ovarian infertility

• Infertility risk factors


  hx or prior infertility<|>premature ovarian failure<|>hx of birth defects<|>substance use<|>occupational exposure<|>sexual dysfunction<|>birth control<|>prior surgery<|>ruptured appendix
• Female infertility factors


  • ovulatory dysfunction
  • tubal/peritoneal factors
  • fibroids
• Symptoms of infertility include regular, timed, unprotected intercourse without pregnancy for 6-12 months
• PCOS sx may include irregular menses, PID, galactorrhea, hirsutism
• Infertility testing


  labs<|>hysterosalpingogram<|>semen analysis
• Workup for male infertility

  1. Get semen analysis

  2. Refer to urology if abnormal
• Male infertility analysis


  • Low total sperm
  • Low motility
  • Abnormal morphology
• Workup for female infertility

  1. Evaluate ovulatory function

  2. Check mid luteal serum progesterone

  3. Use home ovulation predictor kits

  4. Evaluate for hypothalamic/pituitary disorders

  5. Check labs for thyroid/hyperprolactinemia
• Structural abnormalities in female infertility

  • Test for tubal occlusion
  • Peritubal adhesions
  • Endometrial polyps
  • Submucosal fibroids
• Treatment for infertility


  1. Operative hysteroscopy to resect lesion

  2. Clomiphene citrate or letrozole

  3. Timed intrauterine insemination

  4. Evaluate with reproductive endocrinologist
• Ovarian cyst


  Liquid sacs in the ovary
• Risk factors for ovarian cysts

  • Infertility treatment
  • Tamoxifen
  • Pregnancy
  • Hypothyroidism
  • Maternal gonadotropins
  • Cigarette smoking
  • Tubal ligation
• Physical exam findings for ovarian cysts

  • Liquid sacs in ovary
  • Cervical/adnexal motion tenderness
  • Ruptured cyst shows sudden pain
  • Hemorrhagic cyst shows hemodynamic instability
• Types of ovarian cysts

  • Functional cysts
  • Pathologic cysts
• Functional cysts


  • Follicular
  • Corpus luteal
  • Theca-lutein
• Pathologic cysts


  • Dermoid cyst
  • Cystadenomas
  • Endometriomas
• Symptoms of ovarian cysts may include unilateral pain/pressure, sudden severe pain, N/V, dyspareunia, abdominal fullness/bloat
• Imaging for ovarian cysts

  US shows round/oval anechoic mass that is smooth with thin walls
• If complex, an ovarian cyst is considered cancer until proven otherwise
• Workup for ovarian cysts

  1. Labs show urine pregnancy

  2. CBC

  3. UA

  4. Endocervical swab

  5. CA-125 to rule out cancer
• Functional/physiologic cysts don’t need treatment as they will spontaneously resolve
• If an ovarian cyst is over 5cm, intervention is needed due to ovarian torsion risk
• Treatment for ruptured cyst

  1. Observe stable patients

  2. Laparoscopy for unstable patients

  3. Ovarian cystectomy/oophorectomy
• Polycystic ovarian syndrome (PCOS)

  Abnormalities in metabolism of androgens/estrogen and control of androgen production
• PCOS symptoms


  • Menstrual dysfunction
  • Anovulation
  • Hyperandrogenism
• Etiology of PCOS


  • Hyperinsulinemia
  • Excess adipose tissue
  • Excessive LH production
  • Genetic factors
  • Obesity
  • History of gestational diabetes
• Physical exam findings for PCOS

  • Virilization
  • Hirsutism
  • Male pattern baldness
  • Acne
  • Insulin resistance
• Diagnosis of PCOS


  2 of 3 criteria:

  1.Oligomenorrhea/anovulation

  2. Clinical/biochemical signs of hyperandrogenism

  3. Polycystic ovaries on US
• US findings for PCOS

  • Follicles on one or both ovaries looking like small cysts
• Labs for PCOS


  • Elevated LH:FSH ratio
  • Elevated androstenedione
  • OGTT to establish insulin resistance
• Treatment for PCOS


  1. Oral contraceptives to regulate cycle

  2. Clomiphene citrate to induce ovulation

  3. Metformin to increase insulin sensitivity

  4. Ovarian drilling for cystic ovary
• Management recommendations for PCOS

  • Treat symptoms
  • Weight loss
  • Low glycemic index diet
• Ovarian torsion is an emergency occurring when the ovary twists over the ligaments that support the adnexa
• Risk factors for ovarian torsion

  • Ovarian enlargement
  • Strenuous exercise
  • Sudden increase in abdominal pressure
  • Pregnancy
  • Ovulation induction/hyperstimulation
• Symptoms of ovarian torsion

  • Severe unilateral sharp pelvic pain
  • N/V
  • Fever
• Diagnosis of ovarian torsion

  1. TVUS with Doppler

  2. CT/MRI if US is ambiguous
• Imaging findings for ovarian torsion


  • Enlarged swollen ovary with displaced follicles
  • Dec blood flow “whirlpool sign”
• Treatment for ovarian torsion

  Laparoscopic surgery
• TOA is inflammation of the upper genital tract and is polymicrobial
• Symptoms of TOA


  • Cervical motion tenderness
  • Uterine/adnexal tenderness
  • Acute PID symptoms