lead to infertility.
Cervical stenosis can lead to infertility.
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What is the gold standard investigation method for assessing uterine causes of infertility?
What is the gold standard investigation method for assessing uterine causes of infertility?
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The permanent method of tubal ligation is classified as __________.
The permanent method of tubal ligation is classified as __________.
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Match the following uterine conditions with their management:
Match the following uterine conditions with their management:
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What does an AMH level of 1-3 ng indicate?
What does an AMH level of 1-3 ng indicate?
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An AMH level below 1 ng is considered normal.
An AMH level below 1 ng is considered normal.
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What is the normal range for AMH levels in ng?
What is the normal range for AMH levels in ng?
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An AMH level between 1-3 ng is indicative of _____ fertility.
An AMH level between 1-3 ng is indicative of _____ fertility.
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Match the following AMH levels with their corresponding inference:
Match the following AMH levels with their corresponding inference:
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What is indicated by a biphasic temperature chart during the menstrual cycle?
What is indicated by a biphasic temperature chart during the menstrual cycle?
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Cervical mucus during an ovulatory cycle is characterized by thick, scanty, viscous mucus.
Cervical mucus during an ovulatory cycle is characterized by thick, scanty, viscous mucus.
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What hormonal predominance is observed in anovulatory cervical mucus?
What hormonal predominance is observed in anovulatory cervical mucus?
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The study of vaginal epithelial cells for ovulation assessment involves observing eosinophilic superficial cells, which indicate _____ predominance.
The study of vaginal epithelial cells for ovulation assessment involves observing eosinophilic superficial cells, which indicate _____ predominance.
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Match the following cell types with their corresponding characteristics during hormonal phases:
Match the following cell types with their corresponding characteristics during hormonal phases:
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What is the most common cause of female infertility?
What is the most common cause of female infertility?
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Anovulation is the most difficult form of ovarian infertility to treat.
Anovulation is the most difficult form of ovarian infertility to treat.
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What syndrome is an example of Class 1 hypogonadotropic hypogonadism?
What syndrome is an example of Class 1 hypogonadotropic hypogonadism?
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The condition characterized by heavy menstrual bleeding during anovulatory cycles is referred to as __________.
The condition characterized by heavy menstrual bleeding during anovulatory cycles is referred to as __________.
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Match the following ovarian classifications with their characteristics:
Match the following ovarian classifications with their characteristics:
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What is the maximum Karyopyknotic Index observed during?
What is the maximum Karyopyknotic Index observed during?
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An endometrial biopsy is performed during the follicular phase of the menstrual cycle.
An endometrial biopsy is performed during the follicular phase of the menstrual cycle.
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What changes occur in the glands during the secretory phase of the menstrual cycle?
What changes occur in the glands during the secretory phase of the menstrual cycle?
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The presence of _____ cells predominates in a non-ovulatory state.
The presence of _____ cells predominates in a non-ovulatory state.
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Match the following gland types with their characteristics:
Match the following gland types with their characteristics:
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What is the primary drawback of testing for the urinary LH surge for predicting ovulation?
What is the primary drawback of testing for the urinary LH surge for predicting ovulation?
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Follicular monitoring is commonly conducted from day 10 on alternate days until ovulation is confirmed.
Follicular monitoring is commonly conducted from day 10 on alternate days until ovulation is confirmed.
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What is the drug of choice for managing anovulation due to PCOS?
What is the drug of choice for managing anovulation due to PCOS?
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A serum progesterone level of _____ ng/mL or higher indicates successful ovulation.
A serum progesterone level of _____ ng/mL or higher indicates successful ovulation.
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Match the following tests or signs with their respective descriptions:
Match the following tests or signs with their respective descriptions:
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What is the most common cause of B/L proximal/cornual block?
What is the most common cause of B/L proximal/cornual block?
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Laparoscopic chromopertubation is the next step for managing B/L fimbrial block.
Laparoscopic chromopertubation is the next step for managing B/L fimbrial block.
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What is the management of choice for tubal infertility?
What is the management of choice for tubal infertility?
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The collection of secretions in the fallopian tube is known as _____
The collection of secretions in the fallopian tube is known as _____
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Match the steps involved in B/L proximal/cornual block management:
Match the steps involved in B/L proximal/cornual block management:
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Study Notes
Ovarian Function and Feedback Mechanisms
- Granulosa cells produce inhibin B and estrogen, which exert negative feedback on FSH.
- AMH (Anti-Müllerian Hormone) is also produced by granulosa cells from menarche to puberty.
- Theca cells produce androgen.
Tests for Ovarian Reserve
- Tests are performed on days 2-3 of a menstrual cycle.
- Inhibin B levels below 45 pg suggest low ovarian reserve.
- FSH levels are measured to determine ovarian reserve.
- Normal: 2-10 IU
- Suggestive of POI: 10-15 IU
- Diagnostic of POI: > 25 IU
- Ovarian reserve is diagnosed by considering both inhibin and FSH levels.
Antral Follicle Count (AFC)
- The AFC test is done on days 2-3 of the menstrual cycle.
- The number of antral follicles (2-9 mm) in both ovaries is counted using transvaginal ultrasound (TVS).
- A count less than 10 is suggestive of POI.
Anti-Müllerian Hormone (AMH)
- This test can be performed on any day of the cycle.
- AMH is measured using a blood test.
- AMH is a glycoprotein hormone released primarily by pre-antral follicles.
- AMH is considered the best test for determining ovarian reserve.
Hormones In Gynaecology
- Fibroids are tumors arising from the myometrium and are estrogen and progesterone-dependent.
- Diagram 1 shows a proliferative phase characterized by estrogen dominance, depicted as a circular structure in the uterine lining.
- Diagram 2 shows non-functional streak ovaries in Turner's Syndrome, which suggests a hormonal imbalance related to the lack of ovarian function.
- Diagram 3 shows the early secretory phase with a complex structure, indicating progesterone dominance.
- Diagram 4 demonstrates the early secretory phase with subnuclear vacuoles, a key marker of this phase.
Tubal Causes of Infertility
- PID
- Salpingitis
- Endometriosis
Tests for Tubal Patency
-
HSG (Hysterosalpingography)
- A 10C radiopaque dye is injected into the uterus.
- Serial X-rays are taken to assess dye spillage.
- Day 7-10 of the cycle is the time for HSG.
- Drawbacks: The exterior of the tube is not visible and the procedure can be painful, which can lead to false-positive results.
-
Laparoscopic Chromopertubation
- This is the gold standard.
- Methylene blue or Indigo Carmine dye is used.
- A laparoscope is inserted, and dye is passed through the cannula.
- Direct visualization of dye spillage is possible.
- Advantage: Exterior of the tubes can be visualized.
Basic Investigations for Infertility
- Females: HSG + ovulation tests
- Males: Sperm analysis
- Females > 35 years: Tests for ovarian reserve
Female Infertility Causes
- Ovarian cause (20-40%): Most common cause
- Tubal cause: Second most common cause
- Uterine cause: Submucous fibroid, endometrial polyp, Asherman Syndrome
- Cervical & unexplained causes: Anti-sperm antibodies, cervicitis
Classification of Ovarian Causes (WHO)
- Class 1: Hypogonadotropic hypogonadism (eg: Kallmann syndrome) with low FSH and estrogen levels.
- Class 2: Normogonadotropic normogonadism (eg: PCOS Anovulation) with normal FSH and estrogen levels.
- Class 3: Hypergonadotropic hypogonadism (eg: Primary ovarian insufficiency (POI)/Premature menopause) with high FSH and estrogen levels.
- Hyperprolactinemia: Not classified, it's a separate cause.
Class 1 - Kallmann Syndrome
- Management: Pulsatile GNRH.
Class II - Anovulation
- Most common cause of ovarian infertility.
- Most easily treatable form of infertility.
- Anovulatory cycles: Irregular cycles, estrogen breakthrough bleeding, painless.
- Heavy menstrual bleeding.
Mid Segmental Block
- Block in the middle part/isthmus of the fallopian tube.
- Site of tubal ligation.
- Recanalization (reversal) is possible in exceptional circumstances.
- Success of reversal depends on age of female (<35 years), type of anastomosis, length of tube after reconstruction (>4 cm), and type of procedure done for tubal ligation.
Uterine & Cervical Causes
-
Uterine Causes
- Fibroid, mostly submucous fibroid managed by myomectomy.
- Endometrial polyps.
- Asherman syndrome.
- Chronic endometritis due to chlamydia.
- Diethylstilbestrol (DES) exposure in utero resulting in T-shaped/Hypoplastic uterus.
- Mullerian malformation leads to recurrent pregnancy loss, not infertility.
- Septate uterus may lead to infertility.
- Investigation for Uterine Causes: USG and Hysteroscopy (gold standard).
- Cervical Causes: Cervicitis and Cervical stenosis.
Antisperm Antibodies in Females
- Spermicidal leading to infertility.
- AKA Immunological cause of infertility.
- Coincidental finding: Mullerian malformation.
Tests for Ovulation
- History: Retrospective test based on regular cycles and dysmenorrhea.
-
Progesterone: Done on Day 21 of the cycle.
- Basal Body Temperature (BBT): Progesterone is thermogenic. Increase in BBT by 0.5° to 0.8°F. Biphasic temperature chart indicates ovulation occurred.
-
Cervical Mucus Study:
- Anovulatory cycle: Profuse, watery, elastic mucus, spinnbarkeit phenomenon (stretchability), Fern-like appearance under microscope.
- Ovulatory cycle: Thick, scanty, viscous mucus, no stretching, no ferning.
-
Vaginal Epithelial Cell Study:
- Specimen: Lateral wall of vagina.
- Observation of cells under microscope.
- Estrogen Predominance: Eosinophilic superficial cells.
- Ovulation +: Basophilic-Intermediate cells.
- No Hormonal Predominance: Parabasal cells: blurred margins with large nucleus.
Tubal Block
-
B/L Proximal/Cornual Block:
- Cause: Physiological spasm is the most common cause.
- Next Step: Hysteroscopic cannulation (pass guide wire through the uterus into the fallopian tube under hysteroscopic guidance). This helps release the cornual spasm, dislodge mucus plug, and prepare for laparoscopic chromopertubation.
- Possible Causes: Physiological spasm, Genital TB (most common pathological cause).
-
B/L Fimbrial Block:
- Cause: Mild or severe disease.
-
Next Step: Laparoscopic chromopertubation to confirm diagnosis and assess the extent of disease.
- Mild disease: Fimbrioplasty (small nicks in fimbrial ends to open fimbria).
- Severe disease: Hydrosalpinx (IVF).
- Possible Causes: Hydrosalpinx (collection of secretions in the fallopian tube, fluid is fetotoxic).
Management of Tubal Infertility
- Management of choice: IVF (In Vitro Fertilization).
-
Hydrosalpinx management:
- Collection of secretions in fallopian tube, fluid is fetotoxic.
- Management: Clip at the proximal end of the fallopian tube OR salpingectomy (removal of the fallopian tube) followed by IVF.
Tests Which Predict Ovulation
-
Urinary LH Surge:
- Occurs 24 hours before ovulation.
- Tested with kits.
- Serum LH surge happens 36 hours before ovulation.
- Drawbacks: Doesn't confirm ovulation, LH surge doesn't guarantee ovulation. LH levels are constantly elevated in PCOS, so the test cannot be performed.
-
Follicular Monitoring:
- Most common test done.
- Performed from Day 10 on alternate days.
- Studied by transvaginal sonography (TVS).
- Follicle size increases by 2 mm/day up to 18-20 mm, then it decreases and becomes irregular.
Signs of Ovulation
- Decrease in follicle size.
- Irregular follicle.
- Fluid in the Pouch of Douglas due to antral follicle rupture.
- USG: Triple layered/Trilaminar endometrium seen in late proliferative → Ovulatory phase.
Management of Ovulation Issues
-
Ovulation-inducing drugs:
- DOC for Anovulation: Clomiphene citrate.
- Anovulation due to PCOS: Letrozole > Clomiphene citrate.
Additional Information
- Genital TB Diagnosis: Histopathology, Formalin, Acid-fast bacilli, NS.
- Serum Progesterone Levels: Simple, easy, cheapest test. ≥3 ng/mL → Ovulation +; Max: 15 ng/mL (6–8 days after ovulation).
- Sample Collection: AUB (abnormal uterine bleeding).
Maturation Index
- Counting 100 cells.
- A/B/C = No. of parabasal cells/No. of intermediate cells/No. of superficial cells
Ovulation
- Example: 0/10/90 (B predominates)
Karyopyknotic Index
- Number of superficial cells vs intermediate and parabasal cells.
- Maximum during ovulation.
- Depends on estrogen levels.
Endometrial Biopsy
- Done on day 26 of the cycle, in the premenstrual phase.
Non-Ovulation
- Example: 0/40/60 (C predominates)
Gland Types
- Single tubular glands: Due to estrogen.
- Corkscrew/Saw-tooth glands: Filled with secretion, due to progesterone.
- Proliferative phase: Low Ovulation.
- Secretory phase: Ovulation +.
Luteal Phase Defect
- Difference of ≥2 days between history and biopsy.
- Low Progesterone.
- High chance of abortion during pregnancy.
Inference Based on AMH Levels
- 1-3 ng: Normal
- <1 ng: Diminished ovarian reserve
-
3 ng: Uncertain (may be elevated due to polycystic ovaries)
Contraception
- Tubal ligation is a permanent/irreversible method of contraception.
- Tubal ligation can be reversed in exceptional circumstances.
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Description
This quiz covers key concepts related to ovarian function, including the role of granulosa and theca cells, feedback mechanisms, and ovarian reserve tests. It also discusses the importance of inhibin B, FSH levels, antral follicle count, and anti-Müllerian hormone in assessing female reproductive health.
