This couple should be ideally seen together in a dedicated infertility clinic . A consultant with interest in infertility should supervise her care.
A relevant history will be taken. I will take a menstrual history. I will enquire of her last menstrual period (LMP). I will ask about the frequency of her cycles, if there are periods of amenorrhoea and any associated menorrhagia,Irregular cycles are suggestive of anovulatory infertility. dysmenorrhoea and intermenstrual bleeding.I will ask about the frequency of intercourse and any associated dyspareunia. Dysmenorrhoea and dyspareunia will point to endometriosis.A history of previous pelvic inlammatory disease,or, abdominal or pelvic surgery will be noted. This may suggest tubal pathology.
I will ask if she smokes or drinks alcohol or use any other habit forming drugs. I will also enquire of her rubella status and if she is taking folic acid .
I will note her weight and height and calculate her BMI. I will eamine for hair and fat distribution as well as acne, and acanthosis nigricans. I will check for galactorrhoea.
I will examine the abdomen for a mass arising out of the pelvis. A pelvic examination will be done to assess normality of the labia, clitoris and vagina. I will examine the cervix in speculum examination for cervical polyps/masses or discharge. A cervical smear will be done if indicated and any discharge swabbed and sent for microscopy, culture and sensitivity. A bimanual palpation will be done to assess uterine size, position fixity/mobility and to assess for adnexal masses or tenderness. Nodularity in the pouch of Douglas will be checked for . This will be present in endometriosis
b). I will request serum progesterone to see if she is ovulating. If she has a 28 day cycle, this will be done on day 21. If she has irregular periods this will have to be done weekly until her next menses. I will do serum FSH and LH, to assess pituitary function. If she has galactorrhoea, I will do serum prolactin. If she has features of hyperandrogenism I will request serum testosterone, DHEA and DHEA-S and androstenedione. The levels will be used to distiguish hyperandrogenism due to PCOS from that due to an adrenal pathology. An ultrasound will be requested to assess uterine morphology, ovarian size and volume , greaterthan 10 cubic mm and the presence of prepheral cysts in the ovaries 2 to 9 mm in diameter as in seen in PCOS. An HSG will only be requested to assess tubal patency if the history suggests tubal pathology and ovulation induction is being considered.
c) If she is overweight she will be advised to lose weight as weight loss of 10 percent can restore ovulation and regular cycles. She will he offered dietary advice by a qualified nutritionist and she will be encouraged to do regular exercise. Drugs like orlistat has been shown to be effective in achieving weight loss. For morbidly obese patients bariatric surgery may be necessary and she will be referred to the bariatric surgeon.
Ovulation induction using clomiphene citrate from day 2 to day 6 for a maximum of 12 cycles can be offerred. She will be monitored using serial ultrasound to reduce the risk of multiple pregnancy and ovarian hyperstimulation syndrome. This can be done in conjunction with uterine insemination or timed intercourse. She will be given oral and written information about the symptoms of OHSS and how to seek help if it occurs. She will be told of the possible small risk of ovarian cancer .
Gonadotrophins can be offered as second line ovulation induction agents . There is also risk of OHSS and multiple pregnancy.
For clomiphene resistant cases laparoscopic ovarian drilling can be used. There is the risk of laparoscopic surgery and anaesthesia. However there is no associated OHSS or multiple pregnancy and the associated morbidity.. There is the added advantage of being able to assess the pelvis at the same time.
There is no role for metformin used alone as first line therapy or in combination with clomiphene citrate to induce ovulation. If all fails, then IVF can be offerred.
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