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MRCOG PART 2 SBAs and EMQs

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Essay 283: Infertility

ifertility Posted by farzana S.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss will restore  her ovulation.

Ovulation may be induced by clomiphene citrate.with follicular tracking by ultrasound . Metformin may be given in case of clomiphene resistance or along with clomipheneas afirst line meausure.

Second line of treatment will be ovarian drilling .This improves  LH and ovarian androgen levels and induces ovulation.This has the advantage of inducing unifollicular development,thus reducing risk of multiple pregnancy.Both clomiphene treatment and laparoscopic ovarian drilling  may  achieve ovulation in about 80%  with a conception rate of  about 40%. Gonadotrophin s  eg rFSH or HMg injections  can be given to induce ovulation, but there is risk of multiple pregnancy .

Third line treatment option is IVF.Success rate is about 30%,but there is risk of ovarian hyperstimulation syndrome.

She should be given contact number of support groups.

)Woman should be enquired whether it is primary or secondary infertility.Menstrual history is taken about her LMP,age at menarche,regularity of cycle ,amount of bleeding and any h/o dysmenorrhea.

Contraception history is taken regarding any previous or recent  use and type of contraception.

Coital history is taken about libido, frequency and any associated dyspareunia.Previous h/o pregnanacies  and their outcome,miscarriage  needing surgical evacuation.H/o  hot flushes or night sweats is taken.

Sexual history about any STI or pelvic infections

H/o acne ,weight gain or hirsutism is enquired.H/o headache ,visual field disturbance or galactorrhea is taken.H/o smoking or alcohol use  or excessive caffeine intake is taken.

H/o of any abdominal or pelvic surgeries is enquired

Examination includes height, weight  and BMI.Blood pressure should be checked.Presense of acne or excessive facial hair growth is noted. Oily skin with Acanthosis nigricans looked for.Breasts examined for galactorrhea.Abdominal examination is done to look for any any scars ,and abdomino pelvic mass.

b)Further investigations include assessment of ovulation by measuring  serum progesterone on day21 of 28day cycle .If the cycles are irregular this may be done later eg  D28 in a 35 day cycle and repeated weekly until menstruation.Serum  FSH and LH  is measured to assess pituitary function.

Tubal function is assessed by  doing HSG ,if there  is no h/o comorbidities such as endometriosis.chronic PID,or ectopic pregnancy.It is reliable and less expensive.If facilitiesare available  Hysterosalpingo-contrast-ultra sono graphy  may be  done to screen for tubal occlusion ,as it is an effective alternative.

If there is h/o comorbidities Lap and Dye test is gold standard as it will help assessment of tubes and pelvic pathology at the same time.

c)Couple should be given sensitive counseling and verbal and written information before during and after investigations as fertility problems can cause psychological stress.This will also help them make informed choice.

Women with PCOS have anovulatory infertility and ovulation may be induced by following  measures.

If she is over weight or obese,she should be advised to reduce weight, as even 10% weight loss wi

sorry Posted by farzana S.

There seems to be xome problrm with posying .I am extremely sorry .

Posted by mariam M.
I will take the menstrual histroy,her cycle length and regularity which will help me to determine her ovulatory status .regular cycle with ovulatory pain breast tenderness may suggest the patient is ovulating . Severe dysmenorrhea may suggest endometriosis . Obstetric history of previous pregnancies or miscarriage will determine whether primary or secondary infertility . Gynaecological history including sexually transmitted infections and history of previous abnormal pap smear. Iwill take her sexual history sexual dysfunction and infrequent ineffective coitus may cause infertility . I also will take her family history of infertility ,birth defects,genetic mutation or mental retardation.woman with fragile x may develop per mature ovarian failure. Also I will take her occupational history and exercise,stress,change in wt ,smoking and alcohol as all can affect her fertility . On examination I will take her BMI as extremes of BMI are associated with reduced fertility. I will examin her secondary sexual characteristics for features of hypogonadotrophics hypo gonadism .s Short stature squire chest may suggest Turner syndrome.Iwill examin her for thyroid abnormalities as hypo and hyper thyroidism may affect her fertility.Iwill examin her breasts for glactorrhoea which may indicate hyperprolactinaemia,also I will examin signs of androgen excess ,hirsutism,acne,male pattern baldness which may suggest poly cystic ovarian syndrome or adrenal cause. Tenderness or masses in the adnexia or pouch of Douglass are constitute of chronic PID or endometriosis . Palpable tender nodules in the dul de sac or uterosacral ligament or recto vaginal septum may all suggest endometriosis. Vaginal ,cervical structural abnormalities or discharge may suggest the presence of multiple anomalies or cervical factors. Uterine enlargement,irregularity or lack of mobility may be asigns of uterine anomaly,fibroids or pelvic adhesive disease. 2/ I will assess her ovulation by measuring mid luteal serum progesterone level,if it is more than 3ng/ml this is evidence of recent ovulation .If it is less than this I will evaluate the lady for anovulation ,I will do serum prolactin,TSH,FSH and assessment for pco .I will assess her ovarian reserve by day 3 fsh and if it is less than 10 it indicate adequate reserve .Day 3 I estradiol also can be used levels below 80pg/ml indicate adequate reserve.Antimollerian hormone AMH above .5 ng/ml indicate good ovarian reserve,and less than .15 poor reserve. If signs of verilization I will measure testosterone ,DHEAS,androstenedione,sex hormone binding globulin to differentiate pco from adrenal causes. Vaginal ultrasound for uterine size shape and any malformation, also ovarian size and prenatal follicular size and PCO and ovarian size.It can also detect any fibroids ,masses and ovarian cysts or endometriomas .Ican also do follicular trase for ovulation follow up by ultrasound. Tubal patency can be assessed by HSG ( hysterosalpingogram) ,but it will not detect peri tubal adhesions or endometriosis . Hysterosalpingogram contrast sonography can also assess tubal patency and uterine cavity. Hysteroscopy can also assess uterine cavity and is easy and safe. Laparoscopy is the gold standard investigation if there is suspecion of endometriosis or adhesions . 3/ I will mange her sensitively ,and involve amulidisiplinary team . I will advice her to reduce her weight if she is having high BMI as wt loss alone may achieve spontaneous ovulation .Metformin may regulate her menstrual cycle and achieve ovulation.itis not better than life style modifications . I will try ovulation induction by clomifene citrate for six cycles and iwill do ultrasound follicular tracing at least in the first cycle.I will tell her about side effects ( nausea ,vomiting and gastro entestinal upset.If she is not responding I will add Metformin to clomifene or do laparoscopic ovarian drilling. I may also give her gonadotropin ovulation induction and at any case I will antisepate ovarian hyper stimulation and give her information and good counseling . I will not add gonadotropin agonist cause it will not increase ovulation rate and associated with hyper stimulation .Also iwill not add growth hormone . GNRH use in apulsatile manner is not recommended.
infertility answer Posted by Priyadarshini G.

a)Clinical assessment of this patient should include a thorough history.Her regularity of cycles,date of her last       p eriods ,any abnormality of flow,any dysmenorrhea ,intermenstrual or postcoital bleedingshould be enquired .She should be asked about coital frequency,any problems during intercourse,any associated dyspareunia.A history regarding sudden weight gain,and hirsutism should be taken.She should be asked about any abdominal or pelvic sur geries.History of smoking,alcohol and use of recreational drugs should be taken.An examination of the woman will include assessment of her BMI.A general examination to note any excessive hair growth.An abdominal examination to note any tenderness or any palpable mass should be done.A speculum examination to note any vaginal discharge and any pathology like fibroid polyp should be done.A pelvic examination to note size and mobility of uterus ,any adnexal mass or any tenderness,or nodularity in the pouch of douglas should be done.b)D2 serum LH and FSH to note any ovulatory dysfunction should be done .Serum progesterone in the second half of cycle will also give information about her ovulatory status.Serum prolactin can be done if there is any associated symptom of hyperprolactinemia.A transvaginal sonography should bo done to diagnose any endometrioma or polycystic ovaries or TO mass and also to diagnose any uterine polyp ,submucous fibroid or uterine septa.HSG done as an outpatient procedure can help detect a tubal block although this will require confirmation by laparoscopy.However a negative HSG has a high sensitivity.A diagnostic laparoscopy with chromotubation can help assess any pelvic cause as well as visualisation of the ovaries and free spillage or it's absence from the tubes.Also minor procedures like adhesiolysis or ovarian drilling can be done at the same time.c)Since the woman has ben diagnosed with polycystic ovaries so the first line of management will be ovulation induction with clomiphene,50-100mg per day from D2-D6 along with follicular monitoring.Patient to be informed regarding the risk of multiple pregnancy and ovarian hyperstimulation.If she is resistant to clomiphene she can be given metformin which has shown to improve chances of ovulation with clomiphene by decreasing hypersecretion of LH.If she is resistant to both these methods laparoscopis ovarian drilling can be done .This procedure has been seen to be successful in cases resistant to medical management and also has the added advantage of reducing the risk of multiple pregnancy and ovarian hyperstimulation.Another option available is IUI with ovulatin induction.The last resort is IVF either with her ovum if she is ovulating or with donor ovum if she has anovulation.

Infertility Posted by vinivee S.

a.The initial assessment will begin by taking a detailed menstrual history concerning menarche, LMP,frequency and regularity of cycles as regular menstrual cycles usually indicative of ovulation. Any associated dysmenorrheal may suggest endometriosis or pelvic inflammatory disease. Obstetric history for previous pregnancies, miscarriages, ERPC will tell about primary or secondary infertility.Gynae history regarding recent Pap’s smear if abnormal, history of pelvic infections, any pelvic or abdominal surgeries is noted. Sexual history about frequency of coitus {coitus 2-3 times a week improves natural conception} loss of libido, dyspareunia should be taken. She will be asked about her occupation history if any work related stress that can affect relationship and libido. History of sudden gain in weight, acne, hirsutism, increased pigmentation asked to rule out hyperandrogenemia as in polycystic ovarian disease. History of galactorrhoea, headaches, and visual disturbances suggests hyperprolactinaemia. Take the drug history e.g. immunosuppressive or antiinflammatory, antidepessants, and thyroid replacement drugs, can affect fertility. History of smoking and alcohol noted, recreational drug intake to be noted as these all increase risk of infertility.

 Regarding her examination, check her height, weight, B.P, BMI as extremes of BMI associated with infertility.  Look for features of androgen excess like acne, hirsutism, male pattern baldness, oily skin. Secondary sexual characters noted, breast examination for galactorrhea done. Examine thyroid if enlarged as both hypo and hyperthyroidism associated with infertility.  Abdominal examination will be done for any palpable masses [uterine fibroids, endometriomas], tenderness, and surgical scars. Bimanual examination showing normal uterine size rules out fibroids, uterine anomalies, immobility suggests pelvic inflammatory disease, presence of adenexal masses like ovarian endometriomas,TO masses, palpable tender nodules in POD present in endometriosis. Speculum examination will show cervical, vaginal abnormalities e.g. polyps, septum and presence of vaginal discharge in STI ‘S, Chlamydia infections noted.

b Investigations to confirm  ovulation, can be done retrospectively by measuring serum Progesterone levels in mid luteal phase on day 21 of the 28 day cycle or if irregular cycles on day 28 to be repeated weekly till menstruation. Values of 16-28nmol/l are the lowest limit indicative of ovulation. An Ultrasound examination of the pelvis will be done to look for any pelvic pathology like uterine submucous fibroids,polyps,ovarian endometriomas,cysts.Transvaginal scan for total antral follicle count for ovarian reserve on day 3 of cycle,{ considering she is nearly 35 } >16 indicates high response to ovulation induction <4 low response.Antimullerian hormone levels on day 3, levels <5.4pmol/l indicate low response. Serum gonadotrophin FSH,LH levels done if history of irregular cycles, a high LH associated with reduced chances of conception.S.Prolactin measurement as 20% women with PCOS have associated hyperprolactinaemia,Thyroid function tests if features of thyroid disease present, Fasting insulin levels checked [ results in increased androgen production} Tests for tubal patency like Hysterosalpingography[ HSG ],an outpatient,easy,affordable test with high sensitivity will be offered in females who have no known co morbidities .Screening and prophylaxis for Chlamydia trachomatis to be done before HSG. Hysterosalpingo-contrast ultrasonography[Hy-Co-Sy] can be offered if available, and finally in women with co morbidities Laparoscopy and Dye test which is the gold standard will be offered as tubal patency and pelvic pathology assessment can be done at the same time.

c.The couple will be seen together and counseled sensitively as problem of infertility can cause a lot of psychological stress. People with fertility problems should be treated by the specialist team as it improves effectiveness and efficiency of treatment. She will be explained about the diagnosis, its implications and provided with evidence based information supplemented with written and audiovisual aids if available. The proposed treatment and their side effects will be discussed in detail. 

As the diagnosis of PCOS has already been made, the induction of ovulation will be planned. First of all, if high BMI she will be advised to reduce body weight by alteration in diet and exercise as loss of 10%body weight results in return of regular menstruation and ovulation.She will be put on Clomiphene citrate ,an antioestrogen 50 mg from day 2-6 of the cycle. It induces ovulation in 70-85% women with a conception rate of 40-50% and can be given for a max of 12 cycles.Councel her about the side effects of the treatment and monitor follicular studies by Ultrasound scanning. Gonadotrophin therapy, both recombinant FSH and hMG are effective for induction of ovulation in Clomiphene resistant cases [20-30%] but should not be used routinely as has increased risk of ovarian hyper stimulation. Metformin,an insulin sensitizing agent has beneficial effect on reproductive function in women with insulin resistance .Ovulation rates with Clomiphene plus Metformin are higher than with Clomiphene alone,but explain about the side effects like nausea,vomitting.Fourthly,Laparoscopic ovarian drilling using laser or diathermy to be offered in Clomiphene resistant cases, leads to ovulation in 80% of cases by normalization of serum androgens and SHBG in over 60% of women.It does not need ovarian follicular tracking and can be performed when Laparoscopy Dye test is done.The couple should be offered IVF treatment with her own or donor eggs if the above treatment is not successful and referred to a fertility centre.

The couple should be given emotional support and offered counseling before during and after investigations and treatment as it’s known to improve people satisfaction. Suggestions given to contact a fertility support group are also helpful.   

 

 

 

infertility Posted by saRADA C.

 

 

 

A) Her menstrual details are obtained which should include regularity, cycle length, flow, and LMP as regularly menstruating woman is likely to be ovulating. Periods of amenorrhoea, oligomenorrhoea indicated an ovulation. 

 

History of dymenorreohea and dysparuenia and painful defaecation suggests endometriosis. 

Details of coital frequency are noted as vaginal sexual intercourse every 2-3 days a weeks optimises the chances of pregnancy. Particular note is made about the psychological stress which may influence the coital frequency. 

History is taken about watery or milky discharge from the breasts , head ache and visual disturbances which indicates prolactinoma. History of amenorrhoea, oligomenorrhoea, facial hair and acne suggest PCOS. 

Enquiry is made abut symptoms such as weight gain, lethargy and constipation which point towards hypothyroidism.

Details of her life style are taken, regarding intake of alcohol, smoking and use of recreational drugs.

She should be asked about lower abdominal pain, dysparuenia and abnormal vaginal discharge suggesting PID. 

 

Her BMI is recorded. In the presence of facial hair, Ferriman- Gallwey system is used to assess the hirsutism. Examination is performed to assess acanthosis nigricans. Abdominal examination is  undertaken to note palpable masses and tenderness. Speculum examination is done to examine the cervix, abnormal vaginal discharge if any. Cervical smear is taken if she is due. Pelvic examination is undertaken to note the position of the uterus  as retroverted fixed uterus suggests endometriosis. Pelvic masses are excluded.

 

B) Mid luteal phase serum progesterone levels are measured . A level of 16-28nmol/l  confirm ovulation retrospectively. If her menstrual cycles are irregular, serum gonadotrophins are measured as high levels of gonadotrophins are associated with reduced fertility. If she has symptoms of thyroid disease, thyroid hormones are assessed. Serum prolactin levels are measured in the presence of galactorrhoea. Opportunity is taken to screen for rubella. If she is susceptible to rubella vaccination is given. Trans vaginal scan is undertaken to identify polycystic ovaries and to exclude uterine and adnexal pathology. Chlamydia screening is offered as she may need uterine instrumentation for the assessment of tubal patency. In the absence of comorbidities such as PID, Endometriosis, Hysterosalpingogram is offered to exclude tubal occlusion which is less invasive . Hysterosalpingo contrast sonography has good statistical comparability and concordance with HSG and lap & dye assessment . It is well tolerated and can be a suitable alternative outpatient procedure. If the woman is thought to have endometriosis or PID , laparoscopy and dye test are offered which enables to assess tubes and pelvic pathology at the same time.

 

c) If is obese she is advised to lose weight by altering the diet and exercise as 10% reduction of her weight restores spontaneous ovulation. 

Clomiphene citrate or Tamoxifen are anti oestrogens which block oestrogen receptors at hypothalamic-pituitary axis which increase levels of gonadotrophins. Clomiphene is associated with 70-80% of ovulation and 40-50% of conception rate. Treatment should be undertaken in circumstances which allow ultrasound ovarian monitoring in order to reduce the risk of multiple pregnancy. Maximum of 12 cycles is recommended which does not increase the risk of ovarian cancer. 

Gonadotrophins are offered to woman with Clomiphene resistant PCOS. Both recombinant FSH or Menopausal gonadotrophin are effective ovulation inducing agents . 

Metformin is an insulin sensitising agent shown to have beneficial effect on reproductive function and insulin resistance. The rate of ovulation is significantly higher with clomiphene + metformin than clomiphene alone. 

Laparoscopic ovarian drilling with laser or diathermy ( 

4 point diathermy set at 40 W for about 4 seconds for each ovary) is asociated with normalisation of LH , 80 % ovulation rates and pregnancy rates of 40- 69%. It is as effective as gonadotrohin therapy for ovulation induction in clomiphene resistant PCOS and free of risk of multiple pregnancy. 

 

Infertility question Posted by jessy F.
A) clinical assessment started by enquiry about symptoms she has as dysmenorrhea,deep dysparunia,chronic pelvic pain, Recent weight gain ,abnormal hair distribution,nipple discharge,,Menstrual history,regularity of cycle,period of secondary amenorrhea,amount of blood loss,family history of P.OF. Investigation done and setting where investigation done will affect the diagnosis Examination by calculating BMI,look for abnormal hair distribution and categorizing it according to ferryman Galloway score,Breast examination for galactorrhea B)Additional investigation by measuring FSH,LH,to asses ovarian function and ratio between them help to diagnose PCO,then prolactin level and TSH to rule out hypothyroidism and galactorrhea which commonly associatePCO,and to rule out pituitary causes, Pelvic ultrasound will demonstrate ovarian morphology,ovarian volume,picture of PCOthatis peripherally distributed follicles 2-9mm in diameter,also endometrial thickness give idea about degree of estrogen level Assessment of tubal function will be guided by patient history if no comorbidity she will be offered HSG, if history denotes comorbidity then laparoscopy and dye test will be done C)Options in case of diagnosis of PCO have been made includes offering her induction of ovulation in form of clomifen citrate,it is simple ,associated with few side effects familiar for most gynecologist,given in adobe of 50mg O.d for 5days from 2nd day of menstrual cycle, itis better to monitor at least the first cycle by ultrasound monitor of ovarian response to avoid problem of hyper stimulation,and next cycle could be monitored by estimating midluteal phase progesterone level. Itis increased gradually for max. Of 6month and max, daily dose 150mg In case of clomifen citrate resistance or failure the patient offeredLOD,or gonadotropin induction of ovulation LoD has got the advantage in case patient need laparoscopy for other reason ,and it avoid problem with hyper stimulation, it has got good response in patient with pre operative high LH level But carries risk of anesthesia plus risk of laparoscopy, Gonadotropin used low dose chronic step up regimen but carries risk of multiple pregnancy and risk of hyper stimulation. In view of patient age could be offered IVF &ET but this option associated with risk of hyper stimulation and multiple pregnancy, and cost implication could be an issue if couples could not cope Plus itis the option associated with highest degree of psychic Truman in case of failure Patient and partner should be involved in decision making, their view should be respected They will be given information leaflet to read in detail at home so informed decision could be made by them.
Posted by N W.

A) Clinical Assessment:

Female Partner:

  • Age, Parity, Details of previous pregnancies and outcomes. LMP and Smear history . Cycle( regular or irregular), duration and frequency. Any Menorrhagia or Dysmenorrhea? Any IMB? Any dyspareunia or postcoital bleeding? Any premenstrual symptoms? midcycle pain? frequency of intercourse? any previous use of contraception?
  • any past medical history? any chronic illnesses? any past surgical hisrtory? Is she taking any medication or herbal remedies or supplaments?
  • Any known drug allergies?
  • Does she smoke? alcohol intake ( how many units). any use illegal drugs?
  • any family history of ovarian, breast, colon or endometrial ca? any other family history? any hereditary illnesses?

 

 

Infertility Posted by sonu G.
A detailed history including her menstrual cycle, any previous pregnancy with present or past partner,sexual life and use of any agents during intercourse should be taken.medical history should include Previous infection with tuberculosis,chlamydia,gonorrhoea etc to r/ o tubal blockage.any history of wt. loss or gain fatigue or excessive hair growth on galactorrhoe a should be taken.surgical history would include any previous surgery that mey lead to adhesion and there by tubal blockage. Her drug history should be taken to see if there is intake of any medication that may be affecting her fertility. A general examination would include her ht ,wt, look for truncal obesity,signs of hyperestrogenism( acne hirsutism,male patterm hair loss or gain and body form.look for any galactorrhoe,and abdominal mass. Speculum exam. Is conducted to look for any cervical pathology,abnormal vaginal discharge. (B) investigations would include LH and FSH on day 2 if cycles are regular otherwise random if irregular.raised levels can give information regarding premature ovarian failure. A level > 30 iu on 2 occasions done at interval of 4-6 wks suggest premature ovarian failure. TFT has a role only if there is a history of irregular cycle or sudden change in weight. S.prolactin is performed if there is a history of irregular cycle,galactorrhoe ,headache or visual defect suggestive of prolactinoma otherwise it does not have much significance in a asymptomatic women with regular cycle.if there is suspicion of prolactinoma then further investigation with CT head would be required as X-ray might not be able to detect microprolactinoma. S. testosterone and shbg has a role if there is suspicion of PCOS . Ultrasound preferably TVA should be done to r/o PCOS,adnexal pathology , fibroids and and congenital abnormality of the uterus at the same time. Hag is performed in asymptomatic women with no h/o recent vaginal infection to assess the tubal patency.this is a simple outpatient procedure and often well tolerated by woman ,does not need any form of anaesthesia, or special training to be performed. Women with additional suspected pathology like endometriosis,dysmenorrhea or dyspareunia shoud preferably have laparoscopic assessment of tubes with dye as this will give opportunity to see other pathology and as we'll treat at the same time. (C) important to treat sympathetically and holistically. Inform what the diagnosis of PCOS means.(anovulation ,oligomenorrhoea ,clinical or biochemical picture of hyper androgenism,or scan findings consistent with vol.>10ml or follicles>12/ovary) If BMI high to reduce weight which brings ovulation in majority. A loss of wt. by only 5% can bring ovulation.alter lifestyle by exercise and diet. If BMI normal then ovarian drilling highly successful in bringing ovulation and normalising hormones. Has no risk of overstimulation or multiple pregnancy. Ovulation induction with antioestrogens like clomiphene and tamoxifen are highly successful in causing ovulation in around 80% and live birth around 40-50%. Metformin an insulin sensitising agent can be added along with clomiphene to improve the success rate.metformin reduces insulin resistance ,prevents hepatic gluconeogenesis and later prevents miscarriage.when used alone not very effective in ovulation and not licensed for this purpose. Gonadotropin s are useful in clomiphene resistant ovaries can be done along withIUI / IVF. Will need follicular monitoring due to risk of multiple pregnancy and OHSS. Important to give leaflets and information regarding support groups.
Posted by iram F.

a

Posted by zahraa H.

a)First I d  discuss the matter in a sensetive and confedential manner. I d like to ask about a detailed history , and whether either of this couple had childeren from previous relation and if positive for the female detailed obestetric history should be optained, occupation for both parteners,menstrual history regarding menarche , regularity any associated symptom. Sexual history frequeny associated pain ,discharge,difficulty.Contaceptive history and type and duration of use. Id like to ask the ladyif she recognized any change in her body as rapid wt gain , increased body hair. Also Id like to ask about any past medical or surgical history and any medication being used.Then I d proceed for general examination BP, wt ,Ht BMI,Id look for secondry sexual characters , hair distribuition breast develpment.Id ask for general investigation FBC, U &E

b)pelvic U/S assessment for the uterus ovariesand any associated abnormality,HSG to assess tubal patency and ut>anomaly .Hs analysissecond mentrual day LH, FSH,estradiol prolactin and thyroid function .Decting ovultion by midluteal progesterone assessment ( day 21 in 28 d cycle)

c)Id like to emphasize the importance of optimizing female body wt  by dieting and exercise and that this  alone can aid conception. ovulation induction by clomifen citrate 80% ovulation rate 40% concetion. metformin alone or with clomifin citrate . second line of ttt is laparoscopic ovarian drilling, if these failed then IVF can be done

Posted by deva priya dhar M.

history should be asked in a sensitive manner  about her frequency of sexual intercourse,and associated with dyspareunia, menstrual history about the regularity, cycle length,whether associated with dysmenorrhoea.past history of any abdominal or pelvic surgery,any previous history of vaginal discharge associated with fever& lower abdominal pain for that she was hospitalised.social history of smoking/alcohol/caffeine consumption& occupation.

on examination, BP should be checked ,BMI measured, secondary sexual characters, acne,hirsutism,acanthosis nigra should be noted,any thyroid swelling ,cushingoid features like central obesity,moon  face noted.abdominal examination performed for any mass,tenderness.pelvic examination should be performed to detect  any mass,to assess mobity of uterus, tenderness and nodules in pod and tenderness of adnexa 

investigations include serum progesterone on day21 if 28day cycles .and to repeat weekly in prolonged cycles and to be interpreted with the next menses. if progesterone less than 30 mmol/l further tests like fsh/lh/thyroid function tests and prolactin should be done.if signs of hyperandrogenism further tests like serum testosterone,dhea,17 oh progesterone will be required

A trans vaginal ultrasound should be done to see pelvic organs.

tubal patency should be checked by hysterosalpingography or hystero contarst sonography if available , in the absence of history suggestive of any endometriosis. if any risk factors present laproscopy with dye test is the gold standard test to assess tubal function look for  adhesions and other abnormalities

c,,in a women with pcod ,cause for infertility is anovulation

first option is she should be advised to reduce her weight.Meanwhile advice should be given to modify lifestyle,reduce smoking and alcohol.weight reduction will help to acheive ovulation ,increse the efficacy of drugs and have a positive impact on health.her rubella status/ cervical smear history should be checked. folic acid supplementation given.

second is metformin .it can be given alone or with clomiphene citrate. side effects gastrointestinal such as nausea, bloating. advantages are no risk of multiple pregnancy

clomiphene citrate can be given alone  as first line therapyor with metformin .it has significant effect in acheiving ovulation and clinical pregnancy and live birth.  side effects are risk of multiple pregnacy in 10% of women. so ultrasound monitoring is needed atleast in first cycle.

if clomiphene citrate is resistent or failure to acheive ovulation next option is gonodotrophins . 

last will be laparoscopic ovarian drilling. there is no risk of multiple pregnancy.but a small risk of surgery,anasthesia and adhesions & ovarian failure should be counselled.

Posted by abeer E.

Detailed history from the woman regarding her menstrual history-age of menarche, cycles regular or irregular,is it associated with dysmenorrhoea , any intermenstrual or postcoital bleeding.Obstetric history- to know if she had previous pregnancies,miscarriage, ectopic pregnancy.history of PID before. personal history of smoking , alcohol and recreational drugs.sexual history- to know about the coital history, dyspareunia.contraception history- the contraception which she was using before.any treatment tried before and whether she is uptodate with the cervical smear.also to ask her if she has a history of weight gain or weight loss,any hot flushes or any discharge from the breast with or without visual symptoms, excessive weight gain and history of hirsutism, acne.

examination-bp and bmi of the woman,general examination for acne hirsutism,greasy skin and acnthosis nigricans-this will enable me to know if she is having polycystic ovary . p/a- to look for straitions, any masses felt.p/s if vaginal discharge 

investigations-first i will offer her LH, FSH and estradiol to know how the pituitary functions, also mid luteal phase progesterone to know if she is ovulating.t3,t4 and tsh to rule out hyperthyroidism,serum prolactin for hyperprolactinaemia,ultrasound of the pelvis to rule out the polycystic ovaries, also hysterosalpingography to know the patency of the tubes,if the woman gives the history of ectopic pregnacy, pid or she has endometriosis then lap and dye should be advised to know the patency of the tubes.

treatment-lifestyle modifications should be advised, if she is overweight then she should be advised to reduce weight by diet, exercise . advise to quit smoking and if she takes alcohol, then she should be advised to take 1-2 units in 1 week.medical treatment- clomiphene should be given starting on day2-5 of the menstrual cycle. woman should also be told about the side effects of the medications.during the first cycle, ultrasound should be done for follicular tracking. if no response then meformin can be added if she is overweight. clomiphene should not be given for more than 6 cycle. those who are clomiphene resistant can be started on gonadotrophins. for thin woman laparoscopic ovarian drilling isw advised which actually lowers the leutenising hormone.

if still no response then ivf should be tried and as the woman if 34 year old then she can be given upto 3 cycles of complete treatment. 

infertility Posted by dr.nayla Z.

A.My clinical assessment will constitute history and examination that should be in calm, quite and confidential environment according to couple’s preferences. It will include gynecological history including age of menarche, cycle regularity, any associated complaints, premenstrual symptoms, date of last menstrual period, vaginal discharge and last Pap smear date and report if available, any history of contraception. Her past obstetrical history is also important in determining the nature of infertility either primary or secondary. History will also encompass on couple’s sexual life; frequency of coitus, any difficulty experienced dyperunia, ejaculatory problems, libido, I will also assess her information about fertility day’s utilization. Any investigations and treatment she took for infertility up till now. I will ask about endocrine history including wt gain, hirsuitism, acne, about her general life style including exercise, smoking. Partner’s history about occupation, medical/surgical history, history of trauma, infections,  drug usage.

History will follow thorough examination including B.P Ht, Wt, acne, hair distribution, galactorrhoea, and thyroid. Abdominal examination will include any palpable masses, tenderness, and scars.  After informed consent I will do her per speculum and bimanual vaginal examination for any visible abnormality in vagina cervix, vaginal discharge bleeding, to take Pap smear if due, for uterine size version mobility, tenderness fullness in fornices.

B. as semen analysis is normal we will focus on tests to confirm ovulatory status and tubal factor of the female partner. If women is having regular menstrual cycles, more likely she is ovulating still we will confirm it with mid luteal phase progesterone (21 Ist day serum progesterone, lower limit should be from 16 to 28 nmol/l) as 10 % of regular cycles can be anovulatory. If she is having irregular cycles we will do 21 Ist day serum progesterone late in the cycle and repeat it every weak till the onset of next period. If we have suspicion of anovulatory cycles we will go for serum FSH, LH, prolectin. if symptoms of thyroid disease TSH should be offered, as thyroid disease is present in infertile  population in the same ratio as in general population so routine thyroid function tests are not recommended. I will also go for her viral status like HIV, Hep C and B and Rubella because these have potential impact on fertility treatment. As this patient is 34 yrs of age she should also be assessed for ovarian reserve,which will be important to see her ovarian response in natural and IVF cycles. This can be can be done by doing transvaginal ultrasonography to see number of antral follicles and by doing her antimullerian hormone levels.transvaginal ultrasonography is also helpful to diagnose other pelvic pathologies, and when it is combined with the use of contrast medium or saline which is introduced in the uterine cavity and fallopian tubes to see the tubal patency and to outline intrauterine lesions, it becomes a very useful modality in patients with infertility, because it’s an outpatient procedure ,easy to perform and easily tolerable by patients.hysterosalpingo contrast sonography is having comparable effectiveness with hysterosalpingography and laparoscopy and dye test, we should offer it as a first line investigation tool for patients with no history of co morbidities like endometriosis and pelvic inflammatory disease etc. hysterosalpingography is another investigation for assessment of tubal damage which is also a suitable alternative to laparoscopy and dye test in women having no co morbidities as there is a little chance of flare up of pelvic inflammatory disease and sometimes its not easily tolerable for women. It’s a reliable test for tubal patency but not a reliable test for tubal occlusion. tubes which are diagnosed patent on HSG, 94 % are confirmrd on laparoscopy and tubes which are diagnosed occluded on HSG only 34 % are confirmed on laparoscopy. so if occluded tubes diagnosed on contrast sonography or hysterosalpingography or patient is having history suggestive of co morbidities she should go for laparoscopy and dye test which is gold standard to diagnose tubal status as well as other pelvic or abdominal pathologies.

Clamydial antibody titer is significantly associated with tubal damage, but extent of tubal damage has to be confirmed on laparoscopy so in terms of diagnosis it will not add any information, but if any uterine instrumentation needed we have to go for chlamydial antibody titers to give prophylactic antibiotics.

C. the cause of infertility associated with polycystic ovarian syndrome is usually anovulation.80 % of anovulatory women are having polycystic ovaries. First step in the management of such patients is to make patient understand about her disease and what will be the line of management, in both verbal and written form. Management options in this case will be wt reduction, medical and surgical management of anovulation. 60% of PCO pts are obese. if BMI is >= 30 she should be advised wt reduction.10-15% of wt reduction will cause ovulation in 90% of cases and pregnancy in 50% of cases. Wt reduction with the help of support groups has shown good results. Medical methods for ovulation induction will include clomiphene citrate, parentral gonadotrophins and insulin sensitizing agents. Clomiphene has 80% ovulation rate, 40% pregnancy rate and 10% multiple pregnancy rate and < 1% OHSS. Should be first line management and be given upto 12 cycles. Monitoring of response should be done in at least first cycle. Insulin sensitizing agents like metformin is also widely used in patients with PCO along with clomiphene citrate, it has good results. Patients resistant with clomiphene should be given an option for parentral gonadotrophins or laparoscopic ovarian drilling. gonadotrophins are related to increased risk of OHSS and multiple pregnancy.cumulative pregnancy and live birth rate in gonadotrophin treated patients is 60- 70% after 12 months use. Surgical method of ovulation induction in these women can be laparoscopic ovarian drilling which has same pregnancy and live birth rates after 12 months of procedure as that in parentral gonadotrophins. It is a surgical procedure having its own risks of anesthesia and procedure related risks( adhesions) but not associated with risk of multiple pregnancy or OHSS. 50% of patients conceive within 1 year especially in patients with clomiphene resistance, having high LH levels and low BMI.if all measures fail then we should go for IVF and ET.

Infertility Posted by Haytham M.

A)The main aim of my assessment is to determine the type of infertility wheather primary or secondary,ovulatory cause or tuabal factor or unexplained infertility.I will take a detailled obstetrical history to know if she had been pregnant before as if so she will be a case of secondary infertility.Detailled gynaecological history including regular periods with mild pain indicationg ovulation.Oligomenorhoea or amenorhoea suggest anovulation.Dysmenorhoea might give a clue for endometriosis.History of galactorhoea may indicate hyperprolacinaemia.Sexual history including superficial or deep dyspaeunia ,abnormanl vaginal discharge or chronic pain might suggest edometriosis or pelvic inflamatory disease.Medical history including thyroid symptoms,should be obtained.Surgical history of pelvic or gynaecological surgeries might indicate tubal factor.Examination should look for BMI as extremes of weight are associated with decreased fertility.BP is imprtant to diagnose conditions like Cushing disease. Signs of hyperandrogenisity like hisutism and acanthosis nigricans may suggest adrenal cause or polycystic ovary syndrome(PCOS).Abdominal examination to exclude pelvic mass like uterine fibroids should be done.Speculum to look for the vagina,cervix and triple swap should be taken for gonorhoea ,chlamydia and bacterial vaginosis as well as cervical smear if due as part of infertility assessment.Bimanual examination to look for tenderness ,nodularity and fixed uterine mobility might suggest endometriosis.                                                                                                                                                              B)Further investigations include midluteal progesterone level which shows if patient is ovulating.FSH ,LH and LH FSH Ratio might give a clue of the Ovarian reserve or PCOS.Antemullarian hormone of 25 IU or more indicate good ovarian reserve while 5.4 IU or less poor reserve.Pelvic U/S Scan for uterine fibroids or features of PCOS.Thyroid function test and serum Prolactine if features of Thyroid disease or hyperprolactinaemia only.Serum Sex hormone binding globuline ,testosterone for PCOS if history idicating so. Tubal assessment tests depends on other factors.If pelvic co morbidity like endometriosis or adhesions are suspected then Laparoscopy and die should be done.if patient prefered not to go for General anaethesia then Hysterosalpingogram (HSG) should be considered.If uterine cavity pathology suspected then Saline infusion sonography(SIS) or Hysterosalpingocontast Sonography (HYCOSI) may be done. Also as part of the assessment I will consider screening for Rubella ,HIV                                                                                                                                                       C)PCOS treatment needs multydisciplinary team including Obstetrician ,Edocrinologist and Dietician.I will start by weight reduction if she has high BMI as by doing so she might resume regular periods and spontanious pregnancy.Then I will induce ovulation wheather by Clomiphene citrate,or Metformin or both medications as the same time.If failled I will consider r FSH but this is associated with more risks of multipple pregnancy and ovarian hyperstimulation syndrome (OHSS) and need for follicullar tracking.If ressistant to medications I will consider Laparoscopic ovarian drilling as this is associated with less OHSS and multiple pregnancy rates.If not responded to the mentioned options I will refer her for IVF to be done in a specialised centre.Last option is to consider adpotion.I will also provide her with information leaflet ,websites and support group.                                                                                         

essay on infertility Posted by Julie A.
A. Detailed history should be taken which includes menstrual history such as LMP,cycle length,regularity of cycles,past obstetric history such as any previous pregnancy and outcomes,gynaecological history of any tubal disease,sexually transmitted infections,any ectopic pregnancy,endometriosis,contraceptive history which includes use of any contraceptives ,sexual history such as frequency and timing of intercourse,social history such as smoking and alcohol use,any history of chemotherapy,radiotherapy,recent change in weight,acne,hirsuitism,deepening of voice.acanthosis,any drug intake,excessive exercise,eating disorders,galactorrhoea,features of thyroid disease. Examination to look for BMI ,acne,male pattern baldness,acanthosis. Abdominal examination to look for any visible masses,tenderness,bimanual examination to check uterine size ,position,mobility,tenderness,adenexal tenderness,masses,cervical excitation. B.investigations such as blood investigations serum FSH,LH,DHEA,DHEAS,testosterone,SHBG,TFTs,serum prolactin to rule out PCOS,prolactinoma,thyroid dysfunction.USG pelvis to rule out PCOS,fibroids. If elevated prolactin,CT/MRI to rule out pituitary adenoma.If features of endometriosis,STI,tubal damage laparoscopy for diagnosis and ablation of endometriosis /adhesiolysis.otherwise hysterisalphingogram for tubal latency.chlamydia screening to check STI. C.Treatment for PCOS includes weight reduction-10% would result in ovulation and pregnancy rates. Second line includes ovulation induction with clomiphene citrate and metformin if not successful.ultrasound tracking of follicles should be done to prevent multiple pregnancy and OHSS if clomiphene is used .50 mg from day 2-5 with counselling regarding side effects. If not successful,laparoscopic ovarian drilling can be tried.advantage is reduced risk of multiple pregnancy and assessment of tubal latency and treatment of endometriosis and adhesiolysis. if none of these methods work,IVF should be considered if the couple fulfills the criteria.Gnrh agonists and hcg use should be monitored and if high risk for ohsss regime should be individualised.multiple pregnancy should be avoided by use of USG and selective embryo transfer.
Posted by iram F.

 

A.I will begin by asking about the regularity of the menstrual cycles as regular cycles are indicative of ovulation.Oligomenorrhoea along with hirsutism is suggestive of polycystic ovarian syndrome.History of dysmenorrhoea,dyspareunia,dyschaezia is associated with endometriosis.She should be enquired about the coital frequency and timing.History of recreational drug abuse,smoking,alcohol intake of more than 5 units per week is also relevant.Previous obstetric history whether she has any children from a previous partner.History of current medications like antipsychotic drugs,metoclopromide,anti-tuberculous medications.History of chronic illness like Liver Cirrhosis,Tuberculosis,Renal failure is also associated with infertility.Any Contraceptive use should be asked for particularly long acting injectible progesterones are associated with delay in return of fertility.History of any sexually transmitted disease can be suggestive of pelvic inflammatory disease.As her partners semen analysis is normal,a history of any ejauculatory disorders should suffice  from the woman’s partner.The womans BMI should be calculated as extremes of BMI less than19kg/m2 or and more than 30kg/m2 are associated with reduced fertility rates.

B.A serum progesterone test should be performed on day 21 of a regular cycle or day 28 of an irregular cycle to confirm ovulation.Ultrasound scan should be performed to look for polycystic ovaries;ovarian endometriomas;antral follicle count to assess ovarian reserve.If the menstrual cycles are irregular serum FSH,LH ,Prolactin should be performed.Thyroid function tests should be performed if history is suggestive of thyroid disease.Hysterosalpingogram can be performed to assess the patency of the tubes.But if the history is suggestive of any comorbidities a diagnostic laparoscopy should be performed to look for features of endometriosis,adhesions,pelvic inflammatory disease.Antimullerian hormone can also be tested to assess ovarian reserve of the woman.

C.The first line management in women with polycystic ovarian syndrome who associated infertility is lifestyle modifications like weight reduction by diet and exercise as this alone is associated with resumption of ovulation,regularity of cycles,improved pregnancy rates.Clomiphene citrate for 12 cycles is the next line of management.Clomiphene is an antiestrogen associated with ovulation in 70-80% of women and  pregnancy rates of 40-50%.But clomiphene is associated with multiple pregnancy and ovarian hyperstimulation syndrome.Use of it beyond 12 months is associated with ovarian carcinoma.If she fails to respond to clomiphene alone adding a biguanide,Metformin is associated with improved fertility and regularization of menstrual cycles.Laparoscopy with ovarian drilling is another option which is associated with no risk of multiple pregnancy or ovarian hyperstimulation syndrome.But it is associated with anaesthetic and surgical risks and loss of ovarian function if more than 5-6 diathermy punctures are made in the ovaries.Another option is induction of ovulation with gonadotropins.Pure urinary FSH,Recombinant FSH,Human Menopausal Gonadotropins all have equal efficacy. 

Posted by Attia R.
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Infertile couple posted by Attia riz19.06.2013 Posted by Attia R.
Supposing that semen analysis repeated twice female partner should have history of menstrual cycle ,irregularity,dysmenorrhea ,as anovulatory cycles are irregular.history of coitus frequency associated dysmenorrhea .history of wt.gain hair growth ?acne points to PCO.rule out thyroid dysfunction by inquiring about lethargy ,constipation,.ask about previous history of pelvic infections as it may cause tu bal damage.family history of early menopause?genetic problems?autoimmune disorders.any headaches nipple discharge for prolactinomas.drug history like immunosuppressants anti psychotics as all might disturb ovulation.chronic disease?stress .,recent weight loss ...will tell hypothalamic dysfunction. BMI general examination blood pressure,if hirsuitism Farman Galway scoring.breast exam for milky discharge.abdomen for masses? Tenderness.speculum if discharges.vaginal exam for mobility of uterus adenaxa sizable of uterus. B)serum progesterone day 21of28 day cycle(28of35daycycle)ifovulating tubal function must be assess by HSG as it is cheap sensitive enough to diagnose patency.if associated morbidities like PID endometriosis choose lap n dye to treat the disease in same setting.it will be advisable to check FSH level cycle day 3 for pituitary function high FSH check antimullerian harmone for ovarian reserve.NICE recommends Prolactin if symptoms . C)sensitive approach to female reassure her that condition is treatable.lifestylemodifiction stop alcohol .,smoking Weight loss as10%ofwt loss associated with increase ovulation.also her response to treatment will be improve by wt loss less resistance.clomifen citrate should be offered for 6monthscan be combined with meteor in in obese and non responsive patients(NICE2013)laparoscopy n ovarian drilling Is 2ndlinewho don't response to clomifen .less risk of multiple pregnancy and absolutely no risk of hyper stimulation while clomifen carries risk of multiple pregnancy (7%)plusOHSs although small. Ovarian drilling associated with improving ovulation upto 80% and most of them conceive. Next option is gonadotropin recombinant FSHbut risk of ohss.patient should be counseled about risk of ohss morbidity associated with OHSs and should have 24 hour access to hospital.written information and support groups.
BULLET POINTS FOR THIS ESSAY Posted by vinivee S.

Dear Paul,                                                                                                                                                           Please could you clarify regarding the drugs.............?  .the online notes do say that NSAIDS,Immunosuppresives,Antidepessants,Tranquilisers and recreational drugs all have elevated risk of anovulatory infertility..?                           Also,         Could you kindly  give us the bullet points for this essay.     thanks.                                                                                                                                                

Bobey Posted by Bobey B.
a)Detailed menstrual history should be inquired regarding regularity ,frequency ,amount and associated pain. Regular cycles are usually indicative of ovulation. Past history of amenorrhea and oligomenorrhea must be asked for PCOS. A specific enquiry about sexual history should be taken ,including coital frequency . Intercourse occurring regularly 2-3 times a week may raise fecundubility . A specific enquiry about life style including alcohol intake should be taken. Drinking no more than 2 units twice per week and avoiding episodes of intoxication is likely to reduce risk of harm to developing fetus. A specific enquiry about occupation , as exposure to radiation may lead to premature ovarian failure. Detailed drug history should be asked ,as drugs affecting fertility such as : No steroidal anti-inflammatory drugs, antidepressant , tranquilizers have reported to have elevated risks of anovulatory infertility. Also, chemotherapy can induce ovarian failure. Enquiry about recreational drugs as marijuana and cocaine can adversely affect ovulatory and tubal function. History of previous sexual transmitted infections should be taken as Chlamydia and gonorrhea .These are associated with tubal damage . In order to avoid delay in fertility treatment , specific enquiry about timing and result of recent test should be asked. General examination should include BMI , presence of hirsutism , acanthosis nigricans and signs of virilisation to exclude PCOS and late onset CAH . Abdominal and pelvic examination for pelvic mass , polycystic ovaries and fibroid. b)Additional investigations would be offered to assess ovarian reserve and ovulation. AMH shows the potential to be reliable marker of ovarian reserve and hence reproductive performance. Reduced AMH levels are indicative of reduced antral follicle pool and hence ovarian reserve. AMH of less 5.4 pmol/ L for low response and greater than 25 pmol/L for a high response. Total antral follicle count from both ovaries less or equal to 4 for low response and greater than 16 for high response .Total antral follicle count can be measured by TV/US on day 3 of menstrual cycle. FSH values > 8.9 IU/L on the day 2-5 of the menstrual cycle for low response and associated with reduced ovarian reserve . FSH values < 4 IU/L for a high response. She should be offered a blood test to measure serum progesterone in mid-luteal phase on day 21 of a 28-day cycle . Values of 16-28 nmol/L are the lowest limit indicative of ovulation. Other hormonal tests based on the history or examination would be done, but not routinely. Additional investigations for tubal patency and function should be offered. If she is thought not to have co morbidities such as PID, endometriosis, should be offered HSG for ruling out tubal occlusion.HSG is cheap, less invasive and not required general anesthesia. It allows assessment of pelvic pathology at the same time. If she is thought to have co-morbidities, she should be offered laparoscopy and dye test .It is considered the gold standard. Hysterosalpingo-contrast-sonography (HyCoSy) is suitable alternative to HSG, where she is thought not to have co-morbidities .It allows detection of uterine pathology such as fibroid, septae and polyps. If the history suggests PCOS or uterine fibroid, TV/US can be used to assess pelvic anatomy and evaluate pathology such as endometrioma, cysts, polyps, fibroids, adenxal and ovarian abnormality. She should be offered testing for rubella status to confirm immunity. She should be offered vaccination if not immune. Screening for Chlamydia trachomatis should be offered following HSG or being undergoing uterine instrumentation. DNA techniques such as PCR and LGR of cervical and urine specimens are highly sensitive and specific for diagnosis of chlamydial infection. c)If her BMI is 30 or over ,she should be advised to lose weight , as it has value of unifollicular ovulation and it improve pregnancy outcome. Clomifene citrate induces ovulation in 70-85% of women with PCOS with 40-50% conception rate .A maximum 6 months is recommended. Ultrasound follicular tracking to minimize risk of multiple pregnancy. Metformin –Insulin sensitizing agent, shown to have beneficial effects in reproductive function. It is associated with nausea and vomiting. Combination of metformin and clomifene citrate has higher ovulation rate than with clomifene alone. If she is resistant to clomifene citrate, laparoscopic ovarian drilling (LOD) is to be considered after the woman preference. It is not associated with risk of multiple pregnancy. It has risk of visceral injury 1/1000. Gonadotrophins are effective ovulation induction agents in women with clomifene resistant PCOS. Ultrasound follicular tracking reduce risk of multiple pregnancy and ovarian hyperstimulation. No advantages in routinely using GnRh analogues in conjunction with gonadotrophins in these women. It is associated with increased risk of ovarian hyperstimulation. IVF is the last option. She should be informed that chance of a live birth following IVF treatment falls with rising female age.
Infertility essay Attia R Posted by Attia R.
Please Paul sir correct my essay thanks
infertility essay Posted by ghada S.
  1. a) Clinical assessment

I will check history including menstrual history.I will ask about regularity of menses as oligomenorrhea may suggest anovulation, also severe dysmenorrhea which starts before menses & increased during it may point to pelvic pathology i-e endometriosis.I will ask whether menses is spontaneous or withdrawal by medications. Sexual history is also important to check frequency of coitus, any psychosexual problems& any dyspareunia which suggest pelvic pathology: chronic PID, or endometriosis. History of chronic pelvic pain, recurrent attacks of pelvic infection may point to tubal factor of infertility.

Examination should include BMI as obesity is common in polycystic ovarian syndrome (PCOS). Presense of hirsutism, temporal baldness may point to hyperandrogenism. I will check for thyroid enlargement , galactorrhoea &hair around nipple.

Abdominal examination for any masses or tenderness & pubic hair distribution.

Local examination for tender adnexia, adnexial mass & tender cervical movement may suggest chronic PID. The presence of fixed RVF uterus, tender nodules in uterosacral ligament or pouch of Douglas may indicate endometriosis

  1. Additional investigations

I will offer serum progesterone day 21 of 28 cycle to check ovulation. If irregular cycles weekly progesterone can be checked starting 1 week before the expected date of next menses. I will offer test of tubal patency: Hysterosalpingography (HSG) if no suspected pelvic pathology, or laparoscopy & dye if suspected pelvic pathology or abnormal  HSG .

I will offer transvaginal ultrasound (TVU) to check size & shape of ovaries.A polycystic morphology or increased ovariav volume> 10 cm3is one of Roterrdam criteria for diagnosis of PCOS.The morphology is the presence of 12 or more follicles of 2-10 mm which are peripherally arranged around hyperechogenic medulla. The diagnosis of PCOS is made if 2 out of 3 roterrdam criteria is present. This include chronic anovulation,clinical or biockemical hyperandrogenism & ultrasound morphology of polycystic ovaries. TVU can also detect adnexal masses i-e endometrioma& tuboovarin mass.

I will offer serum androgen level as free androgen index & serum total testosterone to check hyperandrogenism. Serm prolactin in case of galactorroea & if abnormal I will check TSH

C) options

Weight reduction if BMI >30. Induction of ovulation by clomiphene citrate50 mg twice daily for 5 dayes from 2ndday of cycle for 6 cycles. Folliculometry should be offered at least one cycle to check response & adjust dose. Metformine can be added especially in obese patient to improve response.

Gonadotropin induction of ovulation is another option.The woman should be informed about risk of ovarian hyperstimulation (OHSS) & multiple pregnancy. Folliculometry is essential to reduce these risks.

Laparoscopic ovarian drilling is another option which is as effective as gonadotropins, avoids OHSS &multiple pregnancy but it can reduce ovarian reserve.

Stimulated cycles of intrauterine insemination can also be offered with low success rate about 10-20%

Considering the woman's age IVF is appropriate option that should not be delayed if other options failed to achieve pregnancy  

infertility SAQ Posted by NAZIA H.

 

A The couple should be seen together in clinic and asked about lifestyle,occupation,sexual actvity,or any disorder associated with it .They are asked about alcohol ,smoking habits,and use of any recreational drugs.They are enquired aboutany existing or past medical illness or surgeries.family history of medical or genetic disease is asked.any history of mumps, or trauma and surgeries in genital area are explored.the woman asked for menstrual irregularities,oligmenorrhea,amennorhea,intermenstrual bleeding ,postcoital bleeding,dysparunia,including last date of cycle and amount of flow.History of galactorrea, pelvic pain,abdominal pain ,urine and bowel problem asked.On examination swelling of neck,signs of hyperthyroidism noted.any disharge from breast seen. abdominal palpation will give idea of tenderness and masses.local examination of genitalia and cervix looked for abnormalities. Hirsutim and signs of virilizaion are noted.

B Man is advised for semen analysis.woman is advised for ovulatory dysfunction; day 28 serum progesteroneif having regular cycle or day 28 level if 35 day cycle or longerand repeated weekly until menses start,FSH levelsdone if cycle is irregular for ovulatory dysfunction.ovarian reserves ar assesed with FSH level ,antimullarian hormone level, follicular count which will also predict  her response to ovarian stimulation.Tubal patency is checked with hysterosalpingography which is simple,and cost effective.hysterosalpingo contrast sonography is done which is more accurate if expertise is available. ultrasonography for uterine abnormalities is required.If history suggestive of endometriosis then laproscopy with dye test is gold standard.thyroid dysfunction needs thyroid function tests and serum prolactin will be raised in galactorrea

C If the diagnosis is polycystic ovarian syndrome,then anovulation is probable cause of subfertility.The treatment options include expectant management which is less likely to be acceptable to couple as they are trying for 24 months. Second option is ovulation induction with clomiphene citrate, metformin , letrozole depending upon her risk of ovarian hyperstimulation.clomiphene is given for six cycles and clear information is given for Ovarian hyperstimulation syndrome risk which can be deceased by follicular tracking with ultrasound for first cycle.

Clmiphene resistant cases are treated with Laproscopic Ovarian Drilling which will improve hyperandrogenemia and ovulation.In LOD four diathermy burn points applied on ovaries laproscopically. 

The last and best option in this couple case is IVF invitro fertilization carried out in specialist clinic involving a specialist  counsellar to reduce psychological stress associated with assisted reproductive techniques.Controlled ovarian stimulation with follicular tracking ,oocyte retrieval under ultrasond guidance and single embryo transfer of high quality is associated with high chance of pregnancy in this coupleor two embryo transfer if top quality embyo not seen. Patient well informed of OHSS and multiple pregnancy befre starting treatment.

 

 


mistake in typing Posted by Bobey B.
Iam so sorry for this mistake .wrongly , I typed in section b) HSG is cheap , less invasive and not required general anesthesia . If she is thought to have co -morbidities such as PID, endometriosis , she should be offered laparoscopy and dye test .It is considered the gold standard . It allows assessment of pelvic pathology at the sametime.
Posted by Bobey B.
a)Detailed menstrual history should be inquired regarding regularity ,frequency ,amount and associated pain. Regular cycles are usually indicative of ovulation. Past history of amenorrhea and oligomenorrhea must be asked for PCOS. A specific enquiry about sexual history should be taken ,including coital frequency . Intercourse occurring regularly 2-3 times a week may raise fecundubility . A specific enquiry about life style including alcohol intake should be taken. Drinking no more than 2 units twice per week and avoiding episodes of intoxication is likely to reduce risk of harm to developing fetus. A specific enquiry about occupation , as exposure to radiation may lead to premature ovarian failure. Detailed drug history should be asked ,as drugs affecting fertility such as : No steroidal anti-inflammatory drugs, antidepressant , tranquilizers have reported to have elevated risks of anovulatory infertility. Also, chemotherapy can induce ovarian failure. Enquiry about recreational drugs as marijuana and cocaine can adversely affect ovulatory and tubal function. History of previous sexual transmitted infections should be taken as Chlamydia and gonorrhea .These are associated with tubal damage . In order to avoid delay in fertility treatment , specific enquiry about timing and result of recent smear test should be asked. General examination should include BMI , presence of hirsutism , acanthosis nigricans and signs of virilisation to exclude PCOS and late onset CAH . Abdominal and pelvic examination for pelvic mass , polycystic ovaries and fibroid. b)Additional investigations would be offered to assess ovarian reserve and ovulation. AMH shows the potential to be reliable marker of ovarian reserve and hence reproductive performance. Reduced AMH levels are indicative of reduced antral follicle pool and hence ovarian reserve. AMH of less 5.4 pmol/ L for low response and greater than 25 pmol/L for a high response. Total antral follicle count from both ovaries less or equal to 4 for low response and greater than 16 for high response .Total antral follicle count can be measured by TV/US on day 3 of menstrual cycle. FSH values > 8.9 IU/L on the day 2-5 of the menstrual cycle for low response and associated with reduced ovarian reserve . FSH values < 4 IU/L for a high response. She should be offered a blood test to measure serum progesterone in mid-luteal phase on day 21 of a 28-day cycle . Values of 16-28 nmol/L are the lowest limit indicative of ovulation. Other hormonal tests based on the history or examination would be done, but not routinely. Additional investigations for tubal patency and function should be offered. If she is thought not to have co morbidities such as PID, endometriosis, should be offered HSG for ruling out tubal occlusion.HSG is cheap, less invasive and not required general anesthesia. If she is thought to have co-morbidities, she should be offered laparoscopy and dye test .It is considered the gold standard. It allows assessment of pelvic pathology at the same time. Hysterosalpingo-contrast-sonography (HyCoSy) is suitable alternative to HSG, where she is thought not to have co-morbidities .It allows detection of uterine pathology such as fibroid, septae and polyps. If the history suggests PCOS or uterine fibroid, TV/US can be used to assess pelvic anatomy and evaluate pathology such as endometrioma, cysts, polyps, fibroids, adenxal and ovarian abnormality. She should be offered testing for rubella status to confirm immunity. She should be offered vaccination if not immune. Screening for Chlamydia trachomatis should be offered following HSG or being undergoing uterine instrumentation. DNA techniques such as PCR and LGR of cervical and urine specimens are highly sensitive and specific for diagnosis of chlamydial infection. c)If her BMI is 30 or over ,she should be advised to lose weight , as it has value of unifollicular ovulation and it improve pregnancy outcome. Clomifene citrate induces ovulation in 70-85% of women with PCOS with 40-50% conception rate .A maximum 6 months is recommended. Ultrasound follicular tracking to minimize risk of multiple pregnancy. Metformin –Insulin sensitizing agent, shown to have beneficial effects in reproductive function. It is associated with nausea and vomiting. Combination of metformin and clomifene citrate has higher ovulation rate than with clomifene alone. If she is resistant to clomifene citrate, laparoscopic ovarian drilling (LOD) is to be considered after the woman preference. It is not associated with risk of multiple pregnancy. It has risk of visceral injury 1/1000. Gonadotrophins are effective ovulation induction agents in women with clomifene resistant PCOS. Ultrasound follicular tracking reduce risk of multiple pregnancy and ovarian hyperstimulation. No advantages in routinely using GnRh analogues in conjunction with gonadotrophins in these women. It is associated with increased risk of ovarian hyperstimulation. IVF is the last option. She should be informed that chance of a live birth following IVF treatment falls with rising female age.
Infertility SAQ Posted by NAZIA H.

         Mr Paul Can you please correct my essay. 

Dr N Hussain

Posted by effat W.

(a) Concerning  the clinical assessment I will start with taking history from the couple. I will ask about the occupations of both partners. I will ask for information on the administration of alcohol as this might adversely affect pregnancy rates. I would like to know if she is smoking or using over the counter recreational drugs. Regarding the menstrual history I will ask about the regularity of the menstrual periods. regular periods might strongly indicate ovulation. Also it is important to know the length of the cycles which help in the timing of further investigations. The presence of cyclic pain related to the periods suggests endometriosis. I will ask about the frequency of intercourse. the past obstetric history is important specially history of previous live births. Considering that it is stated that she is a healthy woman, I will assume that she does not have chronic  medical disorders. However, I will ask about history of PID or ectopic pregnancy. History of abdominal surgeries gives rise to the possibility of adhesions and tubal block. Shifting to the examination, I will check her BMI as obesity as well as BMI < 19 might interfere with ovulation. I will examine her abdomen looking for masses suggesting fibroids, endometriomas or ovarian cysts. I will check the recent cervical smears and vaccinations.

(b) If the woman has regular periods mid luteal  serum progesterone has to be done. This will indicate if she is ovulating. It is ideally done on day 21 of a 28 days cycle. In case the periods are longer it can be done later than that. If periods are irregular serum progesterone is done and then repeated weekly till the next period. Serum gonadotrophins (FSH &LH) must be done if the periods are irregular. Serum prolactin should be only done if she has galactorrhea or pituitary adenoma. Thyroid function tests are only done if clinical symptoms are present.

Regarding checking for tubal patency I will ask for hysterosalpingography as long as she does not have co morbidities ( PID, history of ectopic pregnancy, abdominal surgeries or endometriosis. In the presence of the necessary expertise ultrasonography would be useful instead. If co morbidities are present I will resort to laparoscopy to allow treatment if needed and indicated.

Pelvic ultrasound scan will help identify focal lesions, presence of fibroids or endometriomas. It might be useful to identify anomalies and PCO.

Viral screening is necessary for both partners as the presence of HIV, HCV, HBV might indicate the need for sperm washing and in turn formulate management plans. I will check the woman's immunity to rubella. IF not immune I will offer the rubella vaccine. Screening for Chlamydia is necessary before uterine instrumentation. If the cervical smear is due It should be done.

(c) PCO related infertility is mostly due to anovulation. If the BMI > 30 I will advise her that weight reduction on its own might resume ovulation. If there is no indication of assisted reproduction, induction of ovulation can be started by clomifene, metformin or combination of both. Regarding the use of clomipfene it can only be used for 6 months. In case metformin is used the woman should be informed about the adverse effects including gastric upset. With clomifene US assessment at least during the first month is necessary to reduce the risk of multiple pregnancy.

In case of clomifene resistance laparoscopic ovarian drilling may be used or gonadotrophins. With gonadotrophins there is a risk of ovarian hyperstimulation and multiple pregnancy.

Having all the above modalities failed I will advise them to go for IVF, specially that they have already tried for conception for 2 years.

 

Infertility Attia R Posted by Attia R.
Please dr Paula can you correct my essay
KRA Posted by KWASI RICHARD A.

KRA

HISTORY

 I would take a menstrual history enquiring about her age of menarche, last menstrual period and regularity of her cycles because cycles lasting 28-36 days are suggestive of ovulation.  I would also find out about any dysmenorrhoea during her menstrual period which may suggest endometriosis or pelvic infection.  I would take an obstetric history enquiring about any previous pregnancies and their outcomes, for example any miscarriages, stillbirths, to ascertain whether her infertility is primary or secondary.  I would find out about her coital frequency because sexual intercourse every 2 - 3 days optimises the chance of pregnancy.  I would find out about any acne, hirsutism, weight gain which may suggest polycystic ovarian syndrome or androgen excess.  I would find out about her general alcohol consumption, exercise and smoking which are likely to reduce fertility.  I would find out about her rubella immunity status.

 

Examination

I would check her height and weight to calculate her body mass index, because BMI > 30 is associated with reduced fertility because they are likely to take longer to conceive.  I would look for features of androgen excess like acne and Hirsutism suggestive of polycystic ovarian syndrome.  I would perform an abdominal examination looking for masses like fibroids.  I would perform a bimanual vaginal examination to assess uterine mobility, whether the uterus is retroverted or anteverted, for adnexal tenderness and palpable nodules, to exclude pelvic infection and endometriosis. 

 

I would perform a mid luteal serum progesterone test on day 21 of a day 28 cycle to confirm ovulation if they have regular cycles.  However if her cycles are irregular I would perform serum progesterone test on for example day 28 of a 35 day cycle and repeated weekly until the next period starts.  I would asses her ovarian reserve that is likely response to gonadotrophin stimulation in invitro fertilisation by measuring follicle stimulation hormone greater than 8-9iu/l for a low response and less than 4 iu/l for a high response.  I would perform a blood test to measure serum prolactins if she has galactorrhoea.  I would perform thyroid function test if she has symptoms of thyroid disease.  I would request for her to have a hysterosalpingography HSG to screen for tubal occlusion if she has no co-morbidities like pelvic infection or endometriosis.  It is less invasive.  I would offer laparoscopy and dye test for pelvic pathology to assess the pelvis at the same time.  I would offer her screening for HIV, Hepatitis B and Hepatitis C if she is undergoing IVF treatment.  I would offer her testing for her rubella status if she is susceptible will be offered vaccination and advised not to become pregnant for at least 1 month following vaccination.

I would advise her to lose weight if her BMI is over 30, inform her that this alone may restore ovulation, improve their response to ovulation agent and has positive impact on pregnancy outcome.  I would offer her Clomiphene citrate or Metformin or combination of both.  I would offer ultrasound scan monitoring at least the first cycle of treatment to ensure they are taking a doze that minimises the risk of multiple pregnancy treatment with Clomiphene not longer than 6 months.  I would inform her the side effects of Metformin including nausea and vomiting.  I would offer laparoscopic ovarian drilling if there is know to be Clomiphene resistant.  It is not associated with multiple pregnancy and OHSS however there are side effects of laparoscopy; bleeding injury to bowel and bladder.  I would offer gonadotrophin for ovulation induction if Clomiphene resistant and to reduce the risk of multiple pregnancy and OHSS ovarian ultrasound monitoring to measure follicular size and number.

KRA Posted by KWASI RICHARD A.
Pls my essay is unmarked KRA
Posted by Bobey B.
Dear Dr. Paul It is stated in new recommendations of NICE GUIDELINE That: For women who are taking clomifene citrate do not continue treatment for longer than 6 months. [ 2013 ]. Page 27.
Posted by Bobey B.
Dear Dr. Paul It is stated in new recommendations of NICE GUIDELINE That: For women who are taking clomifene citrate do not continue treatment for longer than 6 months. [ 2013 ]. Page 27.
Posted by Imad Aldeen E.

Details history should be taken including menstrual history about its LMP,regularity,menorrhagea,oligomenorrhea and intermenstrual bleeding.  Medical history should be obtained about any chronic disease such as DM,renal disease or hypertention.  Medication history should be explored currently or previously for medical dieases or for fertility treatment . a history of drug abuse ,smoking or alcohol should be taken. Previous surgical operations such as laprotomy for appendicitis should be known.Contraceptive history sould be asked about which kind and for how long.  Sexual history should be obtained including any previous vaginal discharge or previous pelvic inflammatory disease( PID ). Any incresing of body hair growth and the velocity of growing should be explored. symptoms of menopause should be asked such as vasomotor symptoms or night sweating . Family history for any infertility, autoimmune diseses should be asked. Clinical examination should be started by calculating Body Mass Index , BP , distribution of body hair and check for any hirsutism in abnormal areas. Check the neck for any Goiter .  cheking for any scars and abdominal masses by abdominal exam.vaginal examination by speculum to exam for any vaginal discharge and  the cervix and then bimanual exam for the uterus if it is fix or retroverted and feel with any adexal mass. 

 

Blood tests including hormonal profile such as FSH and LH in 2-3 Days of cycle should be ordered to exclude any Hypotalmic or pitutiry causes in which these hormones will be reduced ( hypogonadotrophic ) and the rate LH/FSH can be useful in Polycystic ovarian syndrom( PCO ). Level of prolactin should be obtained because it can be increased in hyperprolactinemia or Pco ( in 20% ). Progesteron level on day 21 should be obtained to check for ovulation. Tyroid function tests (TFTs) should be ordered because any abnormal TFTs can cause abnormality in cycle. Testosteron , androntestosteron , DHEA and DHEA-S should be ordered because testosteron can increase in PCO.Pelvic ultrasound sould be done to exclude ovarian cysts, PCO and fibroids .Vaginal swabes should be done if the patient hase vaginal discharge or episodes of PID. Hysterosalpingography can be ordered to check the patency of fallobian tubes.Diagnostic laparoscopy with dye test to check for patency of tubes and adhesions intraperitonium and around the tubes and endometriosis.

 

Advice to reduce weigh and exercises because it can support the ovulation when reduce weight about 10% or more and change the life style by stopping smoking and alcohol .

Induction of ovulation by Clomiphene citrate( CC) which can cause ovulation in 80% and pregnancy in 40% with risk of multiple pregnancy and ovarian hyperstimulation ( OHSS ). The CC can be given in maximum for 12 months. Metformin can be added with CC because it increase the rate of ovulation and reduce the hirsutism .

Gonadotrophine can be given with higher risk of   OHSS and multiple pregnancy with approximately the rate of prenancy with CC.

Laparoscopic ovarian drilling is a successful method of treatment by doing 4 – 5 halles in the ovary by special needle with coagulation. It has no risk for OHSS and Multiple Pregnancy but it is effective for 6-9 months with risk of operation.

In Vitro Fertilisation can used in intractable cases with successful rate about 15% and high risk of OHSS and  Multiple Pregnancy .

Posted by Bobey B.
Dear Dr. Paul : Would you mind please to confirm : What was posted up ( It is stated in new recommendations of NICE GUIDELINE That: For women who are taking clomifene citrate do not continue treatment for longer than 6 months. [ 2013 ]. Page 27.
Posted by Farrukh G.

 

Posted by Bobey B.
Sun Jun 23, 2013 08:45 am

Dear Dr. Paul : Would you mind please to confirm : What was posted up ( It is stated in new recommendations of NICE GUIDELINE That: For women who are taking clomifene citrate do not continue treatment for longer than 6 months. [ 2013 ]. Page 27.

 

Thanks - you are right and we apologise for the error. We have updated PCOS notes and added notes on ovulation disorders. We will also post a message in the forum. Thanks again for pointing this out.