Angela's Story: A Case Study on the Reproductive System. Essay Example

You are a columnist for a popular website that deals with women's health issues. Visitors to the site can submit their stories and questions through an "Ask the Expert" link on the site. In this scenario, a 26-year-old woman has posted her story and some questions regarding reproductive health.

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My name is Angela. I am a 26-year-old married woman with no children. My husband, Doug, and I have been trying to get pregnant for over two years now, and my doctor has suggested that I consider fertility drug treatments. The irony of our situation is that I have been taking a birth control pill for five years to prevent getting pregnant, and now my doctor suggests that I take another drug to help me get pregnant.

When I went off birth control, about a year ago, my menstrual cycle became very irregular. I had been taking a birth control drug called Ortho Tri-Cyclen. To be perfectly honest, I don't understand how it works because my periods were more regular when I was on the pill than when I went off of it. My doctor told me that the pill works because it tricks your body into thinking that it is pregnant. That just confused me even more.

When I looked back on my decision to take birth control pills, I realized that I did not understand how they work. I just do not want to make that mistake again. Before I consider taking any more drugs, I want to understand more about how they work. The drug we're looking into is called Clomid. I asked my doctor a bunch of questions, but I still feel confused. I looked up some stuff online when I got home. Here is some information that I learned from a website about how Ortho Tri-Cyclen works:

Estrogen and progestin work in combination to suppress the hypothalamic-pituitary-gonadal (HPG) axis. This suppression leads to a decrease in the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary. The maturation of the dominant follicle is inhibited under the decreasing levels of FSH and LH. Hormonal contraceptive use also leads to an increase in the viscosity of the cervical mucus, which inhibits sperm penetration and movement through the cervical canal.

I am hoping that you would be able to help me understand how these drugs work.

Short Answer Questions:

In my research, I found that the levels of "gonadotropins" in the body are critical to understanding how the drugs Clomid and Ortho Tri-Cyclen work. What are gonadotropins? What role do they play in infertility?

Gonadotropins are hormones that act on either the testes or ovaries, i.e., the male and female gonads, respectively. A gland found in the brain produces them called the anterior pituitary gland, and from there are secreted into the bloodstream reaching the target gonads (de Fried and Kanzepolsky, 2016). In humans, the natural gonadotropins are follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

In males, FSH accelerates the process of sperm production and maturation in the testes, whereas LH induces the production of testosterone (de Fried, and Kanzepolsky, 2016). Testosterone is the main male sex hormone that is essential for sperm production. In females, FSH stimulates the maturation of ovum-containing follicles in the ovaries. LH levels, on the other hand, have a characteristic surge and induce ovulation, which is the process by which a mature ovarian follicle releases a mature ovum. After ovulation takes place, there are remnants of the follicle left behind in the ovary (Abehsira et al. 2016). LH is also responsible for the transformation of these remnants into a structure called the corpus luteum. The corpus luteum then secretes the female sex hormones estrogen and progesterone (Abehsira et al. 2016). These two sex hormones are important in infertility because they act on the uterus to prepare it for pregnancy by causing changes that favor the implantation of a fertilized ovum (the zygote) and the maintenance of the pregnancy (Ng, Chwalisz, Carter, and Klein, 2017).

Some of the references talk about how "negative feedback" is involved in understanding how these drugs work. Can you explain what is meant by negative feedback?

Negative feedback is a mechanism by which physiological functions are regulated in the body. In particular, the end product of a process works to slow down or inhibit the very process. An example of negative feedback is the regulation of the production and secretion of sex hormones. The anterior pituitary is producing FSH and LH (gonadotropins), which act on the ovary, eventually resulting in the production of estrogen and progesterone. The latter then acts on the anterior pituitary gland to reduce the production of the gonadotropins.

My doctor told me that birth control pills contain small amounts of estrogen and progesterone, and these hormones prevent me from ovulating. I don't understand how giving me these hormones in a pill would prevent me from ovulating. I assume that it has something to do with the levels of the gonadotropins that I asked about earlier. Can you explain this to me?

The birth control pill contains exogenous estrogen and progesterone, which have the same actions in the body as their endogenous counterparts. it includes the negative feedback role on the anterior pituitary, as aforementioned. The exogenous estrogen in the pill exerts negative feedback effect on the anterior pituitary gland causing it to reduce the production and secretion of FSH to negligible levels. In contrast, the exogenous progesterone in the pill acts similarly to cause reduced levels of LH (Moore, Prescott, Marshall, Yip, and Campbell, 2015). Consequently, reduced FSH inhibits the maturation of ovum-containing follicles in the ovary, and the reduced LH ensures that the release of an ovum from mature follicles does not take place. Thus resulting to prevention of ovulation due to the scarcity of mature follicles in the ovary and failure of the release of an ovum from ovarian follicles.

In the information about Ortho Tri-Cyclen, it mentions that the hormones in the pill make cervical mucus thicker and stickier. Does this happen during my natural cycle? How are estrogen and progesterone involved in this process?

Cervical mucus undergoes characteristic cyclical changes during the natural menstrual cycle. These changes are mediated by the endogenous estrogen and progesterone produced by the ovary and corpus luteum (Moore et al. 2015). In the first half of the natural cycle, estrogen mediates the production of cervical mucus that is watery and thin. Progesterone exerts its effects on cervical mucus in the second half of the cycle, causing it to be stickier and thicker. This thickened mucus in the cervix forms a plug that makes it unlikely for sperms to penetrate the uterus (Moore et al. 2015).

My doctor also explained that birth control pills "trick the body into thinking it is pregnant." She explained that women do not normally ovulate when they are pregnant. Can you explain to me why a pregnant woman does not ovulate? How is this related to how the birth control pill works?

During pregnancy, the ovaries and the placenta produce estrogen and progesterone in increasing measure. These elevated levels act on the anterior pituitary gland to suppress the production and release of FSH and LH. Consequently, ovarian follicles are not stimulated to mature, and lack of the LH surge that occurs mid-cycle means ovulation does not take place.

Birth control pills such as Ortho Tri-Cyclen contain both estrogen and progesterone. A woman taking these pills will have an elevated amount of estrogen and progesterone circulating in the body, similar to what happens in pregnancy. The result is that ovulation is arrested.

My doctor explained that Clomid works by "tricking the brain into thinking that estrogen levels in the body are low." She explained that this is what leads to the extra stimulation of the ovaries to encourage eggs to be released. One of the references for Clomid said this happens because there is less negative feedback. Can you explain to me how this "trick" and the decreased negative feedback are related? Why would these factors lead to the stimulation of the ovaries?

As discussed earlier, estrogen acts on the anterior pituitary gland to cause decreased levels of FSH and LH i.e.; estrogen exerts negative feedback on the anterior pituitary gland. When there is an low level of estrogen, such as that produced by Clomid, the negative feedback effect is lifted, and levels of FSH and LH are increased in circulation. FSH then stimulates the ovaries to cause maturation of ovarian follicles, while LH causes a mature follicle to rupture and release the ovum to the fallopian tubes.

My doctor told me that if I take Clomid, I would be taking it on days five through nine of my normal menstrual cycle. She explained that this is when it will have the greatest chance of stimulating the ovaries.

From day 5 to day 14 of the normal menstrual cycle, the ovary undergoes what is known as the follicular phase. In this phase, under the influence of FSH from the anterior pituitary, several (6 - 12) primordial follicles start undergoing maturation. Still, eventually, only one matures along enough to undergo ovulation while the rest degenerate (Beeder, and Samplaski, 2019). Taking Clomid during days 5 through 9 of the normal cycle increases the levels of FSH in the body during an ovarian phase, where the principal activity is the maturation of follicles. It enhances the likelihood of follicles maturing, hence increasing the chances of successful ovulation from one or more mature ovarian follicles (Beeder and Samplaski, 2019).

I read an article that mentioned that women on Clomid might be more likely to get pregnant with twins, triplets, or more! The article said that normally, there is a dominant follicle that releases a single egg, but Clomid can potentially make lots of follicles release an egg in a given month. How does Clomid do that?

In a normal menstrual cycle, even though several follicles start maturing, only one will release the egg during ovulation, while the rest undergo programmed cell death (Beeder, and Samplaski, 2019). Women who use Clomid have 2 to 3 follicles that mature all the way and release an ovum during ovulation. These ova are then fertilized by sperm and result in multiple pregnancies.