Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (258 page)

Suggested Readings

Barone MA, Nazerali H, Cortes M, et al. A prospective study of time and number of ejaculations to azoospermia after vasectomy by ligation and excision.
J Urol.
2003;170:892–896.

Griffin T, Tooher R, Nowakowski K, et al. How little is enough? The evidence for post-vasectomy testing.
J Urol.
2005;174:29–36.

Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guideline.
www.auanet.org/education/ guidelines/vasectomy.cfm

OVULATORY DISORDERS

   Definition

   As a group, ovulatory disorders are characterized as either infrequent (oligoovulation) or absent (anovulation). In both disorders, the number of oocytes available for fertilization is reduced. Ovulatory disorders account for 25% of all causes of female infertility.

   Who Should Be Suspected?

   Candidates are women aged 16–40 years who report irregular or absent menses (amenorrhea) and irregular or absent molimina (breast tenderness, dysmenorrheal, bloating). Likely causes are pregnancy, oligoovulation (>36 days between menstrual cycles), or anovulation (>3–6 months without menses). Anovulation patients are classified by the WHO as:

   WHO1: hypogonadotropic hypoestrogenic (15%)

   WHO2: normogonadotropic normoestrogenic (80%)

   WHO3: hypergonadotropic hypoestrogenic (5%)

   Laboratory Findings

   WHO class 1: FSH is low or low-normal, and serum estradiol is low because of decreased hypothalamic secretion of gonadotropin-releasing hormone (GnRH) or pituitary unresponsiveness to GnRH.

   WHO class 2: FSH and estradiol are normal. The majority of anovulation patients belong to this group, with heterogeneous additional symptoms that include obesity, biochemical or clinical hyperandrogenism, and insulin resistance. Follow-up testing would include prolactin (covered in the next section), thyroid-stimulating hormone (TSH), and T
₄
. Thyroid abnormalities occur in up to 4% of patients with infertility. In patients with signs of hirsutism, testing should include testosterone and dehydroepiandrosterone (DHEA-sulfate). This group includes patients with polycystic ovary syndrome (PCOS), of whom 70% demonstrate elevated free testosterone. An additional test for PCOS is the 2-hour glucose tolerance test, which examines insulin and glucose levels following administration of a 75 g glucose bolus.

   WHO class 3: FSH is elevated. In patients with elevated FSH and a normal karyotype, the diagnosis should consider ovarian resistance (follicular form) or premature ovarian insufficiency (absence of ovarian follicles through early menopause). In patients under age 30 with elevated FSH, a karyotype analysis should be performed to check for Turner syndrome (XO) or XY females with gonadal dysgenesis.