PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM
menstruation; fertile women from menarche to menopause
Physiological character seen at regular intervals during the
characterized by vaginal bleeding. Pattern of menstrual bleeding
GnRH secreted from the hypothalamus and GnRH secreted from the pituitary
Between FSH and LH and ovarian sex steroids
coordination and related target organ endometrium
occurs due to cyclic interactions. Generally
Although ovulatory cycles last for an average of 28 days, they are between 21 and 40
into regular cycles ranging from days to
can be found. Cycles of gonadotropin in perimenarchal or perimenopausal women
anovulatory at shorter or longer intervals depending on fluctuations in
can also occur.
In the ovaries, gonadotropins determine two periods as follicular and luteal periods. follicular
The equivalent of the period in the endometrial tissue is proliferative, and the counterpart in the luteal period is secretory.
is the period.
The follicular or proliferative period includes the period from the first day of menstruation to ovulation.
The luteal or secretory period occurs under the influence of progesterone. post ovulation
is the period. Endometrial glands develop. Embryonal becomes ready for implantation, endometrial
glands curl, their secretions increase. Stromal edema occurs. A decidual reaction occurs.
While the luteal phase does not change and lasts for 14 days, the follicular phase varies 7 – 21
it may take days.
Ovulation will occur in approximately 400 follicles throughout life. follicles for growth
The selection mechanism is not fully known. Number of follicles starting with development
dependent on residual ovarian reserve. FSH 3 to 30 antral, which rises in the first five days of the follicular phase
promotes the growth of follicles. Only one of these follicles will ovulate.
others will atrophy. FSH stimulation transforms follicles into preantral follicles.
Estrogen synthesis by androstenodione and testosterone secreted from theca and interstitial cells
they are a resource for. These androgens synthesized by theca cells are transferred to granulosa cells.
it diffuses. As a result of aromatization of androgens in granulosa cells with FSH stimulation
estradiol is produced. This joint work of the theca and granulosa cells in estrogen synthesis
is called the “two cells, two gonadotropin theory”. FSH and ostradiol together
They increase the number of FSH receptors in follicles. Estrogen feedback is dominant
It inhibits all follicles except the follicle. Follicle rich in FSH receptor
While circulating FSH falls in the second half of the follicular phase, increased estrogen
With its synergistic effect, it provides the transition to increased LH receptor formation. LH secretion is low
It is inhibited by high levels of estrogen but stimulated by high levels of estrogen. this much
It provides two critical features:
• Concentrations exceeding 200 pg/ml
• Exposure to estrogen exceeding 50 hours.
While increasing estrogen increases the sensitivity of pituitary gasoline to GnRH, LH peak with the effect of GnRH.
lasts until it does.
Ovulation; Although it varies from cycle to cycle, LH is usually at its peak.
Ovulation occurs 10 to 12 hours after reaching it. Sudden increase of LH from estradiol peak 24 – 36
occurs after an hour. After LH reaches its highest level, estradiol begins to decrease.
Sudden increase in LH causes maintenance of meiosis, luteinization of granulosa cells, cumulus
It allows the expansion of the oophorus. Again, this increase in LH causes a continuous rise in progesterone.
induces. With progesterone, the volume of the follicle increases rapidly. Progesterone, FSH also with LH effect
secreted proteolytic enzymes and PG F2α lead to the release of the ovum.
The luteal phase begins with the release of the oocyte. Progesterone levels increase rapidly after ovulation.
rises. Progesterone reaches its maximum level 8 days after the LH surge. local and
The development of new follicles is inhibited by the central route, also by the effects of estrogen and inhibin A.
is done. If fecondation does not occur, progesterone begins to decrease after 6 to 8 days and the cycle begins.
At the end of the fall, menstruation begins.
EVALUATION OF FEMALE INFERTILITY Establishment of a healthy pregnancy
and the prerequisites for its continuation can be listed as follows.
1. Healthy sperm production in testicles in men
2. Discharge of the produced sperm into the posterior fornix in the vagina with sexual intercourse (coitus)
3. Having regular ovulation in the woman
4. Retention of the ovum expelled at ovulation by the tuba
5. The structure and functions of the cervical canal, uterine cavity and tuba lumens in women are normal and
Being open to passage of male gamete (spermatazoa) and female gamete (ovum)
6. Occurrence of fertilization in the ampulla of the tubule
7. Progression of the fertilized egg towards the endometrial cavity
8. Embedding (implantation) of a fertilized egg that responds to ovarian hormones
presence of a healthy endometrium
9. Uterine structure and hormonal factors that will ensure a healthy continuation of the early pregnancy
presence of support
10. Sufficient general health oxygen for nutrition and oxygenation of fetus and placenta.
So whether there is ovulation in female infertility and the way that the two germ cells combine
whether there is a pathology in the vagina, cervical canal, uterine cavity and tubes
needs to be investigated. An important point to be added to these is the tubaperitoneal
are pathologies. A careful history taking and physical examination before proceeding to the investigation
It guides us on what to prioritize in research.
Ovulatory Disorders Various pathologies take place under the name of ovulatory factor.
These are development of the follicle, absence of ovulation, ovulation and luteinisation.
insufficient, the oocyte cannot be expelled despite the rupture of the follicle,
maturation of the follicle, atresia as a result of maturation disorder in the follicle
is the development. Ovulatory dysfunction accounts for 30-40% of female-related infertility.
In infertile patients, it should be determined whether ovulation occurs or not. For this purpose made
The tests are:
• Menstrual story.
• Serum progesterone level measurement.
• Monitoring of basal body temperature.
• LH monitoring.
• Endometrial biopsy.
• Observation of ovulation by ultrasonography. Menstrual History: Normally ovulated
women usually have regular periods every 21 to 35 days. Quantity and duration are fixed. Piece
premenstrual and menstrual periods such as breast swelling, tenderness, dysmenorrhea
The presence of symptoms are also signs of possible ovulation. Serum Progesterone Level
Measurement: Serum progesterone level is usually <3 ng/ml in the follicular phase. is Ovulation
granulosa cells that become luteinized with subsequent formation of the corpus luteum.
A significant increase in progesterone level approximately 12 hours before the onset of the LH curve.
shows. Elevated serum progesterone level is an indirect sign of ovulation.
Progesterone measurement should be made during the midluteal period when secretion peaks.
To prove that ovulation has occurred, the progesterone level in the midluteal phase is at least 6.5 ng/ml.
ideally 10 ng/ml. or more. Due to the pulsatile release of progesterone
The value of progesterone taken on at least 3 separate days between the 20th and 24th days of the cycle
average should be taken into account. In addition, the duration of the luteal phase, in which sufficient progesterone is secreted, is also determined.
important and should last fourteen days. Monitoring Basal Body Temperature: Ovulation
Another way to show that it is possible is by monitoring basal body temperature.
Basal body temperature is lower than the follicular phase, body temperature in the luteal phase after ovulation
It increases by 0.1 – 0.30C compared to the follicular phase. This is observed at basal body temperature in the ovulatory woman.
biphasic pattern from the first day of the cycle, with measurements made at the same time every morning.
can be detected easily. The lowest level of basal body temperature one day after ovulation
before or on the day of ovulation. by the corpus luteum formed after ovulation
Secreted progesterone has a thermogenic effect on the hypothalamus. body temperature rise
onset, progesterone concentration >5ng/ml. when it happens. The most fertile period
It is the period 7 days before the midcycle peak of basal body temperature.
LH Monitoring: Serial LH measurements can be made in blood and urine. LH curve
Ovulation occurs 34 – 36 hours after the onset of the disease and 10 hours after the LH peak. Daily
Approximately 10% of LH production is excreted in the urine. LH is typically released in the morning and
it can only be measured in the urine after a few hours. Serial LH in urine to be taken twice daily
It is possible to determine the time of ovulation with the measurements.
Endometrial Biopsy:One of the most reliable imaging methods of ovulation is endometrial
is a biopsy. It is taken with a novak curette or pipette in the late luteal period. In endometrial biopsy
tissue should be taken from the anterior or posterior wall of the fundus, the lower vascularized lower
segment should be avoided.
Changes made by progesterone on the endometrium with endometrial biopsy
It is determined whether the cycle is ovulatory, whether the secretory changes are compatible with the cycle.
It can be determined whether there is a pathology such as endometritis, neoplasia or tuberculosis.
Secretory changes are not observed in the endometrium in an anovulatory woman.
It is detected as proliferative or even hyperplastic.
Observation of Ovulation with Ultrasonography: Before and after ovum expulsion
based on the tracking of events. First, by transvaginal ultrasonography on the third day of menstruation.
The ovaries are considered basal. Dominant in spontaneous cycles, on days 5 to 7 of the cycle
follicle is selected. In the last stages of ovulatory development, the preovulatory follicle is 2 mm per day. there you go
and its diameter is 20 mm. when ovulation occurs. After ovulation, the follicle shrinks,
edges become indistinct, an increase in internal echo density is observed, and free fluid in the cul de sac
Peritoneal and Tubal Factors: It is found in 30-35% of infertile couples. pelvic inflammatory
disease (PID) history, septic abortion, appendix rupture, previous tubal surgeries,
ectopic pregnancy, operations performed due to conceivable tubal passage may prevent
should cause disturbances. Peritoneal factors are usually PID, endometriosis or
These are peritubal and periovarian adhesions that occur after previous surgery. From the first PID attack
After the second PID, the risk of tubal adhesion is 10-15%, the risk of tubal adhesion after the second PID is 23%, the third
the risk after an attack is 54%.
Various techniques are used to evaluate the tuba of infertile women. Tubal passage
The most common method used in the evaluation is hysterosalpingography (HSG). your HSG cycle
6-10 of the cycle in the early proliferative period. done between days. HSG medium at diagnosis
While it is highly sensitive, its specificity is close to 90%. The overall risk of infection with HSG is less than 1%
while it is 3% in the high-risk group.
In general, 3 films are sufficient; 1 when radiopaque material fills the uterine cavity 1
one is withdrawn after the late radiopaque material has passed into the peritoneal cavity. at HSG
If bilateral tubal pathology is detected, further investigation is required. Tubal and peritoneal pathologies
The best technique for diagnosis is laparoscopy. Tubal motility, fimbrial
The structure of the ends is evaluated in detail.
Cervical Factor: The properties of cervical mucus reflect sperm receptivity. cervical mucus
It is examined in terms of its characteristics in the preovulatory period (days 12-14 of the 28-day cycle).
To be more specific, the urine test can also be done the morning after the LH surge.
The receptive preovulatory mucus for spermatozoa is abundant, thin, clear, acellular and alkaline.
Features of cervical secretions:
• Allows sperm penetration before and during ovulation; other times
Does not allow penetration.
• It protects the spermatozoa from the unsuitable environment of the vagina and from phagocytosis.
• It supports the energy needs of spermatozoa.
• Selects and filters spermatozoa according to their motility and morphology.
• Acts as a short-term reservoir for spermatozoa.
• It initiates sperm capacitation.
Ovarian hormones play a role in the secretion of cervical mucus. cervical epithelium
17 beta estradiol increases the secretion of cells, while progesterone inhibits it.
Preovulatory cervical mucus is highly receptive to spermatozoa. postovulatory
progesterone-influenced mucus and anovulatory disease with low estrogen levels.
The mucus in the periods is thick and in small amounts and has a dull appearance.
After the estrogen peak before ovulation, the maximum in the cervical glands
stimulation happens, the amount of cervical mucus increases significantly. It becomes clear and elastic. This
The property is evaluated with the Spinnbarkeit test. In addition, Fern, which shows the effect of estrogen in mucus
In the test, the cervical mucus is spread on the slide and left to dry.
microscopic examination reveals a fern leaf-like branching image.
Receptivity of cervical mucus, whether sperm penetrate the mucus and cervical mucus
The effect of the factor on infertility is evaluated with the postcoital test (Sims-Huhner test).
The postcoital test is done at the estimated time of the LH peak. 48 hours before testing
Cervical mucus 2-8 hours after the intercourse of the couple who did not have sexual intercourse before
from the cervical canal, external os and posterior fornix, macroscopically and microscopically
Uterine Factor:Congenital anomalies of uterus, uterine synechia, myoma uteri, endometrial
Various pathologies such as polyps, tuberculosis, endometritis and neoplasms constitute the uterine factor.
1. Uterine Anomalies:
2. Endometrial dysfunction and luteal phase defect. Congenital Uterine
Malformations: In the incidence evaluations of uterine anomalies, it is between 0.03% and 75%
There are figures reported. Publications stating that it is detected in 0.25% of births
In addition to studies with large series, which stated that it was 3.5% in infertility studies,
When examined, it is revealed that the expectation of anomaly in infertility cases is 10-15 times higher.
Although pregnancy loss usually occurs in the first and second trimesters in these anomalies,
If there is an anomaly in the implantation site, it may also disrupt the implantation. The most common and
congenital uterine malformation most associated with infertility; is the uterine septum. septum
Although it occurs at an equal rate (1%) in uterine fertile and infertile women, recurrent spontaneous
It is more common (3%) in women with abortion. endometrium covering the septum
impaired receptivity and impaired septal blood flow adversely affect fertility.
Today, it has low morbidity and is easily applied with hysteroscopic surgery.
is being treated. While the expectation of live birth after the treatment reached 75%, the pretreatment
abortion is more than 60%.
Acquired anomalies of the uterus:Leiomyomas, endometrial polyps and asherman
• Myoma uteri:Although it has been reported that it is among the causes of infertility with a frequency of 10%,
After excluding all causes of infertility, only myoma uteri remained.
rate is 2-3%. Fertility rate is low in women with myoma uteri.
Submucous and intramural fibroids, distortion of the endometrial cavity, cornual obstruction
and cause disruption of the neuromuscular mechanism controlling the uterotubal junction.
they may be.
• Asherman’s syndrome:The most important reason is endometrial curettage and previous intrauterine
are infections. It may present with hypomenorrhea, amenorrhea, and dysmenorrhea. in the treatment
Adhesiolysis is performed with a hysteroscopic approach. 25-70% pregnancy success after adhesiolysis