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MRCOG PART 2 SBAs and EMQs

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ESSAY 193 - Sub-fertility

Posted by Sreekala S.
A detailed menstrual history should be taken to know if the lady is ovulating or not. Examination of the male partner and Semen analysis should be done to rule out a male cause for the subfertility. Serum progesterone should be done on 21st day of the cycle to know if she is ovulating or not.
Her management includes a multidisciplinary approach involving the gynaecologist, dietician and the physiotherapist.
The woman should be encouraged to loose weight. Weight reduction improves the endocrine profile, increases the likelihood of ovulation and a healthy pregnancy. It increases the chances of conception spontaneously and also in those where ovulation has been induced by medication.
She should be referred to a dietician who would give her dietary advice and a physiotherapist who would help her in some exercises to loose weight. Dietary advice should consist of reduction in carbohydrate intake and avoidance of fatty foods. Anti obesity medications have a limited role and if prescribed should be montitored carefully.
Clomiphene citrate is an anti estrogen used for ovulation induction which is given orally 50-100mg from the day 2-6 of spontaneous cycle or an artificially induced cycle. A dose greater than 100mg may impede sperm transport by thickening the cervical mucus. Ovulation induction is successful in 80% of cases but only 40% conceive. The woman should be counselled of the possibility of multiple pregnancy and Ovarian hyperstimulation. There is a possibility of ovarian malignancy and premature menopause if ovulation induction is carried on for a longer time.
Administration of Gonadotrophins is an alternative if she is resistant to clomiphene citrate. Gonadotrophins should be given in low doses and the pregnancy should be closely followed up as the chances of multiple pregnancy and ovarian Hyperstimulation Syndrome are higher with them.
Metformin is a biguanide which is known to reduce the hepatic gluconeogenesis, increases the sensitivity of insulin and restores the menstrual cyclicity and fertility.
A Cochrane review suggests that a combination of metformin and clomiphene citrate is superior to clomiphene citrate alone in inducing ovulation.
The usual dose of Metformin is 850mg twice daily or 500mg thrice daily. Metformin should be commenced after proper counselling, advice about diet, lifestyle and exercise. Baseline investigations should include GTT, FBC, Renal and LFT. The adverse effects include anorexia, nausea, flatulence, diarrhoea which may be reduced by taking it before food and gradually increasing the dose from 850mg at night to 850mg Bd after 1 week. Metformin should be discontinued in pregnancy although no there is no evidence of teratogenicity.
Laparoscopic Ovarian drilling is an option in resistant cases. The exact mechanism how it induces ovulation is not well understood. The advantage with the Laparocopic ovarian drilling is that it can be combined with laparoscopic tubal patency testing as well if there is suspicion of a tubal blockage. The woman should be properly counselled of the possible complications like bleeding, injury to the bowel/bladder, infection and the possibility of laparotomy before embarking upon laparoscopy.
Folic acid should be commenced as soon as possible.
Artificial reproductive techniques should be considered if there is no success with the above treatment options.

Posted by Zaharuddin R.
The main problem for the couple is polycystic ovarian syndrome(PCOS) of the woman. Counseling with appropriate plan and goal of the treatment are important for compliance to follow up and treatment.

PCOS is usually associated with oligomenorrhaea or irregular bleeding. As the patient has high BMI, weight reduction is important as reduction of 10% of body weight may cause the patient resume regular menses. Combined management with dietitian is appropriate to monitor calorie intake. Modified oral glucose tolerance test should be done as PCOS is at high risk of diabetes mellitus especially if the patient has strong family history.

Regularity of menses could be achieved by cyclical low dose progestogen such as oral duphaston for 21 days. Clomiphene citrate for ovulation induction could be prescribed for day2-day6 menses with dosage 50-150mg daily. These could be monitored by day21 serum progesterone which >30ng/ml suggestive of ovulation. Side effects such as hot flushes, insomnia and blurred vision should be warned. Risk of multiple pregnancy of 10% should be informed. Risk of ovarian cancer in future is high if clomophene induction is more than 12 months.

PCOS is associated with clomiphene resisitant. Metformin play a role to reduce resistant with dose of 1gm twice a day and it will avoid operation risk for ovarian drilling.

The other option is laparoscopic ovarian drilling. These is not only could overcome ovulation induction resistant but at the same time tubal patency test and other procedures such as adhesiolysis could be done. Inherent risk of viseral injury of 1:500 with anaesthetic risks should be explained. No risk of multiple pregnancy.

Superovulation with GnRH analogues with intrauterine insemination (IUI) should be offered especially after 6 cycles failure of clomiphene induction. High cost of the drugs and 20% risk of multiple pregnancy must be informed. Invasive monitoring such as trasnsvaginal ultrasound is needed for follicular tracking. Risk of ovarian hyperstimulation syndrome should be discussed.

After that, in vitro fertilization (IVF) should be offered especially after 3-6 cycles failure of IUI. High cost and success rate of 25% per cycle (mainly depending on the centre) should be explained. IVF success rate could be increased if intracytoplasmic sperm injection (ICSI) done at the same time.

Managing the primary subfertile couple need careful counseling and discussion. At the same time, adoption of child should be suggested with help of social worker.Written information regarding procedures involved is necessary to make the couple more understanding of the plan and compliance.
Posted by Ebeinheizer S.
Polycystic Ovary Syndrome (PCOS) is a multifactorial disorder associated with subfertility, hyperandrogenism and metabolic disorders. Common presentation in the Gynaecology Clinic would be for subfertility, mentrual disturbances and hirsutism.

History taking and investigation for possible male infertility and other causes of female infertility need to be assessed as well in this couple. Relevant history for both such as diabetes, mumps orchitis, chlamydial infection and smoking should be sought. The husband would need a semen analysis. The woman should have a fasting serum insulin and blood glucose level assessed as PCOS is associated with insulin resistance and diabetes melitus. Treatment should be initiated if diabetes is diagnosed. Ultrasound, tubal patency test and rubella immunization status should also be performed and managed accordingly.

As the woman has BMI of 38, weight reduction need to be emphasized. Referal to Obesity Clinic, Dietician and encouraging exercise would be necessary. Aiming for BMI below 30 with a targetted maximum weight need to be emphasized. Brief explanation that this has been proven to encourage spontaneous ovulation, improve fertility and pregnancy rates should be conveyed.

Insulin resistance in PCOS when proven with investigations can be improved with the usage of Metformin. Exercise and weight reduction also improves insulin resistance. Increased insulin resistance as contributary factor of infertility in PCOS is well established and the couple need to be counselled about this.

Meta-analysis have shown that usage of clomiphene for ovulation induction is beneficial in PCOS related infertility. This can be used alone or in conjunction with Metformin to improve fertility. Other ovulation induction agent such as gonadotrophins and down-regulation/super-ovulation regimes can also be employed.

In view of the woman\'s age, a time frame of about 6-12 months should be tried with the above methods including intra-uterine insemination (IUI). If pregnancy is still not achieved, assisted reproductive techniques should be considered. IVF and ICSI tend to have long waiting period and the couple need to be put on the queue.

Counselling should include printed leaflet about PCOS. Information about PCOS support groups and websites should also be given. The couple should be made aware that PCOS can increase the risk of Gestational Diabetes, Hypertension and Pre-eclampsia. There is also a small increase in miscarriage rates. Long term risks of the woman developing dyslipidaemia, type 2 diabetes and hypertension, apart from pregnancy should be explained.
Posted by Sarwat F.
This couple can be helped by proper counselling regarding various options of management aided by written information and instituting treatment.
As the problem is polycystic ovary syndrome, woman will be advised regarding weight reduction. 10% weight reduction will result in return of ovulation. It also helps in reducing insulin resistance and risks of noninsulin dependent diabetes.
Ovulation induction agents will be given starting with clomiphene citrarte 50 mg for five days increasing the dose gradually. Clomiphene citrate is an antiestrogen which acts in anterior pituitary to increase the level of serum FSH and LH resulting in ovulation. Woman will be counselled regarding various side effects of clomiphene which include hot flushes, breast discomfort, hair loss, visual symptoms, abdominal distension, headache, nausea vomiting. Risk of ovarian hyperstimulation syndrome and multiple pregnancy are also explained. Clomid is licensed for use for 6 months. Ovulation is achieved in 80% woman and pregnancy rate is 60 %. There is no evidence that it is associated with increased risk of ovarian cancer, however putative risk of ovarian cancer with ovulation induction agents should be explained.
Metformin can be given which is a hypoglycaemic agent. It is given as 500 mg 3 times daily. Sideeffects include gastrointestinal disturbances. Metformin is also helpful for insulin resistance.
Parenteral gonadotrophins can be used for ovulation induction. They require intensive monitoring with ultrasound tracking of follicle and checking serum estradiol levels. Parenteral gonadotrophins are associated with far more risk of ovarian hyperstimulation syndrome and multiple pregnancies as compared to clomiphene. They can be used for 6 months. Use of gonadotrophin releasing hormone analogues for down regulation does not result in increase rate of ovulation.
Laparoscopic ovarian diathermy is also an option especially in woman who are undergoing laparoscopy for any other reason like tubal patency testing. Its success rate is comparable to parenteral gonadotrophins and is free of side effects of ovarian hyperstimulation syndrome and multiple pregnancy. However risks of anaesthesia and procedure of laparoscopy like bowel and bladder damage remain. Also some concerns are raised about the risks of premature ovarian failure with laparoscopic ovarian diathermy.
Woman will be advised to take folic acid as she is planning for pregnancy. Information leaflet given, link with support groups are provided.
Posted by Remi A.
Polycystic ovarian syndrome is a heterogenous disease with variable presentation.
Its important to explain the nature of the disease to the woman in a sensitive way,as she may have a low self esteem and poor body image as a result of morbid obesity.
Although the most likely cause of subfertility in this case is anovulation,its important to rule out tubal blockage and perform a semen analysis in the partner.
The aim of management is to optimise the women\'s health and achieve unifolicular ovulation.
The woman should be encourage to loose weight.Studies have shown that dietary and exercise program is more effective than delivery advice alone.
Antiobesity may be used in extreme cases,but it has not been shown to effective and is associated with side effects.
A 10% weight loss can result in regularisation of periods,spontaneous ovulation and improvehyperandrogenaemia.
She should be offered screening for Diabetes with oral glucose tolerance test,as about 40% of women with PCOS will develop Type2 Diabetes.This will allow good glycaemic control preconception and better monitoring during pregnancy,if positive for Diabetes.
Clomiphene[anti estrogen]given at a dose of 50-100mg from day2-6 of the cycle will achieve ovulation in 80% of cases,but only half will get pregnant. its important to counsel her about side effects like nausea,vomiting,hot flushes and visual disturbances[Drug should be discontnued].Also, there is 10% risk of multiple pregnancy-hence need for follicular tracking by ultrasound.There is risk of ovarian hyperstimulation syndrome.
The Royal college of obstetrician and Gynaecologists recommend that it can be used for up to 12 months..

Metformin used alone or in combination with clomiphene has been shown to improve conception rate,although the studies was confounded by using metformin in clomiphene resistant cases.
Metformin has no effect on weight,and its main side effect are nausea and vomiting.
Gonadotrophins can be used in clomiphene resistant cases.Ovulation rate is about 80%.The main drawback is increased risk of ovarian hyperstimulation syndrome.
Laparoscopic ovarian drilling is an alternative to Gonadotrophin in clomiphene resistant cases.Its achieves unifollicular ovulation and there is no increased risk of OHSS. it can also be done at the time of tubal patency test.
If there is failure of above measures,there should be early referral for assited reproductive teechniques so as to maximise chanches of success because of her age.
She should be screened for Rubella and immunised,if non-immune.
She should start folic acid 0.4mg once a day.
Information leaflets and contact of support group should be provided.
Posted by Balakrishnan V.
Polycystic ovarian syndrome is a multifactoral condition having weight, menstrual, androgenic and infertility problems. Multidisciplinary approach involving endocrinologist, dietician, gynaecologist and psychologist, if required,should be planned to address all of the women problems. As ther are more chances of success of the treatment if health of the women is optimum before the infertility treatment. The explanation of the condition to the couple and councelling regarding compliance to treatment is very important. As infertility in women with polycystic ovarian syndrome is due to anovulation. The objective of treatment is to induce regular unifollicular ovulation while minimizing risk of multiple pregnancy and ovarian hyperstimulation syndrome. This can be achieved by simple measures such as weight reduction.
The women is councelled to modify diet, do regular moderate exersics and an appointment with the dietician will be helpful. Even 15% weight reduction can restore ovulation.
For medical ovulation induction clomiphene citrate can be used as it has lower risk of ovarian hyperstimulation than gonadotrophins. Clomiphene citrate, an anti estrogen, can be given upto six consective cycles. Side effects are nausea, vomiting, abdominal cramps, alopesia.
GnRH analogues are associate with ovarian hyperstimulation so not preferred in polycystic ovarian syndrome. But can be an option in clomiphene resistant PCOS.
Laparoscopic ovarian drilling is operative treatment option which induces ovulation and doesnot have risk of ovarian hyperstimulation in clomiphene resistant PCOS. But the side effects are risks of general anaesthesia, laparoscopy and there is no evidence of what long term consequences of ovarian damage will be.
Metformin is oral hypoglycaemic agent used in PCOS to reduce insulin resistance, may improve menstruation and spontaneous ovulation. Side effects are
Invitro fertilization is an option if all other treatments fail and adoption is the last resort.
The women with PCOS, who conceive, are at higher risks of
miscarriage and pregnancy induced hypertension.
The information leaflets and support groups contact numbers should be given to them.
Posted by adnan S.
History is obtained regarding her menstrual cycles any irregular periods,or an absence of periods dysmenorrhoea, dysparunia.Sexual history regarding coital frequency is enquired..Social history is obtained about smoking,alcohol intake occupation .O/E weight is checked to assess BMI,Chlamydia screen and cervical if needed is performed.Follwing baseline are requested to assess ovulation ,serum progesterone is measured on day 21 of a 28 day cycle to confirm ovulation if regular cycle. If the cycles are prolonged irregular serum progesterone is measured on 28 day if 35 day cycle and repeated weekly thereafter until the next menstrual cycle starts.FSH and LH level on day 2-4, PCOS is the commonest cause of anovulatory subfertility, obesity further increase the risk of anovulation.A test for tubal patency and semen analysis should be performed before ovulation induction.Rubella staus checked if not immune should be immunised .
Life-style modifications is very important in the treatment of PCOS.Weight reduction and exercise show striking improvement in ovulatory cycle,10% weight loss may results in a restoration of regular ovulation ,improves physical fitness with normalization of glucose metabolism and reduce risk of NIDDM .Dietry modifications ,along with cessation of smoking and moderate intake of alcohol,caffeine is advised as cigarette smoking has been linked to decreased fertility and impaired insulin action ,caffeine may influence fertility and alcohol also have negative effect on fertility.Folic acid 0.4mg/day is recommended. Regular intercourse two to three times a week should be advised.Along with the general advice about optimizing fertility,written information and useful website covering PCOS such as www.pcos.i8.com sould be given.
Ovulation induction is done with anti-oestrogens like clomiphene citrate/tamoxifen,metformin-insulin sensitizing agent,gonadotrophin therapy and laparoscopic ovarian drilling.The aim is to induce regular uni-follicular ovulation and to minimize the risk of multiple pregnancy and ovarian hyper-stimulation syndrome.Treatment should only take place if access to ultrasound ovarian monitoring is available.There is no evidence to support an increase risk of ovarian cancer with ovulation induction therapy ,however patient should be counselled about the putative risk. The couple should be offered counselling before ,during and after investigation and treatment,irrespective of the outcome ,and contact number of fertility support group is given.
Posted by Aroosha B.
The likely cause of infertility in this particular Couple? is anovulation secondary to PCOS and obesity .Considering the age of Couple and longstanding history of Infertility ,the woman needs urgent intervention and treatment for ovulation induction to restore her fertility .But before embarking on treatment Couple needs careful Counselling which will include advice to reduce the at weight of the woman ,adoption of healthy lifestyle and discussion regarding various methods of ovulation which will help the Couple in making informed Choice
As this woman is obese (BMI more than 30) ,I would advise her to lose weight which will Subsequently improve her endocrine profile leading to spontaneous ovulation and fertility . She is advised to decrease carbohydrates contents of diet and avoid fatty food in collaboration with dietician .Moreover She is advised to do moderate exercise which will further help her in decreasing weight .The couple would be advised to adopt hearty healthy lifestyle that is to Stop Smoking , decrease intake of Caffine and alcohol which can affect their fertility .Moreover the woman is advised to take folic acid which can prevent NTD if conception occurs .
The next step would be to Start ovulation induction . Prior to this I would like to make Sure that test for tubal patency and Semen analysis are done and are normal .Moreover baseline LFT and KFT are to be done in case metformin is used for ovulation .As regards ovulation induction my first Choice would be to use Anti-estrogen drugs CLOMIFENE citrate which is Started from Second day of cycle till five days .Dose can vary from 50 mg OD to 150 mg OD depending upon ovarian response .Generally it can lead to ovulation in 80 %of cases and conception in 40 percent .The woman is advised to have USG to avoid multiple pregnancies and to ensure that ovulation is taking place .If ovulation is achieved I would Continue the treatment for 6 to 12 months as If used, more than this period ,there?s risk of ovarian CANCER .
In case of failure of ovulation with CC I would add metformin along with Clomid .Metformin corrects hyperandrogenemia and abnormalities of gonadstrophins, decreases insulin resistance, leading to normal menstruation and ovulation .It also enhances the efficacy of clomid .As this Woman is obese Metformin can be more effective .Its dose is started by 500 mg OD and gradually increased to 500 mg TDs s and is continued for six months along with CLomid citrate .Meanwhile I will do her LFTS and KFTS to monitor its side effects . If She will fail to conceive despite ovulation by these regimens I would advise her to do IUI along with ovulation induction which can increase her chances of conception .
If the woman fails to ovulate BY the above regimen ,- choice of treatment would be either to use parentral gonadotrophins or to have ovarian drilling .She will Be informed about pros and Cons. As regards gonadotrophine its use is associated with high risk of multiple pregnancies (25 percent) and risk of OHSS 1-2 percent and requires careful monitoring by USG and Serum oestradiol .while ovarian drilling is not associated with OHss or multiple pregnancies and does not need monitoringAs it decreasesLH AND ANDROGENS and the risk of miscarriages is less but there are concerns regarding small risk of premature ovarian failure (POF) and periovarian adhesions .
If the couple opts for parentral gonadotrophine I would start treatment with lower doses to avoid its side effects and monitor its use by USG and Serum oestradiol .The treatment is Stopped if there are more than 3 MGF or signs of OHSS .. Moreover Couple would be advised to avoid intercourse in this Situation and 1 would withhold injection HCG . Parentral gonadoteophins causes ovulation in more than 80 percent of cases and conception in more than 60% of cases
. If the Couple opts for ovarian drilling facility and skill for laparoscopic procedure is to be ensured,.it is done by laparoscope using 4 points 40 watts current for 4 second in each ovary .
If this woman fails to conceive after ovulation induction and IUI, I will discuss the option of IVF if the couple opts for it I would refer them to ART centre. .DuringIVF , as use of long protocol for GONADOTROPHIN releasing hormone agonist along with gonadotrophins increases the chances of pregnancy ,so their use is preferred.
The Couples is given information leaflet of above treatment modalities and encouraged to make informed Choice. Moreover they are given information of infertility support group .















































Posted by Kishor S.
The aim of treatment in this couple is induction of ovulation. A structured approach, starting with low-cost interventions and advancing to high resource interventions, is warranted for the management.
1. The first step is weight reduction with an aim to reduce BMI below 30. It will improve her endocrine profile with reduced insulin and androgen levels and result in uni-follicular ovulation. In addition, in case of successful pregnancy, it will avoid the complications associated with obesity e.g. diabetes, hypertension, increased fetal loss and thromboembolism. Weight reduction needs motivation and professional help and involves lifestyle modification programmes in addition to diet and exercise. Use of appetite suppressants should be recommended only under close medical supervision. If there is hyperinsulinaemia (fasting insulin >25 IU or fasting glucose in mg to insulin ratio of less than 4.5) metformin will help in weight reduction and improves ovarian response to clomiphene shown by RCTs. The side effects include nausea, vomiting, hypoglycaemia and rarely lactic acidosis. Weight reduction method is tried for 3 to 6 months. Ovulation in low resource setting will be monitored by BBT.
2. The second step is use of clomiphene citrate for induction of ovulation. Approximately 80 percent of women ovulate, but only about 50 percent become pregnant. It will be given at the dose of 50 mg daily for five days starting from the fifth day of a cycle, following either spontaneous or induced bleeding. If ovulation does not occur in the first cycle of treatment, the dose is increased by increments of 50 mg. Increase beyond 150 mg does not offer significant improvement but is associated with cervical mucus hostility.
Monitoring of response is best done by serial transvaginal ultrasound assessment of follicle development. This should be started from the last dose alternate day till the ovulation, which is indicated by collapse of follicle and free fluid in POD. At the same time endometrium will be assessed.
The ovulation occurs from 5 to 12 days after the last day of clomiphene administration an the couple is advised to have intercourse every other day for one week beginning five days after the last day of medication for a week. In general four to six cycles are tried with clomiphene.
10 to 20% may experience side effects of clomiphene such as visual disturbance, hot flushes, rash, breast tenderness, abdominal discomfort.
3. In case there is failure of ovulation with clomiphene, supplementary or alternative treatment will include (a) exogenous human chorionic gonadotrophin injection (10,000 IU IM) when the leading follicle reaches 18 to 20 mm in diameter. (b) If there is hyperprolactinaemia, bromocriptine 2.5 mg BD will be added. (d) If DHEA-S level is high dexamethasone will be added to improve the efficacy. (e) Aromatase enzyme inhibitors have been tried and found to be effective in inducing ovulation, but it is still not approved. (f) In case of cervical mucus hostility in successful with higher dose of clomiphene, intrauterine insemination will be tried.
4. In women who are still anovulatory, therapeutic options include ovulation induction with gonadotrophins or laparoscopic ovarian drilling. The evidence to date suggests that there are no significant differences in reproductive outcomes (range 20 to 65 percent) between these two with the exception of lower multiple gestation rate with laparoscopic surgery. Other considerations include the need for specialized centre and careful monitoring with gonadotrophin therapy, and possibly higher cost. However, there are potential risks and morbidity of laparoscopic surgery with general anesthesia, postoperative adhesion formation, and the theoretical risk of premature ovarian failure. Other important considerations when choosing between these two therapies include availability of local facilities and surgical expertise. The ultimate decision will be made by the couple.
The risk of multifetal gestation is increased with both clomiphene (particularly when it is started before the recruitment of dominant follicle: day 2 ? 4) and gonadotrophin therapy (10% vs. 40%). Another complication is ovarian hyperstimulation syndrome (OHSS), which is a potentially life-threatening complication and higher with gonadotrophins. With clomiphene ovarian cysts develop in about 5% but OHSS occurs in less than 1%.
The use of fertility drugs has been associated with neoplasia, particularly borderline ovarian tumors, though it was not supported by meta -analyses.
Posted by Srivas  P.
Unexplained infertility is a diagnosis of exclusion made usually after semen parameters, ovulatory concentrations of progesterone in mid luteal phase, tubal patency and uterine cavity are normal and it may be a frustrating diagnosis for the couple because it may suggest no effective treatment. Polycystic ovaries and obesity are probably incidental findings in this woman with otherwise normal investigative parameters and ovulatory cycles.

Whether to continue with expectant treatment or start treatment depends on woman?s age and couple?s wishes. A specific enquiry about lifestyle and sexual history should be taken as stress in the male and/or female partner can affect their relationship, and is likely to reduce libido and frequency of intercourse which can contribute to fertility problems. Sexual intercourse every 2 to 3 days optimizes the chance of pregnancy and timing intercourse to coincide with ovulation causes stress and is not recommended.

This women who has a body mass index of 38, should be told that she is likely to take longer to conceive due to obesity even if regularly ovulating and hence weight reduction should be encouraged. History of smoking should be taken as excess smoking can reduce both female and male fertility

Women with unexplained fertility problems could be offered 6 cycles of clomifene citrate as it increases the chance of pregnancy, but that this needs to be balanced against possible risks of multiple pregnancies hence first cycle should have follicular monitoring to give minimum dosage necessary. This can be coupled with intra-uterine insemination because this increases the chance of pregnancy and about 85 % may conceive in 3-4 cycles. IUI alone without superovulation maybe effective as it avoids risks of multiple pregnancies in this PCO patient.

Sometimes endometriosis is found in 20-40 % couples with unexplained subfertility and this should be suspected if there is history of dysparunia, dysmenorrhoea and lower abdominal pain and laparoscopy will aid the diagnosis. Medical treatment of endometriosis has not been found to improve fertility. Surgical treatment with laproscopic laser ablation of endometriotic deposits is more effective than expectant treatment. This could be combined with IUI and superovulation post operatively as results without superovulation has been uncertain in cases of endometriosis. In severe cases of endometrisis, IVF should be offered straightaway.

ICSI is an option in unexplained male subfertility in failed IVF cycles and the coupled should be counseled about transmission of possible Y-chromosome microdeletions to the fetus with associated infertility factor. Donor insemination is another option which could be considered.

All these could lead to a lot of mental stress and sometimes marital discord and the couple may be benefited by concomitant psychological help. They may also find it helpful to contact a fertility support group like Infertilitynetwork UK.

Posted by M H.
Prior to embarking on pregnancy, she should be advised to optimise her health. Advice to stop smoking, reduce alcohol intake and commence folic acid supplementation should be given. With a BMI of 38, she is in the clinically obese range and should be advised to lose weight to reduce her risks in pregnancy (eg increase risk of gestational diabetes and hypertension). Losing weight will also improve her chances of conceiving spontaneously as it has been shown that a weight reduction of as little as 10% will restore ovulation in a woman with polycystic ovarian syndrome (PCOS). Her rubella status should be checked and immunisation offered if not immune. If she has any other health problems (eg co-existing epilepsy); her medical condition and medications should be optimised.

If she requires ovulation induction, several methods can be considered. Administration of clomiphene citrate (an oestrogen receptor blocker) has been shown to be effective. It increases the production of FSH (follicle stimulating hormone) and induces ovulation. There is however, a risk of OHSS (ovarian hyper stimulation syndrome) which can lead to mortality in severe cases. It is essential that any woman (especially women with PCOS as they are more predisposed to developing OHSS) on ovulation induction be monitored by follicle tracking (ovarian ultrasound).

For clomiphene resistant women (about 20% women with PCOS), gonadotrophin releasing analogue (GnRH) and recombinant FSH are good alternatives. Both are also associated with OHSS and should undergo similar monitoring as if using clomiphene. It is not recommended to use these routinely as there is little evidence that there is an increased pregnancy rate with routine use.

If she is clomiphene resistant and/or has limited ability to attend for monitoring, laparoscopic ovarian drilling is an option. It has been shown to induce ovulation and normalise luteinising hormone (LH) levels. Its advantage is that it has no risk of OHSS.

Ovulation induction may be accompanied with intrauterine insemination and HCG (human chorionic gonadotrophin support if necessary.

Posted by SWATI M.
History regarding any irregularities of menstrual cycle ,prior history of pelvic infections should be enquired.Social history about her life styles, smoking,alcohol intake,occupation should be taken account.On clinical examination look for other signs of PCOS such as hirsutism ,acne.Perform serum progesterone levels for detection of ovulation on day 21 with regular menstrual cycles and from day 21, every 7 days if irregular.
If she is not ovulating which is most likely in her case due to PCOS ,semen analysis and tubal patency tests should be performed before ovulation induction.
As she has increased BMI,weight reduction should be adviced.I will refer her to the dietician and advice life style changes ,group exercise , cessation of smoking and alcohol.I will counsel her that reduction in weight may help in resumption of ovulation but she needs to be motivated and will require time ,may be 4-6 months to achieve this.There are no side effects ,no risk of OHSS and multifetal pregnancy as with other modalities of ovulation induction and also improves pregnancy outcome.Counselling may help motivation and improve her compliance .
If she does not ovulate with weight reduction, anti- estrogens such as clomiphane citrate or tamoxifen should be recommended.Clomiphane citrate to be started minimum dose of 50 mg/day from 2nd day of her menstrual cycle ,given for 5 days.Monitor ovulation by serial ultrasound follicular tracking in 1st cycle.If she ovulates ,continue with same dose and it can be used maximum for upto 1 year.If she does not ovulate with minimum dose ,can increase to 100mg/day but increasing more than that will have adverse effect on cervical mucus and may not be helpful.
If she is resistant to clomiphane citrate,metformin can be added ,500mg three times a day which improves pregnancy rate but associated with gastro-intestinal side effects.
If she does not ovulate by above methods ,her options are laparoscopic ovarian drilling (LOD) or use of gonadotrophins and woman should be counseled about both treatment options,risks and involved in making the decision.
Gonadotrophins should be started in minimum doses and perform serial ultrasound follicular tracking to minimize risk of hyperstimulation of ovaries and multiple pregnancy.For the final maturation and rupture of the follicle ,hCG should be given.They are effective in about 80% women but associated with risk of OHSS and multiple pregnancy.
LOD is as effective as gonadotrophins , less risk of ovarian hyperstimulation , multiple pregnancy but has risks of visceral and vascular injuries and effects lasts upto 1 year.
She should be given advice about folic acid supplementation , check her rubella status and provide information about support group and information leaflets.