2. WHO
CLASSIFICATION
CLASS 1 Hypothalamic Failure
(Kallman Syndrome)
CLASS 2 Hypthalamic Pitutary Ovarian Axis
Dysfunction (PCOS)
CLASS 3 Ovarian Factors
1.Anovulation/Oligoovulation
2.Decreased Ovarian Reserve
3.Luteal Phase Defect
4.Lutenized Unruptured Follicle
3. Kallman Syndrome
• Defect in neuronal migration of neutrons
synthesising GnRH from olfactory placode
• Defect in kal1 gene
• Amenorrhoea
• Anosmia
• Infertility
• Delayed Puberty
4. Luteal Phase Defect
Inadequate growth and function of corpus luteum
Inadequate progesterone secretion
Inadequate secretory changes in endometrium which hamper
implantation
Causes of LPD
• Drug induced ovulation,
• Decreased FSH/LH
• Elevated Prolactin,
• Subclinical Hypothyroidism
• Older women,
5. Diagnosis of anovulation
• Indirect
1. Menstrual History
2. Evaluation of peripheral and end organ
changes
3. Sonography(TVS)
• Direct-Laproscopy
• Conclusive-Pregnancy
6.
7. Management of Anovulation
First line drugs-Letrozole,Clomifene Citrate
Second Line Drugs-Human Menopausal
Gonadotropin(Synthetic LH+FSH)
Second Line Treatment-Laproscopic Ovarian
Drilling
Third Line-Synthetic GnRH(Pulsatile Manner)
8. • General measures-
1. Couple counselling
2. Reduction of body weight
3. Quit smoking and alcohol
4. Rule out coital problems
• Letrozole-Drug of choice for ovulation induction
• Aromatase inhibitor-Inhibits conversion of Androgen into
Estrogen
• If female has Insulin Resistance-Ovulation Inducind
drugs+Metformin
• If increase Prolactin-OID+Bromicriptine
9. Ovulation Induction
Clomifene Citrate
Decrease Estrogen
Cervix mucous
Thick and viscous
Negative Feedback
to FSH gone
Difficult for sperms to
ascend
Increase FSH
Endometrium
thin
Unsuitable for
implantation
Stimulate growth
of follicles
10. Follicular Monitoring
After giving the patient ovulation inducing drugs
Call the patient to do follicular monitoring form day 10
When size of atleast 1 follicle becomes 18 micrometer
Endometrial Thickness more than 8 mm
Estrogen levels 450-100pg/ml
Give Injection hcg
Acts as ovulation trigger
11. Ovulation Hyperstimulation
Syndrome(OHSS)
• Hcg can also trigger OHSS only when Estrogen levels are very
high(>6000pg/ml-38%chaces)
High levels of Estrogen
Ascitis
Pleural Effusion
Increase VEGF
Capillaries become leaky
Hemoconccentration Accumulation of
fluid in third space
Ascitis
Pleural Effusion
Pericardial Effusion
Increase Renin and
Prorenin
Electrolyte
Imbalance
12. Grades of OHSS
1-Abdominal Distension
2-Abdominal
Distension+Nausea/Vomiting/Diarrhoea
3-USG evidence of ascitis
4-Clinical evidence of Ascitis/Hydrothorax
5-Grade4+Hemoconcentration,Coagulation
abnormalities,decrease renal perfusion
13. Prevention of OHSS
1.Delay hcg injection
2.Withhold hcg injection if Estrogen>5000pg/dl or
If more than 13 follicles seen
3.Reduce the dose of hcg
4.Stop the cycle if in grade 3,4,5
5.Give Cabergolin(decreases VEGF)
