Endocrine Infertility Case Study
Endocrine infertility – a complex of hormonal disorders leading to irregular ovulation or its absence in women and impaired sperm quality in men. It can be based on disorders of the thyroid gland, gonads, hypothalamic-pituitary regulation. Treatment of endocrine infertility is to eliminate its cause, correct existing disorders and maintain a normal hormonal background. Normalization of impaired functions leads to the onset of pregnancy in 70-80% of cases of endocrine infertility. In other cases, at present, elimination of endocrine infertility by the method of IVF is considered promising.
- Causes of endocrine infertility
- Symptoms of endocrine infertility
- Diagnosis of endocrine infertility
- Treatment of endocrine infertility
- Prognosis for endocrine infertility
- Prophylaxis of endocrine infertility
- Treatment prices
Endocrine infertility – a complex of hormonal disorders leading to irregular ovulation or its absence in women and impaired sperm quality in men. It can be based on disorders of the thyroid gland, gonads, hypothalamic-pituitary regulation. Normalization of impaired functions leads to the onset of pregnancy in 70-80% of cases of endocrine infertility. In other cases, at present, elimination of endocrine infertility by the method of IVF is considered promising. In every third infertile woman, the cause of infertility lies in the pathology of the endocrine system.
The concept of “endocrine infertility” is a collective, including various violations of the mechanisms of hormonal regulation of the menstrual cycle: on the hypothalamic-pituitary-ovarian level, in the systems of the thyroglobulin-thyroid gland, ACTH-adrenocortical cortex, etc. Regardless of the causes of endocrine infertility abnormal ovarian function, manifested by persistent anovulation (absence of ovulation) or its irregularity.
Causes of endocrine infertility
Anovulation can occur with the interest of the central nervous and immune systems, endocrine glands, reproductive organs-targets. Anovulation leading to endocrine infertility can develop as a result of:
It is usually observed after traumatic brain injuries and chest injuries, with tumors of the hypothalamic-pituitary region and is accompanied by hyperprolactinemia . Increased secretion of prolactin leads to inhibition of cyclic production of LH and FSH by the pituitary gland, oppression of ovarian functions, rare menstruation (by the type of oligo and opsoniformes ), the development of persistent anovulation and endocrine infertility.
Hyperandrogenia of ovarian or adrenal origin
The presence in the body of a woman a small amount of androgens – male sex hormones is necessary for puberty and the proper functioning of the ovaries. The increased secretion of androgens can be carried out by the ovaries or adrenals, and sometimes by both glands simultaneously. Most often, hyperandrogenia in women is accompanied by a syndrome of polycystic ovaries , causing endocrine infertility, obesity , hirsutism , bleeding , oligo- and amenorrhea, bilateral ovarian damage with a change in their morphological structure.
Adrenal hyperandrogenism often develops as a result of hyperplasia of the adrenal cortex with secondary involvement of the ovaries (secondary polycystic ovary).
The course of hypothyroidism and diffuse toxic goiter is often accompanied by anovulation, secondary hyperprolactinemia, endocrine infertility, miscarriage, fetal abnormalities.
Deficiency of estrogens and progesterone (in case of luteal phase insufficiency)
The lack of female sex hormones causes inferior secretory transformation of the endometrium, changes in the function of the fallopian tubes, prevents the attachment of the fetal egg in the uterine cavity. This leads to miscarriage or endocrine infertility.
Severe somatic pathologies ( cirrhosis , hepatitis with severe damage to liver cells, tuberculosis , autoimmune and systemic connective tissue diseases, malignant tumors of various locations, etc.).
Obesity or lack of adipose tissue
Fat tissue in the body also performs endocrine function, affecting the metabolic processes in the tissues, including the reproductive system. Excess fatty deposits cause hormonal imbalance, a violation of menstrual function and the development of endocrine infertility. At the same time, limiting the consumption of fat or a sharp loss of body weight disrupt the normal functioning of the ovaries.
Syndrome of resistant ovaries (Savage syndrome)
At the heart of the syndrome is the violation of the pituitary-ovarian communication – insensitivity of the ovarian receptor to gonadotropins, stimulating ovulation, which is manifested by amenorrhea, endocrine infertility with normally developed sexual characteristics and a high level of gonadotropic hormones. Damage to the ovaries can cause infection with rubella viruses, influenza , pathology of a previously developing pregnancy, vitamin deficiency, starvation, stressful situations.
Premature menopause (syndrome of exhausted ovaries)
Secondary amenorrhea , which occurs in young women up to 35 – 38 years, causes changes in the climacteric syndrome and leads to endocrine infertility.
Diseases associated with mutations of sex chromosomes
In diseases caused by chromosomal abnormalities, there is a lack of female sex hormones, sexual infantilism, primary amenorrhea and endocrine infertility ( Marfan and Turner syndromes ).
Symptoms of endocrine infertility
The main manifestations of endocrine infertility are the impossibility of pregnancy and abnormalities in the menstrual cycle. Menstruation can occur with delays of varying severity (from a week to six months), accompanied by soreness and abundant secretions or absent altogether ( amenorrhea ). Often there are spotting spotting in the intermenstrual period.
In 30% of patients with endocrine infertility, menstrual cycles are of anovulatory nature and in their duration correspond to the normal menstrual cycle (21-36 days). In such cases, it is not about menstruation, but about menstrual bleeding.
Patients have pain in the lower abdomen or lower back, discharge from the genital tract, dyspareunia , cystitis . There may be tension and heaviness in the mammary glands, galactorrhea (discharge of colostrum from the nipples) associated with an increase in the level of prolactin. The syndrome of premenstrual tension is characterized by deterioration of the condition on the eve of menstruation. With hyperandrogenia, accompanying endocrine infertility, acne , hirsutism or hypertrichosis , alopecia develop. There are fluctuations in blood pressure, the development of obesity or weight loss, the formation of striae on the skin.
Diagnosis of endocrine infertility
When collecting anamnesis in patients with endocrine infertility, the time of the onset of menstruation, their profuse, painfulness, the presence of menstrual irregularities in the history (including the mother’s patient), the presence and duration of the absence of pregnancies, and the presence and outcome of complications of pregnancies are specified . It is necessary to find out whether earlier gynecological operations and manipulations, type and duration of contraceptive use have been carried out.
The general examination includes an evaluation of the patient’s growth (less than 150 cm or more than 180 cm), the presence of obesity, virilism, development of the mammary glands and secondary sexual characteristics. A gynecologist is consulted , during which the shape and length of the vagina and the uterus, the condition of the cervix, the parameter and appendages are determined by gynecological examination. According to the data of general and gynecological examinations, such causes of endocrine infertility as sexual infantilism, polycystic ovary, etc. are elucidated. Estimation of hormonal function of ovaries and the presence of ovulation with endocrine infertility are determined using functional tests: the construction and analysis of the basal temperature curve, urinary ovulation test, ultrasound Monitoring the maturation of the follicle and controlling ovulation .
According to the basal temperature chart, the presence or absence of ovulation is determined. The basal temperature curve reflects the level of postovulatory ovarian development of progesterone, which prepares the endometrium of the uterus for the implantation of a fertilized egg. The basal curve is based on the parameters of the morning temperature, measured daily at the same time in the rectum. In the ovulatory cycle, the temperature profile is biphasic: on the day of ovulation the rectal temperature drops by 0.2-0.3 ° C, and in the second phase of the cycle, lasting from 12 to 14 days, rises in comparison with the temperature of the first phase by 0.5-0 , 6 ° C. The anovulatory menstrual cycle is characterized by a monophasic temperature curve (steadily below 37 ° C), and the luteal phase deficiency is manifested by shortening the second phase of the cycle for less than 11-12 days.
Confirm or disprove the fact of ovulation is possible by determining the level of progesterone in the blood and pregnaniol in the urine. In the anovulatory cycle, these parameters are extremely low in the second phase, and in the case of an insufficient luteal phase, they are reduced in comparison with the ovulatory menstrual cycle. Conducting the test for ovulation allows to determine the increase in the concentration of LH in urine 24 hours before the ovulation. Ultrasonic monitoring of folliculogenesis makes it possible to trace the maturation in the ovary of the dominant follicle and the release of the egg from it.
The state of the endometrium of the uterus serves as a reflection of the functioning of the ovaries. In scraping or a biopsy of the endometrium , taken 2-3 days before the expected menstruation, with anovulation and endocrine infertility, hyperplasia of varying severity (glandular-cystic, glandular , polyposis, adenomatosis) or secretory insufficiency is found.
To determine the causes of endocrine infertility, levels of FSH , estradiol , LH , prolactin , TSH , testosterone , T3 , T4 , DEA-C (dehydroepiandrosterone sulfate) are determined on the 5th-7th day for several menstrual cycles. Conducting hormonal samples allows you to clarify the state of the various links of the reproductive system with endocrine infertility. The mechanism for carrying out these samples is to measure the level of the patient’s own hormones after taking certain stimulating hormonal drugs.
If it is necessary to clarify the causes of endocrine infertility, an x-ray of the skull , ultrasound of the thyroid gland , ovaries, adrenals , diagnostic laparoscopy is performed. The diagnosis of endocrine infertility is established only after the male factor of infertility has been eliminated (normal spermogram is present), as well as pathologies from the uterus, immunological and tubal forms of infertility.
Treatment of endocrine infertility
The first stage of treatment of endocrine infertility includes normalization of impaired functions of the endocrine glands (correction of diabetes mellitus, obesity, adrenal activity, thyroid gland, removal of tumors, etc.). In the future, hormonal stimulation of the maturation of the dominant follicle and ovulation is carried out. To stimulate ovulation, a drug called clomiphene citrate is prescribed, which causes an increase in pituitary glandular follicle-stimulating hormone. Of pregnancies that occurred after stimulation with clomiphene citrate, 10% are multiply (more often twins and triplets).
In the absence of pregnancy, during 6 ovulatory cycles, clomiphene citrate is used to treat gonadotropins: CHMG (human menopausal gonadotropin), p-FSH (recombinant follicle stimulating hormone), and hCG (human chorionic gonadotropin). Treatment with gonadotropins increases the incidence of multiple pregnancy and the development of side effects.
In most cases, endocrine infertility is amenable to hormonal correction, while others show surgical intervention. In the syndrome of polycystic ovaries resort to their wedge-shaped resection with laparoscopic method or laparoscopic thermal cauterization. After the laparoscopic thermal cauterization, the highest percentage of pregnancies is observed – from 80 to 90% of cases, because the formation of adhesions in the small pelvis is excluded.
In endocrine infertility, burdened with a tubal peritoneal factor or a decrease in sperm fertility, an in vitro fertilization (IVF) method is performed with transplantation of embryos ready for development into the uterine cavity. Achieve the onset and bearing of pregnancy in women with endocrine infertility is possible only with a comprehensive solution to this problem.
Prognosis for endocrine infertility
Today, endocrine infertility is not a verdict. Up-to-date gynecology and endocrinology together successfully cure 80% of patients, using only medical methods. If there is a recovery of ovulation and there are no other factors of infertility, more than 50% of women become pregnant during the first six cycles of stimulating hormone therapy. Less favorable results from drug therapy for endocrine infertility, caused by dysfunction of hypothalamic-pituitary regulation.
Immediately after the onset of pregnancy, careful monitoring of its development is established, hospitalization of the patient is performed with signs of spontaneous abortion . Often discoordination and weakness of labor are noted.
Prophylaxis of endocrine infertility
Care for the prevention of endocrine forms of infertility is necessary from childhood. Reduction and prevention of childhood infections, chronic tonsillitis, rheumatism , influenza, toxoplasmosis in childhood and adolescence will avoid violations of ovarian function and processes of hypothalamic-pituitary regulation.
Preventive value has the correct emotional and physical education of girls, because the function of the ovaries often suffers from mental overstrain, psychological and sexual trauma. It is undeniable that often endocrine infertility develops after pathological birth, interruption of pregnancy , intoxication, inflammatory infections of the female reproductive sphere, therefore attention should be paid to the prevention of these conditions.
Proper management of pregnancy , the wise use of certain medicines, especially hormones during pregnancy, will help to avoid congenital hypofunction of the ovaries and hyperplasia of the adrenal cortex in girls.