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Re: anovulatory cyclesFrom: George M. Grunert, M.D. (ggrunert@obgynassociates.com)Mon Nov 15 14:11:00 2004
Seems to be a lot of smoke about a little fire: The only absolute proof of ovulation is pregnancy. The second best evidence is ultrasound documentation of follicular growth and rupture. This requires a pre and post ovulatory scan. An elevated luteal phase serum progesterone level is the next best test. BBTs and urinary LH testing are less sensitive and accurate. The first thing to do is make a diagnosis: is she ovulation or not? With irregular cycles, an erratic BBT, and no LH surge, most likely she is not ovulating. If she's not ovulating, why not? You've gotten a lot of specific suggestions without much direction. If she's not ovulating, the most likely causes are a failure of the pituitary to stimulate the ovaries (fairly rare), a failure of the pituitary and ovaries to communicate, another endocrine or metabolic problem, or ovarian failure. Start simple with an FSH, estradiol, TSH, and prolactin - on day 3 of her menses. If she has evidence of androgen excess (hirsutism and/or acne), also check DHEA, 17-hydroxy-progesterone, and free testosterone levels. Use the results to narrow down the possibilities. Once you have a diagnosis, her desires guide your therapy. If she wants pregnancy, she may ovulate if you find an underlying problem, or she may need ovulation induction. You should also check other fertility factors - sperm count and HSG - so you don't waste her and your time. If she wants regular periods without pregnancy, and you don't find something else, birth control pills are ideal. In general, testing for insulin resistance is not worthwhile unless you're in an academic institution with an excellent lab. Insulin levels at Quest or LabCor aren't reliable. If you make a diagnosis of PCOS (oligoovulation plus evidence of androgen effect or excess), you can presume that she has insulin resistance and treat her accordingly. If she has PCOS and pregnancy is her goal, start her on clomiphene once she's on metformin. If you're concerned about overt diabetes, do a fasting and 2 hour blood glucose first. George M. Grunert, M.D. Director, Assisted Reproductive Technology Program Obstetrical and Gynecological Associates 7550 Fannin Houston, Texas 77054 713-512-7851 fax 713-512-7853 grunert@ivfhouston.com http://www.ivfhouston.com The information contained in this message may be privileged and confidential. If you are NOT the intended recipient, please notify the sender immediately with a copy to grunert@ivfhouston.com and destroy this message. -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod Darryl G MAJ 48 MDOS/SGOBO Sent: Wednesday, November 10, 2004 7:06 AM To: Multiple recipients of list OB-GYN-L Subject: Re: anovulatory cycles You can assume that someone is ovulating from an ultrasound. If you look at the endometrium from the early follicular phase into the early secretory phase you can see a trilaminar pattern and in the secretory phase it becomes homogeneous. (Hofmann G et al, High-Resolution endovaginal ultrasonography of the endometrium Obstet Gynecol 1991;78:200-204 It is not absolute proof that they are ovulating, but along with a corpus luteum is good evidence. As for clomid, you have to remember its effects on cervical mucous when giving it. Glen D. Glen Elrod, Maj USAF, MC Obstetrician/Gynecologist Maternal Child Flight 48 MDOS/SGOBO UNIT 5210 Box 23 APO, AE 09464 DSN (314) 226-8334 Comm 01638-52-8334 Notice of Confidentiality Under the Privacy Act of 1974, you must safeguard all information reflected on this Email and, if applicable, all attachments. Disclosure of information is IAW AFI 33-119, AFI 33-127, AFI 37-131, AFI 37-132, AFI 33-219, and PL 93-579" This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance Portability and Accountability Act (PL 104-191) and its various implementing regulations and must be protected in accordance with those provisions. Healthcare information is personal and sensitive and must be treated accordingly. See <https://sg.usafe.af.mil/HIPAADisclosure.cfm> for full details. -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Steve & Eryl Raymond Sent: Wednesday, November 10, 2004 11:15 AM To: Multiple recipients of list OB-GYN-L Subject: Re: anovulatory cycles 1.Where do you get the idea from that you can tell if someone is ovulating from an ultrasound? There are only two ways to be sure of ovulation - one is to show a sustained rise in serum progesterone in the luteal phase, the other is to show secretory changes in the endometrium. 2.What percentage of women, ovulatory or anovulatory, show a rise in testosterone without symptoms? Estimating a testosterone level would be one of the least useful tests you could do for anovulatory cycles. 3. What percentage of anovulatory women are proving to have insulin resistance? Before doing something as expensive as an insulin resistance test how about something as cheap and reliable as a Glucose tolerance Test. 4. The prescription of Clomiphene Citrate should never be "take this it might enhance your ovulation". If the normally ovulating patient takes it, it may in fact reduce ovulation chances. It should not be prescribed unless there is proof of anovulation or of a poor luteal phase. 5. If the LH stick remains negative then it means without doubt that she has not ovulated and confirmatory tests for the luteal phase need to be done. If you are unsure of these basic reproductive endocrinology/infertility processes I suggest you send her to someone with the necessary skill and knowledge.
Judith Cerdà Belmonte wrote:
>I would make
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