ASSESSMENT OF OVARIAN RESERVE. Ovarian reserve is defined as the pool of ovarian follicles that can be stimulated to produce oocytes to achieve conception. Ovarian reserve tests are divided into. 1 ) Clinical markers : age,menstrual pattern and previous cancelled cycle. 2 ) Endocrine static markers.: FSH,LH,E2,PROGESTERONE( P4 ),FSH /LH RATIO P4/E2 RATIO.,AMH,TESTOSTERONE,VASCULAR ENDOTHELIAL GROWTH FACTOR,INSULIN GROWTH FACTOR - 1. 3 ) Endocrine dynamic tests.CCST,GAST,EFORT.@ 4 )Ultrasound markers.o Varian volume,ovarian follicular vascularity and ovarian blood flow. 5 ) Histology. Ovarian biopsy. CLINICAL MARKERS 1) Age. 2) Menstrual pattern. 3) Previous failed cycle. AGE : Natural fecundity and pregnancy rates decline as age of women advances.This is due to decrease in quality and quantity of ovarian follicles. MENSTRUAL CYCLE. Menstrual cycle length is dependent on the duration of follicular phase.Shortened cycle length is associated with decreased ovarian reserve. PREVIOUS FAILED CYCLE. Previous cancelled cycle is linked to cancellation in subsequent treatment cycles. ENDOCRINE STATIC MARKERS. FSH : High FSH levels are associated with decreased ovarian reserve and poor response to gonadotrophin stimulation in ART cycles.FSH levels of >>15 IU/L is an indicator of poor ovarian response and higher chances of ART cycle cancellation. LH : Mean LH,LH amplitude and LH response to GnRH were higher in women with imminent ovarian failure. FSH / LH RATIO An increase in FSH/LH ratio ,even with normal FSH is a sign of decrease ovarian reserve. ESTRADIOL E2 : Decrease in E2 levels with increasing FSH levels is a more certain sign of decreasing ovarian reserve. INHIBIN A & B: INHIBIN are glycoproteins secreted by granulosa and theca cells of the ovarian follicle.I INHIBIN B inhibits FSH release. Inhibin B as a test of ovarian reserve is investigational. AMH : AMH is produced by granulosa cells of growing pre- antral and small antral ovarian follicles as soon as they are recruited prior to their responsiveness to FSH. Follicles secrete AMH till they are about 6 mm in size.AMH is an important clinical marker in the assessment of female infertility. AMH levels <<< 1ng / ml =poor response. AMH levels of 1 - 4 ng/ml =Normal response. AMH levels >>> 4 ng/ml =high response. ENDOCRINE DYNAMIC TESTS. CLOMIPHENE CITRATE CHALLENGE TEST (CCCT) Test involves administering 100 mg of clomiphene daily from day 5-9 of Menstrual cycle.FSH levels are measured on day 3 and day 10.DIMINISHED OVARIAN RESERVE IS DETERMINED BY DAY 10 FSH MORE THAN DAY 3 FSH. AN ELEVATED SERUM PROGESTERONE LEVEL >>1.1ng /ml ON DAY 10 OF CCCT IS ALSO PREDICTIVE OF DECREASED OVARIAN RESERVE. GONADOTROPHIN ANALOGUE STIMULATION TEST (GAST ): GAST involves sub cutaneous administration of gonadotrophin analogue leuprolide acetate on day 2 and looking at change in FSH,LH,inhibin- B,E2 concentration from day 2 to day3. EXOGENOUS FSH OVARIAN RESERVE TEST (EFORT) 300 mg of recombinant FSH is given on day 3. FSH,E2,INHIBIN - B levels are measured prior to FSH administration and 24 hours after FSH administration. ULTRASOUND MARKERS. ANTRAL FOLLICLE COUNT.(AFC) AFC is measured as follicles measuring between 2 - 10 mm between day 2 and day 5 of Menstrual cycle.L ow numbers of antral follicles are a sign of ageing. OVARIAN VOLUME : OV has little applicability in prediction of poor response. OVARIAN BLOOD FLOW Not significant. OVARIAN BIOPSY. Not recommended. FINAL WORD. FSH,LH,E2,P4,T,AMH LEVELS. ULTRASOUND -AFC. Mostly followed.
Mam this is my favorite topic,on this platform, a lot of new things are being learned.not only having knowledge, but sharing is very very important.learing a lot from you mam.inspired by your zeal to teach us.
very informative.. Particularly role of AMH should be underlined in the discussion.
Very informative & important post,thanks for share.
Very informative and helpful post madam Can you please update some posts regarding infertility.... Thanks again
Very useful information. Thanx.
Wow.. Excellent post Mam
Excellent information.Thanks.
Fantastic info, thanx for sharing Mam.
Really nice information. ..Thank U mam
Nice, Thanx.
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what management will be needed for this person with TSH level 4.95
Dr. Mohibbul Siddiqui2 Likes17 Answers - Login to View the image
HSG FINDINGS IN GENITAL KOCHS : Female genital tuberculosis is a major cause of tubal obstruction leading to infertility , especially in developing countries. Genital tuberculosis is difficult to diagnose. DEFINITIVE DIAGNOSIS OF GENITAL TUBERCULOSIS IS MADE BY 1 ) POSITIVE MYCOBACTERIUM CULTURE IN ENDOMETRIAL TISSUE . 2 ) HISTOLOGICAL DIAGNOSIS OF TUBERCLES / GRANULOMAS . HYSTEROSALPINGOGRAM IS THE GOLD STANDARD IMAGING PROCEDURE IN EVALUATING THE INTERNAL ARCHITECTURE OF THE FEMALE GENITAL TRACT. The radiographic features of genital tuberculosis is described in two parts 1 ) PART I / SPECIFIC FEATURES : Related to tubes . BEADED TUBE. PIPESTEM TUBE . GOLF CLUB TUBE . COBBLE STONE TUBE . LEOPARD SKIN TUBE . 2 ) PART II : Related to endometrium. This describes the adverse effects of tuberculosis on the structure of endometrium. DWARFED UTERUS WITH LYMPHATIC INTRAVASATION AND OCCLUDED TUBES "T" SHAPED UTERUS . PSEUDOUNICORNUATE UTERUS. COLLAR STUD ABSCESS. HSG FINDINGS : 1 ) CALCIFICATION OF FALLOPIAN TUBES ,OVARY .Tubal calcification is usually seen in the form of small linear streaks in the course of tubes. 2 ) HYDROSALPINX : HSG shows dilated fallopian tube filed with contrast and absence of free spillage of dye. 3 ) TUBAL OCCLUSION : Distal tubal occlusion causes hydrosalpinx and in proximal tubal occlusion, dye fails to enter the tubes and therefore tubes are not visualized. 4 ) TUFTED LIKE APPEARANCE / ROSETTE LIKE APPEARANCE : Caseous ulceration of tubal mucosa creates an irregular, ragged or diverticular appearance on the contour of tubal lumen in HSG These diverticular cavities surrounding the ampulla produced by caseous ulceration gives the tubal outline "tufted like appearance / rosette like appearance. 5)TB-SIN : TUBERCULOSIS-SALPINGITIS ISTHMICA NODOSA : Penetration of contrast medium between the mucosal folds due to ulceration of tubal mucosa causes diverticular - like outpouchings. 6 ) COTTON WOOL PLUG APPEARANCE: Distribution of contrast medium in a reticular pattern produces cotton wool plug appearance. 7 ) SAW TOOTHED APPEARANCE: when the tubal lumen is filled with putty like caseous material, the HSG outline is irregular with pockets or Laguna giving a saw toothed appearance. 8 ) BEADED TUBE : Multiple constrictions along the fallopian tubes gives a beaded appearance. 9 ) PIPE STEM TUBE : Absence of normal tortuosity and curved / straight pipe like rigid appearance in fibrotic stage of tubercular salpingitis causes pipe stem appearance. 10 ) LEOPARD SKIN TUBE : Multiple rounded filling defects following intra luminal granulomas formation within the hydrosalpinx gives leopard skin appearance . 11 ) GOLF CLUB TUBE : Sacculation of tubes in distal portion with an associated hydrosalpinx gives a golf club like appearance. 12 ) COBBLE STONE APPEARANCE : Intra luminal scarring gives rise to cobble stone pattern which indicates intra luminal adhesions . 13 ) TOBACCO POUCH APPEARANCE : Eversion of fimbria secondary to adhesions with a patent orifice produces tobacco pouch appearance.
Dr. Suvarchala Pratap13 Likes21 Answers - Login to View the image
pt.31/m c/o dry cough since 1 month.. CXRay provides fo comments..
Dr. K. Akash2 Likes20 Answers - Login to View the image
This is an x-ray chest PA view from a 26-year-old boy who presented with a left scrotal swelling for 6 months and low grade fever for 2 months. On examination, built and nourishment is below average, afebrile. No lymphadenopathy, clubbing. Mild pallor present. A swelling of size 2 X 3 cm is found in left scrotum arising from left spermatic cord, non tender with no local rise of temperature. Rest of the systems WNL. The case is open for discussion.
Dr. Arnab Debbarma8 Likes19 Answers - Login to View the image
18years female C/o intermittent pain abdomen since 2 months, back pain, nausea since 2 months. H/o white discharge PV since 2 months. USG abdomen(report attached) showing Complex left ovarian cyst ?Hemorrhagic. What is the management??
Dr. Ravikanth Moka1 Like20 Answers
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