What is new in our knowledge on Physiology of Ovarian Reserve and Endocrine Function

What is new in  our knowledge on Physiology of Ovarian Reserve and Endocrine Function

Q.1. Is there any  recent change in aassesing   ovarian reserve which was so long  popular for last 3 decades like AMH & AFC:  Ans:You will  be surprised that many scientists have recently questioned the validity of AMH & AFC  imp assign   follicular stock ??

Q. 2. What was known to us??  :

Ans; Ovary contains a stock of follicles number of which gradually declines as age advances by a process of physiological apoptosis. Physiological atresia starts from intrauterine life the process of atresia continues through childhoodà puberty-à  adolescence à child bearing age till the stock is exhausted by the time when woman reaches menopause. We also know that from several millions of follicles appearing in intrauterine life the number is reduced to two millions at birth and 3,00,000 at puberty.

Q.3 . As she enters in reproductive life??

Ans:What happens in each menst cycle?? Ans:-During reproductive years with each menstrual cycle some 30 to 40 follicles are wasted.

Q. 5:-Which Follicles undergo  apoptosis first??

 Ans:-It should be noted that better quality follicles’ are exhausted in the first half of reproductive years followed by relatively interior quality follicles.

Q. 6 . Leave me alone: I am a Lady? Don’t you know manners?? Haven’t attend classes of Dr Pal (how gentle he is to me  !!)  For havens sake please don’t disturb me.  I shall communicate to my body guard Prof Pal, if you drill me or do unnecessary stripping of my cyst  wall which are too small based on USG ?? Prof Pal then, will sent to you Jail if U unnecessary touch me,

.Ans:- Dr. Pal has told me what is bad touch ( excess drilling too many holes, high current ., deep holes –the law of 4 forgotten )  & what is good touch(big chocolate cyst) !! You must know that one President gently slapped Queen at Brimming ham Palace but that was a good humorous touch.

Ans:-Therefore no unnecessary ovarian surgery please: During this long journey from puberty to menopause any trauma or insult to the ovary may lead to qualitative and quantitative loss of follicles reducing ovarian reserve prematurely

Q.7:-What was the parameter of Ov reserve so far?? What about FSH on day 3 of spont cycles ?? 

Ans:- FSH does not indicate the quality of oocytes available.. One clinically useful indicator was to predict ovarian reserve is to measure the level of baseline follicle – stimulating hormone. Gradual rise of baseline FSH in consecutive cycles indicates diminishing ovarian reserve. Now scientist has concluded that FSH is a quantitative predictor of oocytes level of borderline elevated. FSH does not indicate the quality of oocytes available. From that point of view patient’s age and assessment of AMH are better qualitative predictors of ovarian reserve than baseline FSH.

Q.8. Is this hold good(Basal FSH)  in cases of genital Kochs induced affection of Ovary or T O mass ?? 

Ans:-As genital tuberculosis affects women of younger age better quality eggs are still available although ovarian reserve may be borderline. This fact provides a favorable scope for treating infertility by ART for women with genital tuberculosis. In genital Kochs there has been shown that demonstrates that though numbers of eggs are less quality of eggs is better because of relatively younger age of the patient affected with genital tuberculosis.

Q . 9. So FSH gone, which parameter of Ov reserve  next to consider ? Which  test will be the best predictor  of Ov reserve?? 

Ans:-A better qualitative predictor for ovarian reserve namely anti mullerian hormone has recently been identified. AMH is synthesized and released by granulosa cells of the follicle. Unlike other biomarkers for ovarian reserve like FSH inhibin or E2 estimation of AMH can be done on any day of menstrual cycle. This is because levels of serum FSH, E2 and inhibin B depend on individual feedback mechanism whereas production of AMH depends on health and integrity of granulosa cells and is not dependent on feedback mechanism.

Q.10:-Physiology of ovarian endocrine function : Ans:-What is our expectation , being under gonadotropin control ovaries  should be able to respond to appropriate  levels of gonadotropin and in response should be able to generate optimum amounts of ovarian  steroids namely oestrogen  and progesterone

Q. 11. What are the 33 Autocrine factors which are continuously governing the action of  FSH in the Granulosa  cells & theca cells and possibly on oolemma as well?? What controls –Intracellular signaling in ovarian cortex?? ?? ?? NDA?? UPA –Govt of many political parties!!  What is not known by NASA about the universe?? Who is Megnadh -who fights/ helps somebody himself  hiding  behind the cloud ? Parde pichhee kaea hai??

Ans:-to Q. 11 :-In  addition intraovarian peptides play important roles in regulating gonadotropic consist of autocrines  and paracrine. At least 33 putative Autocrine – paracrine regulators for follicular growth have been identified. They play a major role in follicular growth and atresia. The important members of Autocrine paracrine family consist of inhibin Activin insulin like growth factor vascular endothelial growth factor transforming growth factor alpha etc. They play important role in modulating gonadotropic effects on ovarian function and ovulation. These cordinate  ovarian endocrine functions are disrupted either directly through toxins produced by NTB or indirectly by adverse immune modulatory  change in intra follicular  environment . The consequences may be gonadotropin response deficiency anovulation endometrial hyperplasia luteal phase defect etc.

Q.12: Genital Kochs ?? How is the Ovarian  function affected  in genital tuberculosis ?? Kochs may  be adversely affected in following ways

a.  Morphological involvement of the ovaries: Ovaries are involved in 20 to 30% cases of genital tuberculosis . The degree of morphological involvement depends on the severity  and stage of the disease. There may be either tubercles on the ovary or adhesion caseation tubo ovarian cyst or mass formation. Rarely the ovaries may be completely destroyed by the disease. These types of tubercular ovarian affection may lead to both follicular stock depletion and endocrine disruption.

b.  Tubercular hydrosalpinx: TB hydrosalpinges may interfere with ovarian function either directly or indirectly. Fallopian tubes are involved in almost all women with genital tuberculosis involvement is usually bilateral. Tubercular hydrosalpinx is not uncommon in India. Other causes of tubal dilation include pelvic inflammatory disease adhesion and obstruction due to any cause. Scientists  have observed tubal dilatation with or without obstruction in 46%  of their patients with genital tuberculosis . Incidence  of tubo ovarian  mass has been reported to be 15.3%

Q.13:-Then?? Will full course of ATD I can’t become mother –Why??  Ans:-a possible link between LGTB and endometrial receptivity one of the key factors determining implantation which has not been studied so far we therefore aimed to evaluate  the various biochemical and morphological markers of endometrial receptivity  during implantation window in endometrial tissue of women with LGTB . The biochemical markers examined in th study were  the endometrial adhesion  molecules mucin a and an interleukin – 6 class cytokine leukemia inhibitor factor

Q. 14 “: TB what else is now known?? A significant decrease in a vB3 integrin . LIF, E cadherin, MECA- 79 and MUC-1 expression was observed in women with LGTB as compared to controls.

Q. 15 : What is Bologna criteria 2011 ?? Why that was frames?? I am sinking am drowning!! Please tell my father for my marriage .I am already 34 yrs!!! Ans: Over the past few decades  DOR / POR  has emerged as a challenge. The incidence in a population undergoing assisted reproduction treatment is estimated to be 9-24% . Measures have been taken to identity  such patients at risk or during treatment  for appropriate management  Bologna criteria 2011 is one such crucial step taken towards the introduction of a uniform definition of POR to guide the management and intervention strategies. It states that presence of at last two of the following three features are required for the diagnosis of POR:

1.  Advanced maternal age ( > 40 years ) or other risk factors

2.  Previous POR ( < 3 oocytes with conventional stimulation protocol )

3.  An abnormal Ovarian  Reserve Test (AFC 5-7 follicles or AMH 0.5 -1.1 ng/ml )

Q. Q. 16:- : New defn of por responders??  Ans:-Two episodes of POR after maximal stimulation categories  patient as poor responder in absence of advanced maternal age or abnormal  ovarian reserve test. Poor response  can be expected from patients with age> 40 years and abnormal  ORP. Then starts the quest for oocytes laying out plans and hoping for a good response.

. Q. 17 : Then we,  who are poor responders , have no hope to become biological mother ??  Ans: No. Not at all. Don’t lose your hope.  I don’t mean that. Hope is always there because Dr Pal is still typing personally at the age of 77 yrs, Then why I can’t produce my own good quality fertilizable egg at 39 yrs  with no post fertilization developmental errors ? !!  Ans: What are the steps so long adopted for so called poor responders??

Ans :: Various strategies have been tried so far  Modification : 1) gonadotropin dose adjustments

Modification : 2)  use of antagonist Modification : 3 Use of cofollitropin alfa, Modification 4:  Estradiol in luteal  phase. Modification :5:Addition of Growth hormone. Modification : 6 :Another such novel approach  is the use of Androgel.

Modification :  7 :: Will DHEA work?? How much money is spent per day for DHEA by couple?? What other modifications and deviation from Sc?? Ans:  Pretreatment with androgen has been a hot topic for  debate for many years. Androgen  acts primarily during FSH dependent  early folliculogenesis. Androgens act on granulose cells in early follicle  maturation and increases the sensitivity of the follicles to FSH via cANP mediated pathway. Androgen  receptor protein then decreased with advancing follicular maturation. Thus androgens and FSH work synergistically . A positive correlation has been observed between serum testosterone concentration and number of oocytes retrieved and the amount of FSH required.

Modification: 8: Other modalities of androgen administration??  Ans:-Various modes of testosterone administration are known  like DHEA, 1) testosterone patches and 2)  testosterone gel or androgel. Although DHEA has already found its way into the practice use of Androgel seems to be the most promising due to acceptable safety profile and better convenience. Androgel 1% gel contains 50 mg  testosterone which is biologically similar to testosterone which is biologically similar to testosterone secreted by human body.

Modification: 9 :Information on drug and its usage: Each  5 gm gel contains 50 mg of testosterone. So the dosage is a quarter of a gel which makes approximately 12.5  mg testosterone.

Modification: 10 :: How to use :  Androgel is to be used prior to ovarian  stimulation. It has been used in studies for a variable time period of 4-6 weeks. The feasible and systematic way to use it would be from Day 6 of previous cycle to Day 2 of stimulated menstrual cycle.

Modification: 11 :: How to apply : Step  1:. The gel should be applied preferably on inner upper arm or on shoulder or abdomen over a dry and clean area with intact skin. Step  :.  2. Take full gel in a syringe, apply  and discard the remaining gel. Step   3. Apply at night before bedtime Step  4. Leave it to dry for 3-5 minutes .5.Cover with clothing 6. Wash hands thoroughly Step  7. Nobody should come in contact with  the area  the gel has been applied to . Take bath after intimate contact.

Modification: 13: I don’t like be a male!! I am a woman. I am proud of my woman hood though I am still unable to reproduce. That is one aspect but believe me I am caring to my hubby and other family members.  .Then doc why you are prescribing male hormones to me? Do U like to change me as transgender-which I don’t like!!  Ans:-Special warning from Dr Pal about Safety profile of androgen ?  : Apart from possible local skin reaction such as irritation and dryness at the site of application not much of side effects have been observed  with such small dose used for short period of time.

Take home message from Dr Pal : :

Various studies have shown that use of Androgel in poor responders may result  in the increase in the number of mature  eggs, good quality embryos and better implantation rates but a randomized controlled trial is much needed to put this into practice. Few other studies state that although there is a definite increase in the number  of follicles  retrieved but the quality remains the same. This  goes  in consensus with the fact  that in condition such as PCOS  although there is hyperandrogenism and more number of follicles may be retrieved but quality is inferior. This is the point where the data falls short. With that said being said this simple approach has shown promising results and has entered the vernacular as a viable option to treat poor responders.

 Q.1. How we can reasonably confirm /diagnose Adenomyosis? Ans: -We know that subjective symptoms of adenomyosis are like endometriosis e, g. dysmenorrhea subfertility, pelvic pain and menometrorrhagia, but for confirmation there are basically two modalities which help us to confirm the clinical diagnosis of adenomyosis. Such are 1) MRI 2) USG.

Q2: what are the sonological features? In USG we should look for:-

1) Heterogeneous myometrial area.

2) Globular asymmetric uterus.

3) Irregular cystic spaces.

4) Myometrial linear striae.

5) Poorly defined / demarcation of endometrial – myometrial junction.

6) Myometrial anterior- posterior wall asymmetry. Usually the post wall is thicker than the ant wall,

7)  Both the walls of myometrium may be thickened say anterior and posterior wall.

8) Increased or decreased echogenecity

Most of us use only USG for diagnosis confirmation as a cost savings approach while others have used all two parameters for diagnosis of adenomyosis like USG & MRI. This is truer when one considers for ART. Regarding endoscopic diagnosis the diag remains uncertain though hysteroscopy is more helpful in diagnosing than laparoscopy. In fact in fair number of cases the laparoscopy may be negative inspite of moderate to severe adenomyosis.

Q.3:-What is meant by Junctional Zone & what is the role of JZ in the etiogenesis of adenomyosis. , The area of endomyometrial junction is known as junctional zone. Junctional Zone consists of three layers as detailed below:

a. Innermost myometrial layer

B. and the sub vascular layer above the endometrial cavity – also known as archi myometrium

c. Including basal endometrial layer

We know that the normal thickness of junctional zone is 7-8 mm. In adenomyosis the junctional zone thickness increases to > 12mm.

Q.4: Why & how adenomyosis develops? In case of adenomyosis this Jan zone play a vital part and in most of the cases the disease initiates with the invagination of JZ into myometrium due to various causes of which abnormal uterine peristalsis is mostly attributed.

Why abnormal peristalsis causing high intra uterine pressure??   The process of invagination of this JZ is thought to be suing either to a) abnormal peristaltic function or wave of peristalsis originating in this JZ or local structural abnormalities in the myometrial tissue. This structural abnormality may be congenital or acquired. These two factors are the chief causes of genesis of adenomyosis usually favour development of adenomyotic uterus. Besides c) abnormal hormonal and d) immunological conditions also have a commanding role to play in the normal functions of JZ and if any one goes wild then this increased pressure induced by uterine peristalsis may cause invagination of endometrium.

We know that the normal thickness of junctional zone is 7-8 mm. In adenomyosis the junctional zone thickness increases to > 12mm.

Q.5:-How adenomyosis cause subfertility or enhances spont miscarriage rate?

Ans:-Impediments to conception is brought about by A) increased uterine peristalsis, as mentioned earlier, which is partly governed by junctional zone. In cases of adenomyosis there is primary abnormality in junctional zone thickness à which leads to uterine dysperistalsis and therefore B) impairment of sperm transport...  In addition in adenomyosis there is also C) increased colonization by macrophages’) Secretory products of these macrophages have adverse impact on oocyte quality fertilization and implantation. These noxious products released  by macrophages trickles down to F tubeàthen via fimbrial end to the surface of ovary and it is believed that the said noxious agents / toxins liberated by endometrial macrophages is brought about via utero ovarian countercurrent systemà impedes oocyte dev environemetyt.

Q 6: What is Junctional Zone? Junctional Zone consists of three different components:-

a. On the outermost part is “innermost myometrial layer”.

B. In the middle part is “sub vascular layer deep to but adjoining the endometrial cavity – also known as archi myometrium “

C. and most inside close to uterine cavity is the “basal endometrial layer”’

We know that the normal thickness of junctional zone is 7-8 mm. But in adenomyosis the junctional zone thickness increases to > 12mm.

Q.7. what is meant by normal uterine peristalsis? How such peristlasis may go wild and may become an etiologic factor of genesis of adenomyosis? Ans: Increased peristalsis which creates increased intra uterine pressure – leading to invagination of basal endometrium into the myometrium --Uterine myometrium has a regular pattern of peristalsis regulated by endocrine and paracrine stimuli. Junctional zone thickness causes increased peristalsis which creates increased intra uterine pressure – leading to invagination of basal endometrium into the myometrium. Invagination is more commonly found on posterior wall of uterus. Invagination is also facilitated by weakness of smooth muscle tissue of uterus .Weakness may be due to high estrogen  concentration in the local area or impaired immune related growth factor.

Q8. What are the other pelvic pathologies which may be associated with adenomyosis? Apart from pelvic endometriosis adenomyosis may be associated with other pelvic pathological conditions like 1) leiomyomas 2) endometrial hyperplasia 3) endometrial polyp 4) atypical endometrial hyperplasia and rarely 5) adeno carcinoma. However presence adeno myoma or adenomyosis has no adverse effect on the prognosis of endometrial carcinoma.

Q.9. How we can confirm the clinical diagnosis of adenomyosis? There are two modalities which help us to confirm the diag of adenomyosis? Such are 1) MRI 2) USG.: In USG we should look for:-

1) Heterogeneous myometrial area.

2) Globular asymmetric uterus.

3) Irregular cystic spaces.

4) Myometrial linear striae.

5) Poor definition of endomyometrial   junction.

6) Myometrial anterior- posterior wall asymmetry.

7) Thickening of anterior and posterior wall.

8) Increased or decreased echogenecity

Most of us use only USG for cost savings while others have used all both parameters for diagnosis of adenomyosis .Hysteroscopy is more helpful in diagnosing than laparoscopy...

Q.10: How best to treat adenomyosis?? A) If Uterus exceeds 10 cm –presenting with menorrhagia and dysmenorrhea hysterectomy with preservation of ovaries for future surrogacy is considered to be the rational /effective treatment. Therefore Conservative surgery +- agonist (GnRH agonist) or one can use Danazol loaded intra uterine device. In rest cases where the uterine length is less than 10 Cm then following 7 options are available. Like 1)GnRH a for six months 2) Wedge biopsy 3) Uterine artery embolization 4) High intensity focused ultrasound

5) Ultra long GnRH followed by IVF vs. conventional Ivf. 6)

Combination of conservative surgery plus GnRH-a

7) LNG or danazol loaded IUs 8) Conservative surgery alone .9) High intensity focused ultrasound & Uterine artery embolization 10) Laparoscopic partial resection of uterus with uterine artery occlusion.

Q.11: What will the Obstetric Outcome in adenomyosis? Ans:-The obstetric outcome in an adenomyotic uterus include 1) Increased risk of preterm premature rupture of membranes 2)

Uterine rupture or perforation -29 cases from 1904 to 1984 plus an ectopic pregnancy in adenomyotic area were reported by Aziz et al 3) Rapid enlargement of adenomyotic uterus in pregnancy conceived after controlled ovarian stimulation has been reported. In fact, ART may lead to red degeneration during pregnancy and 4) PPH during and following delivery.

Q. 12: If you like to moderate a session in a CME on adenomyosis / endometriosis then may put such 11 questions as Chair person. I firmly believe the Conference Hall will be vacant and all the delegates including the panelists will be assembling there.

 Be that as it may what are those tips which will cause annoyance to audience??  :

Take home message 1:-Diag modality: The best method??  Apart from many diagnostic markers as is imaged by MRI and or USG- a) thickened endomyometrial junctional, b) anterior posterior uterine wall asymmetry c) heterogeneous myometrial areas with irregular myometrial cystic spaces are the characteristics for diagnosis of adenomyosis. It is believed that increased peristalsis which creates increased intra uterine pressure – leads to invagination of basal endometrium into the myometrium.

Take home message 2:-

Etiology? What cause adenomyosis i.e. formation of ectopic stromal tissues /glandular/surface epithelium of endometrium to go inside the deep into myometrium? Apart from being a diagnostic parameter through USG  and MRI – JZ thickness has a great impact on inducing normal myometrial contractility which creates a favorable peristaltic movement of the myometrium for sperm and embryo transport within the uterine cavity. This coordinated movement of JZ is governed by many endocrine, neuronal & paracrine and growth factors. We know that the normal thickness of junctional zone is 7-8 mm. In adenomyosis the junctional zone thickness increases to > 12mm as it is overactive and in most cases of adenomyosis the disease is initiated from this JZ.

Take home message: 3:- Why subfertility?? 1) The myometrial peristalsis of may misdirect sperm entry into the uterine cavity which may be an independent cause of infertility in women with adenomyosis. 2) Other direct cause of infertility due to adenomyosis only is migration of macrophages into the uterine myometrium leading to production of local inflammatory exudates. 3) Release of exudates within the myometrium produces adverse utero ovarian reflex signal to the developing follicle in the ovaries resulting in liberation of poor quality oocytes.

Take home message 4:-Besides subjective symptoms of dysmenorrhea and menometrorrhagia there are four other objective signs for diagnosis of adenomyosis. These are A) laparoscopy or B) hysteroscopy with or without directed myometrial biopsyà histology. C)  Transvaginal ultrasonography and 4) MRI. TVUS and MRI are non invasive and dependable diagnostic procedures. Between the two, USG is easily available and least expensive.

Take home message 5:-In initial years association of adenomyosis with pelvic endometriosis was reported to be much less than what is being reported currently. This is because of improvement of diagnostic facilities awareness of patient population and perhaps late marriage of women.

Take home message 7: TR of adenomyosis: Some without desire for babv: Currently with adenomyosis infertility is the primary problem – conservative line of treatement is the rational approach. Medical treatment with 1)GnRH a 2)danazol or 3)aromatase inhibitors , 4) LNG-IUS and recently introduced 5) dienogest are effective but not very popular for fertility restoration

Medical TR: - Adenomyosis has a negative impact on ART outcome.

With conservative surgical treatment or with ART may produce some positive outcome.

High intensity focused ultrasound or uterine artery embolization are the alternative options with questionable outcome.

Diffuse uterine adenomyosis measuring 10 cm or more with menometrorrhagia is beyond the scope of conservative management:--Such patients require abdominal hysterectomy with preservation of ovaries for future possibility of surrogacy.

Impact of adenomyosis on obstetric outcome includes – miscarriage, ectopic pregnancy within the adenomyotic foci, preterm labor, uterine perforation, and postpartum hemorrhage.